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Home My WebLink About7252-z FOEM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE P~EMIS~S UNTIL FULL COMPLETION OF THE WORK AUTHORIZED~ Permission is hereby granted to._o_o~ -~ . ~ // ot premises located ~t/~..../~~.~.}~,.., ............ ~.~ .......... ~Z~...~.(.~......~~: ...... ~~...~.Z ................................. pursuant to ~pplic~tion d~ted .... ; ........ ~ .......... ?.., ]9. , ~nd opproved by the Building Inspector. FOI~M NO. 1 TOWN OF $OUTHOLD BUILDING DEPARTMEN~ TOWN CLERK'S OFFICE! SOUTHOLD, N. Y. Examined .... 7... ¢~.~--,~7...../....~.....,- 19. ~proved ................ f~...~.........~ ...... , 19 ........ Permit No. . Disapproved a/c ........................... ~ ............... ~ ......................................... ... Application No.../~O~.'~ ........ APPLICATION FOR BUILDING ~ERMIT .......... ....................... , .... INSTRUCTIONS o. This application mus~ be completely filled in by typewriter or in i~qk and submitted in triplicate to the Building Inspector, with 3 sets o~ pla,ns, accurate plot plan to scale. Fee according t~o schedule. b. Plot plan' sh~wing lo,arian 0flat and of buildings on premises, relatiCnship to adioining premises or public streets or areas, and giving a detailed description of layout ofproperty must be drawn ~n 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 aT this opplic~ation, the Building Inspector will issue b Building Permit to the Qpp[icant. Such permit shall be kept on the premises available for inspection throughout the worlF. 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 code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessaw in~spections. !SignatuCe 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. Nome of owner of premises ....................... ; .......................................................................... 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 ............................................... Location of land on whic,b prop, ose/cL~w/o~rk~wilJ,~be done. Mop No.: ~'~.~..~'~Lot,~No..w/~../.., .......... Street and Number ~&'~....cx~.¢,~..~.~...' ............................... ~, ...................................... .~.¢~.~ ......... ~ / ~",~ ~ , Municipality State existing use and occupancy of premises and in~ended use and, occupancy of proposed construction: a. Exisiting use and occupancy ..~,~.~..~gL..~,~......, ...... 'I'~ ....................................... b. Intended use andoccupancy ...... ~.: .................. '~. ..................... ¢......i .......... ~~....~ .................. 3. Nature of work (check which applicable): New Building .................. Addition ............... :.~Alterotion .................. Repair .................. Removal .................. 'Demolition .................... Other Work ............. (Descrip~''{~,., ........ '"" s,,mat,d Cost ..................... ................... 0 0 (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 Stpries ...: ............................ 8. Dimensions of entire new construction: Front .................................... Rear ............................ Depth ........................ Height .................... Number of Stories ...................................................................................................................... 9. Size of lot: Front ........... l.~..(g.. .................................... Rear ........... j.~..~. ....................... Depth ...... ~....~...~. ............... 10. Date of Purchase ........................................................ Name of Former Owner ........................................................ 1 1. 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' . ........................... ~ill excess fill be removed from pre,rgis~ ( ) Yes ( ) No 14. Name of Owner of premises~/~.'~~ ............ Address,~p,71~...~...-~.. Phone No ....................... 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 property lines. Give street and block number or description according to deed, and show street names and indicate whether i,nterior or corner lot. STA'FE OF NEW//YO~-~,, j~ [~¢ COUNTY 0~:.: ......... ~'~ ............................. ~..; ................................................................. being duly sworn, deposes and says that he is the applicant (Name of individual signing contracf) o'bove 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 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 perfbi'/hed in the manner set forth in the application filed therewith. Sworn to befozr?,~me this ............ of ........ Not a ry P u b I i c ~.~'~..' ./~..~, .~.-~ou nty ~~~t )'~')~' -'~'~' .............. JUDITH T. BoKEN Notary Publlc, State of New york No. 52.0344968 Suf[oJk Coun~ Commission Expires Mamh 30., 19~