HomeMy WebLinkAbout2387-z FORM NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT'
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ONTHE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 2387 z , Date · .~,~ ~ , , 19~.~ ....
Permission is hereby granted to:'
~''---"-----~a~.~..~...~d.:,~.::,:..... ....... .~...~ ................
8 ~...:.~.~..~ ..............................
..... ~r~r..~.,,~ .........................................
to ~.~o.~t~.l...~r~.~,.. ~.a~e~.~.:~am.e~i ~.t l~g...bu&id,~..~.. ~., on~...~,~.~..d~o~.ng
· .~o.~,~.~¢~.~ ................................... Sm~ho~,...~.~r.~ ..................................................................
pursuant to application doted: .............................. ~,~.~ ....... ,~ ............. 19~;~..., and approved by the
Building Inspector
Fee $~.O~. ~.0 ............
Building Inspector
FORM NO. 1
TOWN OF SOUTHOLD
BUILDIING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined ...................... .~. .......
Approved ........................................ , 19....'....Permit No..o._.......?.. ...............
Disapproved a/c ............... ~,': ~... ...... ;.,,./.'...( ......... >~-~ ............... 'L~'-~ ' '/-''' l .... ~'~.~/
........................... '~ ; ......... (Building~';'"~Z"~ ............................................ nspector~)~
Application No..~..?...g.'....l ............
APPLICATION FOR BUILDING PERMIT
'Date /~Xc~ ~[ '~ 19.~.~.~. .....
INSTRUCTIONS
a. This application must be comPletely filled in by typewriter or in ink and submitted in duplicate to the Building
Inspector.
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or
areas, and giving o detailed description of layout of propertymust be drown on the diagram which is port of this application.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such
permit shall be kept on the premises available for inspection throughout the progress of the work.
e. No building shall be occupied or used in whole or in port for any purpose whatever until a Certificate of Occupancy
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, os herein described.
The applicant agrees to comply with all applicable laws, ordinances, building code and regulations.
(Signature of applicant, or name, if a corporation)
,
(Address bf oppli~:ant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of ~r~ ~
premises ......~..~ ............ ....~ ......................................................................................................
If applicant is a corporate, signature of duly authorized officer,
(Name and title of corporate officer)
1. Location of land on which proposed work will be done. Map No: ............................................Lot No: ....................
Street and Number ..........................................................................................
Municipality
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
o. Existing use and occuponcy .................................................................................................
b. Intended use and occupancy ...~~..~.. ....................................................................................................
10.
11.
12.
13.
Nat re of work (check which applicable): New Building .................. Addition .................. AIt~,_~,c.~¢¢~..~.
Repgir .................... Removal .................... Demolition .................... Other Work (Describe) ..................................
E/. s ~¢rL~ '
sheared Co t ..~..~.. ................................................... Fee ......................................................................................
' (to be paid on filing this application) '
If dwelling, number of dwelling units ...... I ...................... Number of dwelling units an each floor ...... l ....... i ........
If g~rage, number of cars .......................................................................................................................................
f I~usiness, commercial or mixed occupancy specify nature and extent of each type of use ................. ^ . ..
He ht .... 1 ...... la' Number of Stories 'l . . .
...... '.:., ~ ~ ;; ....................... :f',","~'"f4w .......
Dimensions of same structure w~th altcrat OhS or additions Front ,,fi ~ ~ . Rear ~.~ ..~.~ .......
Depth ...~.!....~. ................. Height ......[.~.I ................... Number of Stories ...... ] ................................. .
Dirt ensions of entire new construction: Front ............................ Rear ............................ Depth ........................
Hei. ht ............................ Number of Stories ............................
Size of lot: Front .....~....~. ............... Rear ............................ Depth ................................ r-, ~,
Dar of Purchase ....~...J ......... ~ ............................ Na~e 9fCFo~rm%Owner .................. i..l~...[~.
Zor or use district in which premises are situated.....'~.~ ................................................................... ;
Doe proposed construction violate any ~,oning law, ordinance or regulat~ion? .. .. ,~... .. P,~ .. . .b ...... ~ ............. ; .........
Nar~e of Owner of premises ~c~,:~ek ~ Address~'~' ~'-'-~' ~ ~'3~h~I~ ~'~'14~ *~%;
Nar~e of Architect ...................................................... Address ............................................ Phone No.
Nar ~e of Contractor .................................................... Address ............................................ Phone No.
L_ocat,
property Ii
whether in
PLOT DIAGRAM
clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimension:
~es. Give street and block numbers or description according to deed, and show street names
erior or corner lot,
STATE OF
COUNTY
above nar
of said ow
this applic
and that t
Sworn
Notary Pul
....... ~..~._.. ........................ being duly sworn deposes and says that he is the applic(
ame of individual signin~plication)
d. He is the ...................//~/~/-~.~ ................................................................................................ ; .........
(Contractor, agent, corporate officer, etc.)
~er or owners, and is duly authorized to perform or have performed the said work and to make and ~
~tion; that ail statements contained in this application are true to the best of his knowledge and bell
~e work will be performed in the manner set forth in the application filed therewith.
efore me this ~ /~ ~ __ ~ '
......... day of .....;~ ........... , ........ , 19....0;¢1D ,. J^OOFSK¥ ...~... ~ O~ ~ ;