HomeMy WebLinkAboutLeeds, Bill TOWN CLERK
REGISTRAR OF'vITAL STATISTICS
~/~AGE OFFICER
RECORDS ~{u~NAG]E~ITT OFFiGER
FREEDOM OF II, FORMATION O~'~'iGER
Town Hall, 53095 Main Road
P.O. Box 11'/9
Southold, N~v York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
southoldtown.no thfork.net
OFFICE OF ~ TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential ~ $10 ~/ or Non-Residential~$2~
Permit No,.
ApPlicant N~me
Applicant Mailing Address
PECONIC CESSPOOL
P. o. BOX .._487
LAUREL, NEW YORK 11948_ _
S~tic T~r;: ~ ,or Cesspool
BricfD~s~,~tion ,~/~/p/osext Const!%iction or Alteration.
~fi~°ner:fP;°roP~r~:C°nstru~°?~terati°n~/]? Owner Mailing Address:
Tax Map No: Section ']/4 Block / Lot
Cross Street
NOTE: LOCATION MAP MUST BE SUBMITTED ~P~. NEW
CONSTRUCTION REQUIRES SURVEY WI~ APPROVAL
Signature of^ppli ant. Date
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
FOUNDATION 1ST
FOUNDATION 2ND
FRAMING / STRAFPlNG
FIREPLACE & CHIMNEY
m,J ~s~'t,~'r oom'muo't~ [
[ ] ROUGH PLBG.
[ ] INSULATION
[ ] FINAL
[ ] FIRE SAFETY INSPECTION
] RRE RESISTANT PENETRATION
REMARKS:
INSPECTOR
DATE