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HomeMy WebLinkAbout5679-z ~ORM NO. ~ 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) 5679 Z Dote ........................ ~ ...... .~& ........... , 19....~ Permission is hereby granted to: to .....~1~-1~...~1~..ll~&~l& .. ~ ~e~,.).. t ..elE~ ~1~..~ll/e~ ........................................ pursuant to application dated .............................. .~l~.....:l~l~ ........... , 19...~1., and approved by the Building Inspector. Building Inspector TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined .................... Approved ........................................ , '1~ ........ Pemit No ..................................... APPLICATION FOR BUILDING PERMIT Date ........ ./. ................ . .......... I NSTRUC'TIONS 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 ofproperty 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 rathe 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 purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY/v~,DE to the Building Department for the issuance of a Building Permit pursuant to the State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises .......................................................................................................... If applicant is a corporate, signature of duly authorized officer. ~,~.~/~ ~' c~( ~,~' (Name and title of corporate officer) 1. Locat on of and on wh ch propose, d work wjJ be done Map No' .~..~..~' - ,)"~¢..Z.~. Lot No .,~m~..---~ Municipality 2. State exJstJngr use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ........... ..~.~.~.~,~J,~...~ .................................................................................. b. Intended use and occupancy ~..~...~..~..~ ....... /. ................................................................. ~ ............... 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration .................. Repair ........... ~ Removal , ................. Demoliticm ............... ,,. Other Work (Describe)~.:..~. ........ 4. ~timat~ C~~ ............................................. ~ee .;.~.~ ........................................................ .~ ...... (to be paid on filing this application) 5. If dwelling, numar of dwelling units ~.~ .......... Number of dwelling units on each flor ............. ~ .............. If gara~, number of ~ .......... ~] .................................................................................................................................. 6. If busine~, comme~ial or mix~ ~cu~ncy,_~ .~sp~i~ aoture and extent~ ~°~ach ~e of use ...... ~7"~; ...... ~ .......... 7. Di~ns,o~of ex,shngstructures, fi any: Front .'~...~.. ......... Rear ..... ~.....~. .......... Depth .~.T.~. ......... of ....... ;; ........................... ....... Height Dimensions of.sa~ structure with olteratiops or additions: Front ....~:...~ . Rear ~pth ..~...~ ........... Height ..~..7.~ .......... Number of Stories~~~ 8. Dimensio~ o[ e~jre n~ construction: Front ..... ~..~. .................. Rear ...... ~..~ ...........Depth ../~..~ ..... . . Hmght .................... Nu~er of Storms ..... ~ .......................................................................................................... 9. Size of lot: Front ...~..~.~[~ ....... Rear ....~.~.~.~..' ............. ~pth .~.~.~..~.~.. - 10. ~te of Purchase ..... ~.~.~. ................................. ~_ ~ n , ~--N°~e ~ormer~ner ......~ ................................................. !1. Zone or u~ district in which premises am situated ...~..:.....~~~ ........................................ 12. ~s proposed construction vi~e a0y zoning law, o~inance or~egulation? ...~...~ .......................................... 13. Name of ~ner of premises ....;.~~A~res* ~~...~..~ P~e NoT~..~ .... ~am~ of Archlt~t ...................................................... A~res~ ............................................ Ph~* ~o ..................... ~a~ o{ ~ntractor .~~ ....................... Addr~*~ ............................................ P~ne ~o ..................... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions fram property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or comer lot. STATE OF NEW~---Y, OP-~ , ,, t c c .......... . ...,Z~"~.,t~4~....,~L/'~'~.Z~x~'~Z~."~..~... ............. ....being duly sworn, deposes and says that he is the applicant (Name of individual signing application) above named. He is the ................................... ~-'-~.~.~m~- ............................................ ' ......................................... (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or hay. e~performed the s~id work and to make and file this application; that all statements contained in this opplicatiop~'a~6 true to the best/of his knowledge and belief; and that the work will be performed in the manner set forth in the ap~l~c'ation filed th, el~wj~h. Swam to before me this -- 2D / I / .... ....... NOTARY PUBLIC, State of New York No. 5~-St25850, Suffolk Term Expires March ~0, !