HomeMy WebLinkAbout2347-zFOEM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S oFFICE
· ' SOUTHOLD, N. Y.
Disapp roved aV/c ..... ...~....~....~.. X~......~... }~ (.{.....~ ~.~...~.....~:...<~..
APPLICATION FOR BUILDING PERMIT
Application No,?...?....~....7. .............
Date .... :./. ...................................... ,19 ....
INSTRUCTIONS
o. This application must be completely filled in by, typewriter or in ink and submitted in duplicate to the Building
Inspector.
b, Plot plan shpwing location of lot and of buildings on premises, relationship to adjoining premises or public streets or
areas, and giving a detailed description of layout of propertymust be drawn on the diagram which is part 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 part 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~,e~molition, as herein described.
The applicant agrees to comply with all applicable laws, ordinonce~dbuilding code ag4rre~ulations.
........... ......................
(Address of applicant)
Stoto whethor opplicont is ownor, IOSSO0t a~ent, ~mhitect, enoinoor~ oonerol contractor~ oloctriclon, plumber or buildor.
........... ......................................................................................................................................................................
o, ....... .......................................................................................................
If applico/~t is a corporate,,,,~ature of duly authorized officer.
(Name and title of corporate officer)
1. Location of land on which proposed work will be done. Map No: . .~'..~.¢T../?...~.~ ..~.~.~:.'.~...~..,.~..,~.... Lot No: ..../'..~... ..........
Street and Number .....~..?.../~../~'.~,.~......,/,.~-~.~..~........~...¢.,¢.¢...~. ......................... L ................................. ¥. ....................................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ........... ./,/..~.//.~, .............................................................................................
b.
Intended
use and occupancy .................. ......... '7' ................ ...... '~ ..........................................................
/
3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration
Repair ................ ...~e ~m,,o~ol .................... Demolition .................... Other Work (Describe)
4. Estimated Cost .../.....~',.~.....o'2~. ...................................... Fee
(to be paid on filing this' application)
5. if dwelling, number of dwelling units ...... ~ ................. Number of dwelling units on each floor ....~"
if g,arage, number of cars ..........~'
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ...... ..~..~).,
7. Dimensions of existing structures, if any: Front ....... ..'(/('.~..~ ...... Rear ............ ~ ............. Depth '---
Height .............. "-'7. ............. Number of Stories "'
Dimensions of same structure with alterations or additions: Front ........ ~ ....................... Rear
Depth .......... '---............... .... Height .........~ ................. Number of Stories ............ ~ ...........................
8. Dimensions of entire new construction: Front .....~.~. ................ Rear ...... .~,.,,~.:...~.. ......... Depth
Height ....... ../.(.. ............... Number of Stories ...... ~.. ...................
9. Size of lot: Front ....~..~..~.../..x(.~..t'...~../'~.&r. R.,ear ............................ Depth ................................
10. Dote of Purchase .....~./~..~.~.~......~..~..,..../...~.~...~.. .......... Nome Former Owner ...6'./.~..~.~..~.f:~'.......~./..~.~...~..¢,
11. Zone or use district in which premises are situated .........
12. Does proposed construction Violate any zoning law, ordinance or regulation.;) ....... ..~..~.~.. .........
13. Name of Owner of premises ...~..¢./Z'..~.E.~...../.~.$J.~. ....... Address .../...~...~/~...~...~.~..~.¢.~..~.~..C. Phone No.
Name of Architect ..~.¢,~.¢'.~..~......~..~...Z~'..,~...~.¢..~. ............ Address ...../~..~/~../..<?'~..~.x~..~.~,~ ..... Phone No.
Nome of Contractor ....~.¢h~.~.7../)......~...~.~...~.R ................ Address ...'(.[.~.,¢~.'~'~...~...~..~?.~..~..~.C... Phone No.
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions
property lines. Give street and block numbers or description according to deed, and show street names and indi
whether interior or corner lot.
STATE OF NEW y~RI¢,, ,9 / S S
cou rr OF ' ·
~.~..~ ........ :,...~...:'.'. ........................... being duly sworn, deposes and says that he is the appli¢
(Nome of individual signing application)
above named. He is the .......... . .~.~'.~.~.~,~../.~..~.......~.....~...~'....,,~'..~.../2. ...............
(Contractor, agent, corporate officer, etc.)
of said owner or owners and is duly authorized to perform or have performed the said work and to make and f
this application; that all statements contained in this application are true t~f~'/the best of.hisxk'M'6~edge and beti~
and that the work will be performed in the manner set forth in the applifL~ion filed thery~'~itb,
Sworn to blefore me this ' '//~' --
Notary
~./...7..L.:~...~k,r.~.45..~,,~.,,c,~,.(~-~f6~:~,~.. County ~ ~ (Signature of applicant)
PuNic, ..--~r.,., . ~ :-~ ,. · ............................................................................................
~ r-2 3233~20 SUffOlX t;os;~t~v ~ *
"'~er~m' Expires March 30, 19~.~-