HomeMy WebLinkAboutMenchini, GinoREGISTRAR OF VITAL STATISTI~
MAP/UA~ oFFICF, a
]~,OOP. DS M~%.NAGEM]gt~ OFFK~,~
FP.~F, DO~& OF INFORMATION O~~FIcER
Town Hall, 53095 Main Road
P.O. Box 1],79
Southol~, New York 11971
Fax (6S1) 765-6145
Telephone (631) 765-1800
southold~wn.no~ork.net
Omit'iCE OF ~ TOWN CLEI~K
TOWN OF SOUTHOLD
$OUTHOLD WASTEWATER DISTRICT
APPLICATION
CONSTRUCTION or ALTERATION PERlVIIT
CESSPOOL or SEPTIC TANK
Residential ~ $10 or Non-Residential (~ $25 .... Application No. ~01 ~/
- - - P~mitNo..
Applic,~nt N~r,~ PECONIC CESSPOOL
Al~llcantM. i~in§Adckess P.o. ~OX ._487
LAUI~.L; NEW YORK 1194~.'
Brief D~s~.ipuon ofPropos~ ~;onstmcuon or Alteration
Owner Mailing Acldl~ss:_
Owner Property Address:
Name and phone number of contact person _
Tax iV~ No: Section ,~ ~ .. Block /~ LotI ~ r
Cross Strew_ ' W
f~ Si~. ature 0 fxi~:~cant Date
?
?
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
[ ]FOUNDATION 1ST
[ ]FOUNDATION 2ND
[ ]FRAMING / STRAPPING
[ ]FIREPLACE & CHIMNEY
[ ]RRE RESISTANT CONSTRUCTION
[ ] ROUGH PLBG.
[ ] INSULATION
[ ] FINAL
] FIRE SAFETY IILSI~CTION
[ ] FIRE RESISTANT I~.NETRATION
REMARKS:
__ INSPECTOR_~ ~~