HomeMy WebLinkAbout3777-z FOI~I NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
fi.HIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 3777 Z
Permission is hereby granted to:
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to ~.X~ ~ ~,~:t.t.~. ~. ~ ~.,.t.~ ~. ................... - .........
at premises located at .................. ~ ................................................... :. ...............................................
............... .~..~'l,.~..~m~ ....... ..r.~.~..,.x.~.....~.:~.,. ................................. i ...................
pursuan¢ to application dOted .......................... ~..,,..~ ..............., 19;..~., and approved by the
Building Inspector.
B uC~ild~n~g I :nspector
FO~M NO. 1
Examined .....~ .................................. , 19 ........
'i~OWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Approved ........................................ , 19 ........ Permit No ........
Disapproved a/c ............... ~'~L ~ ..................................
'" (Building' Inspecto/) .................................
Application No .............................
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 Per,it pursuant to the
Building Zone Ordinance of the Town of Southoid, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, building code and regulations.
A. O'olm Oad~ ~eneral Co~t3mc~, Inc.
(Signature of applicant, or name, if a corporation)
Dra~ B
~Xehers Zel~,, ~e~ ~o.,"k 06390
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engi.neer, general contractor, electrician, plumber or builder·
~eneral
Name of owner of premises ................................................... ..~..a/..l~..~.~t..~....~...,...~..~..~....~ ..........................................................
If o~ont ~c~orate, signoture~ of~ authorized officer.
y(Nome and titJe of corpo/~te officer)
Municipality
9. State existing use end occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy J[~l~&~l~
b. Intended use and occupancy ~8~e~c~e ~'~ ~,0~/~ ~ ·
3. Nature of work (check which applicable): New Building .................. Addition ...,ill ........... Alteration
Repair .................. Removal .................. Demolitian .................. Other Work (Describe) ........................................
0 '
(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 ...........~. ................................................................................................................... i ...........
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ............................
7. Dimensions of existing structures, if any: Front ...JJ.l~.t..~ ............. Rear ..... ~0...~ ................. Depth ....................
Height ........................ Number of Stories ............~,. ...................................................................................... i ...........
Dimensions of same structure with alterations or additions: Front ........ SO.i.~ ................ Rear ....... ~O..J ...........
Depth ......~.JJ.I. .................... Height ............................ Number of Stories ......... ~ .....................
8. Dimensions of entire new construction: Front ............... ~JJ ................ Rear ...... J~J ................. Depth .~.~...~ .................
Height .................... Number of Stories ...... ,J, .............................................................................................................
9. Size of lot: Front ...~.~:~.? ................ Rear ........... .~.~.~.~ ................ Depth
10. Date of Purchase ..~...i~l~l~..~...].J.,....~J~. ................ Name of Former Owner .~.~....~...~...~..~.....~..~.....~....~....~..~. ................
1 1. Zone or use district in which premises are situated ................................ I~..~1~ ................................... ! ...........
12. Does proposed construction violate any zoning law, ordinance or regulation? ............ JJ~ ..........................................
13. Name of Owner of premises I~...j~.j~.~...~l.J~.iR~ .........Address~..l~l..~...~.~.~.~.~.~..~.~..?.. Phone No..~.?...t~....~..~...~.~..
Name of Architect ......... .~.~ ................................... Address ............................................ Phone No ......... ! ...........
Name of Contractor &.,...~..~....~...~. ,.~....~.~.....~....~...~...~ddress .~..~..~..J~....J'.~..~..~..~...~..~.~.l~.?..~..*Phone No. ~.l~J~.?.2]l.
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 i.nterior or corner lot.
STATE OF NEW ¥~)1~,
COUNTY OF~.: ...............
................ ~~..~' ....: ..................................... being duly sworn deposes and says that he is the applicant
-(Narh'e of individual ~igning application) ~//, . .
above named He s the ~ .............
(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 ond 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.
Swam to b~fore me this
....... .......... .................
Notary PubJict~.../,.l~~/~:i;i:.,¥.' .............. C::: '~ ........... ~(~['g"n'~¥'L~i~';"(~'f'"(~'J~'~ii~'~ .....................
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