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Home My WebLink About4090-z FORM NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMEN~ ~ TOWN CLERK'S OFFICE: ,~ $OUTHOLD, N. Y. BUILOING PERK~IT (Tills P~:RMIT MUST gE? KFpT ON TIlE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) /~ L F~I !,iN APE: at premises located at ................................................................. ! .......................................................... / 19.{/.¢;, and approved by the pursuan,t to application dated ..................................................... ~ ...... , Building Inspector. Fee $.....~. ............. Building Inspector NO. I TOWN OF SOUTHOLD BUILDING DEPARTMENT i' TOWN CLERK'S OFFICE~ SOUTHOLD, N.Y. : Examined .............................. ~:~i:. 19 ..... ~ Approved ........................................ , 19.. mit No ............. : .............. ~. Disapproved a/c ............................................................................................ (Building ~d~tor) :: AppJ icot ion No. , ./.~',~./~.~ .)/./.,~. ;L?. ........ APPLICATION FOR BUILDING PERMIT ,ate ....................... ........... ., I NSTRUCTI ONS a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building Inspector. b. PJot ~[~n shov~ing Ioc(~tion of lot and of buiJdings on premises, reJat(0nship to adjoining premises or pubJic streets or areas, and giving a detailed description of layout of property must be drawh on the diagram which is part of this applica- tion. c. The work cove~ed 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 avadable for inspect'on throughout the progress of the work. e. No building shall be occupied or used in whoie or in part for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS H,EREBY MADE to the Building Department for the !ssuance of a Building Permit pursuant to the Bud ng Zone Ordinance of the Town of Southold Suffolk County, New Ybrk, and other applicable Laws, Ordinances or Regular ohs for the construction of buildings, additions, alterations, or fbr removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances and ~egu arians. ,. ,/,/" (Si~atuie of applicant, or name, if a~rporation) .... ...... ........ State whether applicant is owner, lessee, agent, architect, engineer, gener~al contractor, electrician, pJumber or builder. ........... ......................................................................................................................................................... If applicant is a corporate, signature of duly outhorized officer. (Name and title of corporate officer) 'l, Location of land on which proposed work will be done. Map No.: ...., ........ : .......................... Lot No.: ...................... ~treet and Number ..... ~,, .. MunicipaJi~ 2. State existing use and occupancy of premises and intended use an8 occupancy of proposed construction. a. Existino use and occuponcg ........ ~.L~.~.:~(~.~ ................ ~ ......................................................... b. intended use and occupancy ~.0.~ 3. Nature of work (check which applicable): New Building .................... Add, ition .................. Alteration .................. Repair .................. Removal .................. Demolition .................. Other Work (Describe) .................. ................ ¢~...Q.Q ................................... Fee ........................................................................................ 4. Estimated Cost (to be paid on filing this application)~ 5. f dwelling, number of dwe nfl un ts .................... Number of dwelling units on each floor .. f garage, number of cars ........ ~.:.~...[h.¢:..~. ........................................................................... 6. If business, commercial or mixed occupe'ncy, specify na,tu,,re ,and extent of each type of use ........ ...~.... ..................... 7. Dimensions of existing structures, if any: Front ....... ,~..~..9, ............ Rear ...... ..~,,~,',~,'~ .......... Depth Height ........ .(.~.~ ........... Number of Stories ..... ./'. ......................................................................................................... Dimensions of same structure with alterations or additions: Front ~' Rear ~-~ Depth ............ ..~T..: ............... Height ................ ~ ........... Number of Stones ................................ ' 0 ' ' . ...... ............ 8. Dimensions of entire new construction: Front .... ~.. ........ Rear ......... ..~.....,o. ............ Depth Height ............. .~ ............... Number of Stories ............/. ................. 9. Size of lot: Front/r~"~' '~'': '~"~"~ ....... Rear ......~.'~..:.;~.. .............. Depth ..,~../~..:.'.7...~. ......... 10. Date of Purchase ../~.~...,~..... ........ ~.~.~ ................. Na,m~ of Former Owner ............. 11. Zone or use d str cf~n v~ch prem ses are s tuated .~q~ '~..~.~.i~./. .......................................................... 12. Does proposed construct on v o ate ar),y zon ng aw, arc nance or regu at on? ...... ~.~..~ ................................................ 13. Name of Owner of prem ses ,'~. fi.J: ..~..~.b.~!.v.~.,~.~a.. Address ...... ~C~.ff..r......~..< ................ Phone No.~.~'~.'.Z..~..9.,~. Name of Architect ...~..~..¢.....~.D.~. Address ~' .................. ............................................................................. Phone No. Nome of Contractor .............~...¢.]..~! ......................... Address .................. :.~ ........................... Phone No ......(!. ......... PLOT DIAGRAM Locate clearly and distinctly ali buildings, whether existing or proposed, and indicate all set-bock dimensions from property lines. Give street and block numbers or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NE~ Y.Ol~l<,,, ~, ) S S COUNTY OF ....~... ~ ....... ) ' · ................... ~.,z.~?.....~ ............... being duly sworn, deposes and says tha~he is the applicant (Nc~he of~individual sigm~c~n) ~ above named. He ~s the .......................................................... :~..M~....~ ...... :~.~%~ ....................................... ~ntra~or, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform ~r/have performed the said work and to make and file this application; that all statements contained in this applicaEion are true to the best of his knowledge a,nd belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn t~ before me this ...(.~:~; ........da~ of ..~.~ ..................... , 19.~.~. ~/ ,, ~ · ~ ~ ~ ~ ~. m~N~ . , ~~ ....... ~.~~~ ........ Notary Public .....~~~0 .......... County// / (Signature of applico,nt) T~z ........ z ~)x~.~TM '-~ ~i~ch 30, lg ~ ~.