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Home My WebLink About6780-z l~Ol~M 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) Ne 6780 Z Date .............................. ~ ......................... , Permission is hereby granted to: ~ /~ ^z ,,~ ~IZ /~, WA /v i Building Inspector. Fee $....; ................... Build ng, nspector FOI~M NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMEN~ TOWN CLERK'S SOUTHOLD, N. Y. Examined ................................ ;,. , 19 ........ Approved ......................................... , 19 ........ Pemit No ........................... ! ......... Disapproved a/c (guildin0 Inspector) Application No ................................. APPLICATION FOR BUILDING PERMIT Date ..... ~ ..................... , .............. INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and ~ubmitted in triplicate to the Building Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, rel~tionshil~ to adjoining premises or public streets or areas, and giving a detailed description of layout of property must be drawn on diagram which is part of this application. c. The work covered by this application may not be commenced before issuance ~f Building Permit. d. Upon approval of this application, the Building Inspector will issue a Buildin~ Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the work. ' e. No building shall be occupied or used in whole or in part for any purpose wl~atever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION iS HEREBY MADE to the Building Department for the issuanc~ of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffoik County, New York, and other applicableiLaws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. ~he 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) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ..................... .~.~...~........,~..C..~~-~i' ........................................................ 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 Trade's License No ................................................... ~ ,- '~ 1. Location of land on which proposed work will be done. Map No ......... ~..~ Lot No Street and Number ................................... . .~r.,~.zf~4~'/.,f?:~........~.:-,~....i ............................ ~.~.~.~ .............. Municipality 2. State existing use and occupancy of premises and intended use and occ(~pancy of proposed construction: a. Existing use and occupancy .... ~:~!(~...~.../..~.~. ......... ' ................................... b. Intended use and occupancy ......................... .; ...... ~ ............................................................... 3. Nature of work (check which applicable): New Building ....................... Addition ..................... Alteration...,',i ......... Repair ......................... Removal ......................... Demolition ........................ Other Work ........ i' "~'~'i )n) 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 ....................... i ..................................................... Dimensions of same structure with alterations or additions: Front .......................... Rear ......................................... Depth ............................................. Height ......................................... Number of Stories ........................................ B. Dimensions of entire new construction: Front ........ ~ ...........Rear ............................ Depth ........ I...~L..'. .................. Height ............. Number of Stories ............... ~;i7~ nl~ Iht' Front ~ \ Rear ~ ~ .....~ ....................................... r3onfh ~ ~ ~.~-'7 ....................... 10. Date of Purchase ..................................... Name of Former Owner ............................................................................ 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 ................ ~..O. ........... Will excess fill be removed from premises: [ ] Yes 14. Name of Owner of premises .~,.¢~t~,...,~~.~....~.U~,,...~.,3..~...,%....,~.,.,~,,~ ...... (Address) {Phone No,) Name of Arch tect ,~ .............. (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 dimen~ ions from property lines. Give street and block number or description according to deed, and show street names and indic~ ire wheth- er interior or corner lot. STATE OF NEW YORK, ) COUNTY OF ................................................... ) SS ................ ~.~:'f~.. ....... ~/..~.....~ ................. being d~ly sworn, deposes and says that he is the applicant al: ,ye named. (Name of individual signing contrac~ He is the ....................................................................~..: ~.~ .~ .......... ~' · ( or, agent, corporateofficer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this applica statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed forth in the application filed therew;th. ~ _ . ~N0~ARY PUbLiC, Stat~ ........................ % ........... .ay o* .................... Notary .......................................................... uounty (Sig, ature of applicant) on; that all the manner NENNiNG