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HomeMy WebLinkAbout6777-zApproved ........................................ , TOWN OP SOUT,OLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE ~UTHOLD, N. Y. ...................... .............................. ._ APPLICATION FOR B~I~DING PERMIT/,~. r3'~/Y~i-I ~ ....... ........... , I NSTRU~IONS ~ a. This application must be completely fill~ in by ~pewriter o~ in ink and s~mitted in triplicate to the Buildin~ Inspector, with 3 ~ts of plans, accurate plot plan to ~ole. Fee according to sch~ule. ~ b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets o~ areas, and giving o detailed description of layout ofproper~ must be drown on the diagram which is po~ 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, ~e Building Inspector will issue a Building Permit to the applicant. Such permit ~ shall be kept on the premises available for inspection throughout the work. ~ e. No building shall be ~cupied or used in whole or in po rt for any purpose whatever until o Ce~ificote of Occupancy shall hove ~een granted by the Building Inspector. .APPLICATION IS HEREBY MADE to the Building Deportment for the issuance of o Building Permit pursuant to the _,ilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or .(egulations, for the constr~ction 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, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. ......... ...... ...................... (Signature of applicant, or name, if a corporation) (Addres~ of applicant)' '~ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. If applicant is o corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ..................................................... Electricians License No ........ iZ...L..:. ......................... 1. Location of land on which Rr,opo_s~ed w~ork will be done. Mop Nd.:,.J.~.~0~P~...~Lot No..,~.~.....~.. ........ Street ~d Number ........ ........ ...................................... ~;;Z.:~~~ .......... ' Municipa-1~ty 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: 3. Nature of work (check which applicable): ... Addition .................. Alteration .................. Repair .................. Removal .................. Demolition .................... Other Work .................................................... (Description) 4. Estimated Cost ........ ~.....I..~.?. ................................... Fee .......................................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ............................ Number of dwelling units on each floor ........................... f. rs ............................................................................................................................................. 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ............................ 7. Dimensions of existing,structures, if any: Front ........j~. ................. Rear ................................ Depth .................... He ght ~.: ~ Nbmber of Stor es ].'..9~... ..................................................................... Dimensions of ~me ~tFucture with alterations or additions: Front .......... r-~.~ Rear ............................ ~ Depth .~,:.~....~....,~...~.~ ....... Height ............................ Nu~mber of Stories ................................ 8. ~i~.t~sj~ns, g}~e~tj~e,~w construction: Front ..... ,...~..~...~.... ................ Rear ............................ Depth ....... .'Z.. ............. Heigl~t .. -- ;..',~¥~,'.~,t~.:: Number-" "~ of St~r,e~ ............ ~ ....................................................................................................... 9. Size of lot: Front i: ........... t..8...~.....~...Lo.....~~. ................ Rear ......................... ; ......... .,~..~De~th 10. Date of Purchase .......................... !.~.,~ ................... Name of Former Owner ....... r~,.~.~.....~..~,~.~.~_..:..~_.._) .......... 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ............ ..~ ................................. 13. Will lot be regraded ..........~..~: ........ V~II excess fill be removed fr~om premises: (,) Yes ( ~4. Name of Owner of prem ses .~....~.B J ...~-~. ............... Ad~lress~..~..~..... Phone No. Name of Architect .......... : ........ ~ .......................................... Address ................................ Phone No ....................... Name of Contractor ............................................................ Address ................................ Phone No ....................... PLOT DIAGEAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all s~t-back dj.me~ions from property lines. Give street and block number or description according to deed, and show stFeet nan3eS and indicate whether interior or corner lot. STATE OF NEV~h~J~/~ COUNTY OF~ ....... ~' "~ ............................. /~. ................................................................ ' being duly swor~ deposes and soys that he is the appHcam (Name of individual signing controct~ above named. He is 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 and fi~e this application; that all statements contained in this application are true to the best of his knowledge and belief; and ~r the work will be performed in the manner set fo~h in the application filed therewith. Sworn to be~me~ this ]~1~ ~ ~KEN FOI~M NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENTi TOWN CLERK'S OFFICE' SOUTHOLD, N~. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISE~S UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N-° 6777 Z Date ............. Permission is hereby granted to: pursuant to applif:ation dated .......................... J~1~.....~ .......... ~,..., ~al~er'-&..B~rbra...6c, ek .................................. ......... ~,~:.~o~ .......................... i ................. to.. bu~l..:L~t...aec., ee ce ~.~o.~...s te~g~..bl~t~ .................... , ......................................................... at premises located at % ....... ~Qt,, ~;[ ...... ~O~.,J~O~'. ....... ~ ........................................................ .................................... ~:~/$,..,.~.~.. ~. ........ ~....tt ~ ...... ....................................... 1_9...~.~., and opproved by the Building Inspector. FORM 1~O. 1 TOWN OF SOUTHOLD ~ BUILDING DEPARTMENT~ TOWN CLERK'S OFFICE~ SOUTHOLD, N. Y. Exam,ned ....... ....... 19...Z2 Approved r I '~ , 19...r..~ Permit No. APPLI~ ' Dote INSTRUCTIONS a. This application must be completely filled in by typewriter o~ in i~k and submitted in triplicate to the Building Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according t~ schedule. b. Plot plan showing location of lot and of buildings on premises, relatidnship to adjoining premises or public streets o~ areas, and giving a detailed description of layout ofproperty must be drawn 6n 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 wor~. 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 ~ssuance 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 (or removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, buildipg code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. (Signature of opp~icont~ o~nome, if a corporotion) State whether applicant is owner, lessee, agent, architect, engineer, genergl contractor, electrician, plumber or builder. ................................. ........................... , ....................................... Name of owner of premises...~) · .~.~..~..': ......~..... t~..~O~.~q,. ~'..-~ ....i .~.. ~.~.'.~ .............. iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ..................................................... Plumber's License No ................................................. Electrician's License No ............................................. Other Trode's License No. ~' , ...~,~%.~.~.~.~.? Location of land on whicb,aroDosed work will be done. Map No.:~ ~)~;~'~X~.. . Lot ,N,o ...... :~..:~.~ ........ f~,~.__ ~ Street and Number ....... ................................................... ~wunicipality State existing use and occupancy of promises and intended use anc( occupancy of proposed construction: ' ............ a. Exisiting use and occupancy ..... ,~.',..~2~q~..~...,.;.~. ......................... b. Intended use and occupancy ........ ~.'~....-~:..?..~. ..................... i ..... :~..~.: ..........~ ................... 3. Nature of work (check which applicable): New Buildir~g .'~.... ............ Addition .................. Alteration ............ Repair .................. Removal .................. Demolition .................... Other Work .................................................... (Description 4. Estimated Cost ~.,.,.[.'.~...,(r:',~ ........................................... 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 ......... I .......... Height ........................ Number of Stories ........... ~..,"A~ .............................................................................. ~ ............. Dimensions of same structure with alterations or additions: Front ......... ,m~.~...c~. ,.~:~..:...~. I~e,~r .~. ........................ Depth ................................ Height ............................ Number of Stories ................................ 8. Dimensions of entire new construction: Front .......... ..........................~<~ r Rear ............................ Depth ..... ~.. Height ,.,,~../..~.,.r.r...- Number ;of Stories ........ ~......! ................................................................................................... 9. Size of lot: Front ........ I.Q.~.. ....... ~ ........... [~..?. .......... Rear ......................................... Depth .............................. / 10. Date of Purchase .............. ~..4,~. ................................ Name of Former Owner ...... I..~.,?...~..~.~. ...... .~-.).X..<~! ~...~-~..... 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violat[J~6ny zoning law, ordinance or regulation: .......... .~.~...~. ...................... / ........ :. ~'~ . . . /,~ 13. W~II lot be regraded ............ :.~ ............. Will excess fdl be removed fr0,m premises. (~) Yes ( 14. Name of Owner of premises ...... i..~.~....~M~../4.~ Add resso~ .~,~..~'~ ~o, Phone No..~. ,~.'] :!..~. ,~..¢ Name of A~chitect .............................................................. 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 dimens ms frorn property lines. Give street and block.,~umber or description .accordi~g~to~deedz-and-cJ~ow-street names ant indicate whether interior or corner lot. STATE OF NE~_5¥Q'I~'I~, ''/ ~-S S COUNTY OF ......... '~ ...................... ~ ' ................................................................................................. being duly sworn, deposes and says that he is the ~pplicam (Name of individual signing contract) above named. ,z , He is 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 and file this application; that all statements contained in this application are true to the best of his knowledge and b~ lief; and tha~ the work will be performed_ in the manner set forth in the application filed therewith. Sworn to befogs'me this .... , , , >