HomeMy WebLinkAbout5755-z FORM NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
No. 5755 Z
Permission is hereby granted to:
BUILDING PERMIT
('THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
Dote .......................... .~...~k...~... ....... , ~9.~.....
........... J~a~eX4 .................................................
to .. ~lJ.t~,~J... ~JJl~JJ ~. ........................................................................................................................
at premises I~ated at ....~..~.~ ....... ~.~..~.~.~...~e.~. .........................................................
................................................. ~..~.....~&....J.~. ...........................................
pursuon~ to application dated ............................ ~?.~ ....... ~..~ ...... , 19~..., a~ appr~ by the
Building Inspector.
Fee $...'J...~..O0 .........
..... '1Building Inspector J
Examined
Approved ............... t..~. ...... ~.! ........... , 19.2...~T Pemit No.
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFIGE
SOUTHOLD, N. Y.
Application No ..... ~.,..~, ,,~, ,,.~,,,. .......
APPLICATION FOR BUILDING 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
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 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 cod~ regulations.
.... ........... .......
(Address of applicant) '"
Name of owner of premises ........ .~..,....C .......... G.~.~. ,l~JJ~ l llJl i~Jl,~
If applicant is a corporate, signature of duly authorized officer.
.................. .........
1. Location of land on which_ '1' .- t ~ ~ --.P~;°p°sed work will be done, Map No.:.. ............. : ......................... Lot No .........................
Street and Number .~,~g~....,..~:~.{~,~.4~. ~,~.....~'~.~L~..~/:~..~...(~..~.~.~..~. .............................................................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
D.
a. Exisiting use and occupancy ~. ....... .~ ............. LI,2...~,~...t .......................................
b. I ntended use a nd occupancy .,.~.,.a~.,.....~d-~k ....~.~. ~ .~.k.... f;~J~_.~.,. ,~T;,,~_.~ L2~ ~ ~ .~. ,~ ~,,~., ~.~,,.~, .....
3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration ..................
Repair .................. Removal .................. Demolition .................. Other Work (Describe) ....~.'.~-~.YI.~.-4~. .............
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 ........................
Height .................... Number of Stories ......................................................................................................................
'~. Size of lot: Front .../...~..~:~. ............. Rear ...... ~.~..~::?. ................... Depth ....;~..~..~......?T....~'...(..~
10. Date of Purchase ..... ,..~/~2/7...~;~ .......................... N~a_rnte' ~.Fo~_~_r_O~vner ........................................................
1 1. 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 ..~ .......... .C..~...~..~.G...~..i~Address ..~/.~..~-~-~.../~. ............... Phone No .....................
Name of Architect ...................................................... Address ............................................ Phone No .....................
Name of Contractor ...~.~,~.~v..,.....~..~....~...~ddress .......~65~.~..;...J~'D..~.~ .......... 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 comer lot.
STATE OF N l S S
COUNTY OF'~Clll~J~ ............. $ '
........... ...~.~/~1~ ...... .~[, ......... .~.~x~,~---*~..~..- ..................... being duly sworn, deposes and says that he is the applicant
(Name of individual signin~{~pplication)
above named. He is the ................................. ~d~.4~'~/~.~..4~.../~.. ..........................................................................................
(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.
.... .......of .................... ,
Notary Public ..... County,S' ~'~t~//~ (Signat~e'~>f applicant)
NOTARY PUBLIC, State of New York
No. 52-8125350, Suflo~k Cou,~
Term Expires March 30, 19