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HomeMy WebLinkAbout4021-zExamined .... r~ 19. I, ~ 19...!~.. Permit No. ~'~ I~ ~- J Approved ........................................ , ............................ 'TOWN OF SOUTHOLD , BUILDING DEPARTMENT ~/ TOWN CLERK'S OFFICE SOUTHOLD, N.Y. ~ / App,ca,an ...... "3 Disapproved a/c ..................................................................... (Building InspectcJf) APPLICATION FOR BUILDING PERMIT Date ..~.....k~.. C~ ~ ............... , 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 a detailed description of layout of property must 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 Perm t pursuant to the Building Zone O. rdinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, f<~the Construction of buildings, additions or alterations, or for removal or demolition, as herein descr bed. The apj~ffc6nt agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations. ( gnatu · of applicant, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engi.neer, general contractor, electrician, plumber or builder. Name of owner of 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 ...~..~.~...~--~0.~.....~. ....... ~..~. .............~.-. ..................... Municipality 2. State existing use and occupancy of premises and intended ~e and.occupancy of proposed construction: a. Existing use and occupancy ................................................................................................................................... ntended use and occupancy ~ .~ ~ 3. Nature of work (check which applicable): New Building .....~....~....~..... Addition ..................Alteration .................. Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................ 4. Estimated Cost /.~..,~ ~ ~ Fee / ~. ~ , (to be paid on filing this application) 5. If dwelling, number of dwelling units ..... ~ ...... Number of dwelling units on each floor ............................ If garage, 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 ........................ 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 ....~..4...-....0. ....... Height .................... Number of Stories ......... ~ .............. 9. Size of lot: Front ...1.~....~.... ...... Rear ....L.~........~:.. ............. Deplh .J./...~.'..~/..././..~...' ~ ....................... 10. Date of Purchase .................. /..~...&....~'.. N,aj~e of~ormer Owner Zone or use d str ct n wh ch rem se are u ,- , ........ -' '"-'"'"t'l'"~ .................................. 11. ' ' ' ' p ' s s't ated ....... ~L...JI.~ .......................................................................... 12. Does proposed construction violate~, O~.~ /. j^ ~ ~, _~__.,aM zoning law ordinance or__regulation? ...... .~......O. ............................................. 13. Name of Owner of premises ./.tQ.l[l'.l.~J..l/~.~...~w~ddress ..~..~. .................. Phone No ..................... Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor ........ ..~..~ .................... Address ............................................ Phone No ..................... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEV~C,~_ORJ~,. above named He is the (Cont~ctor, agent, co~orate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to ~ke and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to b~re me this ................... (Si~noturo o{ opplic~nt) NOTARY PUBLIC, State of New York No. 52-3233120 Suffolk Coun~ Term Ex~ires ~rc~ 30, 1~ FOI1.M NO, 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) NV 1021 Z Permission is hereby granted t~ ,~ ~,~ ~,' [ / d, ~ ....... ~;.~....~.:.f.~.~l..4......W...~~ ....... ~..u ......... ~;...~ ....................... ,o .... ,...~,~.L....~,~ ........ ~.'.'.'.'.'~....~..~ .... Building Inspector. 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