HomeMy WebLinkAboutBrunet, Beverly
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INSPECTION
[ ] FOUNDATION 1 ST [] ROUGH PLBG.
[ ] FOUNDATION 2ND [] INSULATION
[ ] FRAMING I STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS:
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DATE 1/'?f ~06
INSPECTOR
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ELIZABEtH A. NEVIr,+E
TOWN CLERK. .
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Teffiphone(631) 765-1800
southoldtown.northfork,net
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD W ASTEW ATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential@$IOL or Non-Residential@$25_
Application No.~
Permit No.
Applicant Name Df \1!C. ..\~ \2)'\1.) ~.-t
Applicant Mailing Address \ 1,L-\ lYIo.rce\ \ ~ ~'" ~d
Nt {Ie 0\0 N~ \ \5D \ ''\"' .Q..q \ 3>
Septic Tank_or Cesspool v
Brief Description of Proposed Construction or Alteration
A.n.A'\("\0> 0\.)('('+\O\..D faU \
Location of Proposed Construction/Alteration:
Owner of Property: 'OC\1Q.(\'j ~(UrQ..-t
Owner Mailing Address: \ ~l.\ Il'({(Cl p \ \,...S ADGd
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fV:IN-'t,\O l\JI...j \ \c:.r, I
Owner Property Address: C~O \.lO!\:<rt<"f'l ?-0 .
C, )\( n(~0JL ~ 'C-I~
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Name and phone number of contact person '1.3"-1 -, -
Tax Map No: Section If J.3gz{9 Block) 0"1 Lot J 2-9 ..,
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITIED WITH APPLICATION. NEW
CONSTRUCTION REQUIRES SUR,,!: ~ ~ DEPARTMENT APPROVAL
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../~ Signature of Applicant Date
Received by:~ C ~ :>
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MAP OF LAND
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Scale : 50'~-I"
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\HWfMOIIDD A&.TflATION at A.ODmON
to '*' SUlYIY IS A VIOlATtON Of
SIChON 7209 OF ntl NEW YOlK STAll
IlUCArioN LAW.
CONS Of rHlS SUlVlY MAP NOT IEAIIHCJ
fMI LAte SUIlVFtOI'S INKED stAL OR .
IMIOSSIDSlALSHAUHOTllcoNslOlRB) G~va~+eed \"..;J ,""e Tl"+)e
YO.. VALlO JlUE COPY. . ,Gwa YO ....,4 #.0: C.;>tl-' 'PQ)o'l"'i .,;;1<1;10
GiUMANtBS NMCATED HEREON SHAU lUH SL4VyeL.jC:o OC+"::'~:>'~'t' ,I. ,9-r3~
-.1O..._roaWHOMlHESUIlVlY,..... _', "... p_
II........ ANDOHMlS IEHALF TO fHE ~ooeR'1......'" vA......_ I W'i"'L, .\.......
..... COMPANY. ,,,,.........,'" 'G<NCY _ r:;:> .../ ..-r-~
UteaCi INSftJUlJON U$TED HWON, AND I.c...' of V ~ I ~
10 _ AmGMIS OfJME UNOMi IHSI" -.'
........ GiUMAN1US AlII NOT TlAHSFUAIU. Llc.e....,s.eol 1-~~f::t St.-\ V.:.~j.!".!"'$
10 'WT} 1 N1m.lDON$ 01 SUI$tQlJEHI' GY'ee...t.po'Y"t. New .":>y~
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