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HomeMy WebLinkAbout5027-zIPOBiE NO, I TOWN OF sOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOI.D, N. Y. Approved ........................................ , 19 ........ Permit No..... .. ...............,. - Application No. '~ ~'~ 7 Disapproved a/c ........ ~ ............................................................................. " ................................. i 'i ............................... APPLICATION FOR BUILDING FERMI'r Date ~'~ ¢ OcT 70 INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink und submitted in duplicate to the Building Inspector. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premieee or public streets or areas, and giving a detailed description of layout of property must be drawn on the diagram whlch It part of thio application. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval c~, 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 port for any purposa whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Deportment for the issuance of a Building Permit pureuont to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Lawl, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, al herein described. The applicant agrees to comply with all applicable laws ordinances, building code housing c~:le, and ragu et OhS (Signature of applicant, or nome, if a corporation) (Address of State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of ~ner of premise= ................................................................................................................................................... If applicant is a corporate, signature of duly authorized officer. ................................................................................................ ,, (Name and title 'of corporate officer) 1. Location of Io~d on which p~pased work will be do~e. ~op No.: ........................................ LOt No,: ........................ $tra~ Gnd Number ............................................................................... /. .................................................................... Muflicl~ll~ 2. State existing u, and ~cu~ncy of promises and intended use and ~cuponcy of pmpm~ co~tmctl~: a. ~isting u~ a~ ~cupancy ................................................................................................................................... b. Intend~ use and ~cuponc, . ................................................................................................................................ 3. Nature of work (check which applicable): New Building ~ ................. Addition .................. Alteration ................. Repair .................. Removal .................. Demolition .......... , ....... Other Work (Describe) ....................................... 4. Est mated 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 ......a(..(~ ........... Number of Stories ................... ~..~...'~. ................................................................................. Dimensions of same structure with alterations or additions: Front ............ .~.....O. ................ Rear ....~.....O. ................ Depth ........... ~...~.. ............ Height ........... /...~. .......... Number of Stories ..........~...~..~;.~ .......... 8. Dimensions of entire new construction: Front / 0 Rear ....... /...~ .............. Depth ........ ~ Height ........ ~ .......Number of Stories ................... ~..~...~..'~. ................................................................................ 9. Size of lot: Front-- ......... .,.~.....0. .......... Rear ........... ,~.....O.. ............... Depth ............... ./...0...~....~... 10. Date of Purchase ..............~..~..m~. ............................. Nome of Former Owner ....~.~....C...A..[.~. ......... ..(~....~....~..~. ............. 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 . .~.......~...A....T..~..~...~.. ....... Address ..,.~..!..L.../T.......L..A....).....~...LT'...C=.. Phone No..W?.~..~......~.... 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 whether interJ~ or'~emer lot. ~'o' - STATE OF N~ YORK, lee ~ COUN~ OF ................................ ~' ~ ............................ ~/~..~.../)..5.. ........... ..~...A....T....~...../~....~....~.. .......... being duly sworn, deposes and says that he is the applicant (Name of individual signing application) above named. He is the ....................... ~)....v~....~..~......~ ................................................. .-. ........................................................ (Contractor, age~t, 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. Swam to before me this ................ ,~.~.~,,.,,~, , - _ - ..daY of ................................. O...C...?..., 19.'Z....0.. .............................. ...'~;.,~:a,,~ Notary Public, ,.~/.~e.4b~~~L..t~nty (Signature of al~llcont) Ho. 5~-8125850~, Term ~xpi~res March