HomeMy WebLinkAbout3454-zTOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
$OUTHOLD, N. Y.
(TH!S PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMP[ETlON OF THE WORK AUTHORIZED)
N?' 3i5 z
Permission is hereby granted to:'
to
et premises lOCated ot ..~.~,..,.~L~t~..~t~ ............................................. {~ ..............................................
pursuan~ to application date~d ..............~ .............. ~-~.....~.~ ....... , qg~.,., and apprOVed by ~the
Building Inspector., c . : ,,, .
Fee $,0,2'4'.0 ........... ~.
......... ~;....C '2 ...;..L., , ....; ....................
Building Inspector . ~ .
NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Approved ~ 'k 19 ........ Permit No......'Cz. ..........................
Disapproved a/c~......~.~ ...........
Applicat,on No..?.~.~( ...........
(Building Inspector)
APPLICATION FOR ~ PERMIT
.................. ................ .....
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 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 demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, building code and regulations.
(Signature of applicant, or name, Jfa corporation)
(Address ~f applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
..... .................................................................................................................
Name of owner of premises .............. , ................... ~....r. ....... ~ ....................................................................................................
ff applicant is,a/~orpor~,e, signature of-duly authorized officer.
.................................... L* ** ', ........................ **"*~ ....................
e e M ' '~
1. Location of land on which proposed work will b don. ap No: ........... ~: .......; ........ :. ....... Lot No: ~ ..........
Stre~ and Number .~.~.....~.~......~...~~..~ ....................................................
Municipality
2. State existing use and occupancy of premises, and intended use and occupancy of proposed construction:
a. Ex~Stmg use and occupancy ................................ r .............. ~ ................... ~ ............... z .........................................
b lntendeduseandoccupancy ~~ ~~ ~.~~
3. Nature of work (check which applicable): ~g .~.)../.F../~...... Addition .................. Alteration ..................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ......................................
4. Estimated Cost ............................................................ Fee ....L.O....~...~.~..~ ........................................................
(to be p/~id on filing this application)
5. If dwelling, number of dwelling units ...... Z~...O. ............ 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 ~pe 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 .............................. Nu~er of Stories ........................................
8. Dimensions or entire new construction: Front ............ ~.~..((~.;~. ~e~r ......... .~......~.~¢ Depth ........ /¢ ................
Height ....... ~.~Z .............. ~es ....~.¢~..~
9. Size of lot: Front ............................ Rear ............................ Depth ................................
10. Dote of Purchase ........................................................ Name of Former ~ner ........................................................
11. Zone or use district in which premises are situated .................................................................................................
12. Does proposed construction violate any zoning law, ordinance/or regulation.:) ......................................................
13. Name of ~ner of premises/~...~..., ....... :¢....(.....¢..Address~' ~ ....... F ................
' -- . ........ ' hone No.....................~C ~z / ~ ~t~ ~17~
Name of Architect ...................................................... Address ............................. Phone No .....................
Name of ~o~,4':c,o,.,..__~..~.L ...... Address ................. ~Phone No ....................
.LOT
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from
property lines. Give street and block numbers or description according to deed, and show street names and indicate
whether interior or corner Jot.
STATE OF NEW~ yQ_RK_,
COUNTY OF .~.~(.%..U..r..f.'.)..~ ......... / S.S.
'JI-k-~/~j2v ~'~(C-~/~/ .ben du sworn, de osesondso sthat he stheo cant
-. ............................... g Y P Y PP
(N(]me of individual signing app_.p~at~on)
above named. He is the ...~..~)..~'.~..%~i¢.~.(.-'.(..lJ ....... ' ......................................................................................................................
~ (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 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 before me this j //
........ ~...~. ............ day of ....~..~..k...l .......................... ,
Notary ubl,c,. ........................................................... Count,: ...................... ...... ": ...... i ........