HomeMy WebLinkAbout23386-ZFORM
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD, N.Y.
N?
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
Date ....~...~,,..~.. ......................................... 19 ~...,~....,
23386 Z
............................................ ............................................................................
Coun~, Tax Map No. 1000 Section .......... ~i~ ....... Block .......... ~ ...... Lot No. ...~...~t....r..~ .......
puts,ant tO application dated...~...~,...,~ .............................. 19...~...-~.. ........ c~nd approved by the
Building Inspector.
Rev. 6/30/80
FORH HO.
'l'O'~N OF SOUTHOI.D
BUII.DIN(~ D F. PAItTHI'~ HT
TO~./N UAl.I.
SOUTIIOIA), N.¥
'IT;I,: 165- I,q02
BO^Ri) (}F IIEALTII ...............
3 SETS OE PI.ANS ...............
SURVEY ........................
CIIECK . .. .......................
SEPTIC FORH ...................
a. 'lhis al~lieaticm sm.st Im ccs~¥1eteiy Filled iii by lying,niter (Ir in ink mM mdsnitt~l to the ~dldi~ hm~clor with
b. Plo~ plan ~i~ hx:atia~ of lot alxl of Isdhli~s ~ proni~s, relationM~ip to mi.joining proni~s or ixdflic
str~ts or areas, ar~ givii~ a (~tail~l &scripti~ of la~t of prolmrty ,~mt Im drmm ~l the divan ~idl is ~rt of
this a[~)l icati~.
c. 'lhe ~rk c~r~l by this a~licaticm v~y ~x)t I~ c(m~e~l t~fore ismm~-e of ~dldis~ Pemit.
d. II[~ a~al of this alqflicaticm, Ihe I~lilding lnal~ctor will isstm a lkdlding Pe~it to the applicant. ~ch
Iminlit droll Im kept ~ tI~ pr~ni~s available for insl~cti~*
e. ~) Indhli~ Mtall I~ ~q~i~l or u~l in ~}le or
{~mq~m~:y Mmll have I~n grant~l I~ lira I~lihliu8 lns~:lor.
Al~.l(~'l'l~ 18 IEI]~ ~E to tie Ikdlding l~lmrt]mnt for the is~m~:e of a l~dhling l'emit p~vmmnt to Ihe
I~dhlii~ 7xn~ Onli{m~e of tim Tam of ~adl~hl, ~lffolk (knmty, ~ Yod% aim outer applicable l~s, Onli~n~es or
I~gulatiam, for tim ~}stn~ti~ of Ixdhli,~s, ~liti{nm or ah:erations, or for ~al or {~lition, as I~rei.
~scril~l. 'lira applican~ ~r~s to ca,ply with all al~dlc~d}le I~s, ordi{~i~es, Indhling c~, I~}si~ c¢~le, a{~l
(siglmlu~e of applicant, or m~, if a corl~)rati~O
(Fk~i I lng ~klress of alii leant)
State xdmther al~flicant ia {~er, le.qsee, agent, archi tel:t, english, r, gestural contraclor, elecLrlelan, ph~Imr or Istihler.
......... ~¢.~¢.~e. .... C~.~.~.t~e.c ..........................................................................
...... .....
...................................................................
(as a~ Ila tax ~oll or latest
If alq)l icm~~, sigTmtut~ of duly mlll~}rlz~l officer.
(~a,e a,~l title ot corl~rale officer)
Iluilders l.icense Il) ..........................
Phsd~era l.icense No ..........................
Electricians License ~.
Oiler 'IY~'s l.icen~ ~) .....................
~fl~livisi~t .......... ~ffff ....................... Fil~l t~q, NO ...... ~/~ ..... l~t ...... ~/¢. ....
',. Eu' i,,~,l,nl (),,1: ...... '. ~ ~.~_:~ ........ fee ..............................................
5. 1[ I~ellinli, ~ler of ~llhyl i,dls ............ Ii,lief of ~llinB unils t~ e~ch [h~r ................
1. IH,,~,,,,i,~,. Of exi~l in~ fltll[:tLIl,~,, if miX: I'1(,11 ...... ~ ...... ]~a[ .... ~ ........ I~pth ...~.~ ..........
Ik~i~lc ......................... ~,ll~e[ Of SIo~'ie9 ....... ~ .............
/
,,. ,.,~,,~ ,,,,:, ,.,.,, ....... ~/.. ........ ,~,,, ....... ~Z~ ........ ,~,,,,, ....... .~z~ ........
I]. l~e, prOl~l (:~wmlil~:li(~l violllle any ~(~lillB h~. f, dh~3~:e or tel~uhllJ(~l: ....... ~ .............
15. 1~ Ihis llml~rl~ ~i~hi~ ?Il [~1: ~[ ~ ti~l~l ~l:lm~l'l ~ ~IL~ .......... ~) ,~ ......
,ppli(:~th,q Ilml: ,11 ~lal~r~_l~l, ~:onlail~d in Ihi~ ~p[H.ic,tlun ,~e I~a Io Ihe be,l: or
thai the ~)rk ~il I 1~ i~rl:olmed in l Il(! II[l[.~! t~el: Iollh in the ,ppi Jc,l:ion f'| led Iler[~Jtll.