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Home My WebLink About8621-z FORM ]NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE P~REMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 8621 Z Date ~'l~e 3 76 Permission is hereby granted to: ~,~.Lqg~,~.J...~.e..k~c.,~ ................................................ ........................ .c.:.~,~.%,q.h..o..~.~.e. .................................. ......... ~.~.e.,.g,., ........................................................................................................................................... at premises located at ~D.~..,~...1.Q.....~].QZ'.t. hW. QD,~.S ............................................................................ ...... [.....'..~.~ ...................................................................................... ~,~ne pursuant to application dated ............................. .~.~.~7.fl.....3 .......... , 19.~.~.i., and approved by the Building Inspector. ~' Fee ~'. ~..'.'[!.0. ............. TOWN OF $OUTHOLD Tow. CLERk'S OmC~ ~ SOUTHOLD, N. [...,.od ........... ,,).,.. / ............. ........................... ......... "'7'" (Buildin~ I n~octor) INSTRUCTIONS a. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate to the BuildingS'... Inspector, with 3 set~ of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets oF 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 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 Tov<n 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 i~ buildings for necessary inspections. ....... ............ ~(Signature of ap~Ticant, or nome, 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 ........ (~-~4~......~.~....,~.4~....~ .......................................................... If applicant is a corporate, signature of duly authorized officer. -, (Name and title of corporate officer) ..,der's,,cense No ........... Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............................................... 1. Location of land on which propg_sed work will be done. ~op. No.: ............ ~.~ ...................... .~ot No. ..~. ........... Street and Number .~.~...-~.~...~.r,~,7~,~*,~/......~.~.~ ........ ~' Munici~ality-- 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a.b. Exisitinglntended USeuse andand ~Yy 3. Nature of work (check which applicaNe): New Building.. ................. Addition ........ ~,~... Alteration ............... Repair .................. Removal .................. Demolitior ..................... Other Work ..... ~.L..). ...................... v (Defcription) 4. Estimated Cost ............................................................ Fee / ~'' ¢g~ (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 oars ............................................................................................................................................. 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 some 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 .................................................................................................................... 9. Size of lot: Front ........................................................ Rear .......................................... Depth ................................ 10. Dote of Purchase ........................................................Nome of Former Owner ........................................................ 1 1. Zone or use district in which premises ore situated ..................................................................................................... ]2. Does proposed construction violate any zoning Iow, ordinance or regulation: ........................................................ 13. Will lot be regroded. .......... ~ .............WilAexcess fill be removed from premises: ( ) Yes ( ) No , ,omo of Owner of premises ~.~..~....~....c..~..~.~....... Address"" [.I ,* ~/)-- ................................ Phone No ....................... 14. Namb aY-I/Architect .......... ~ ................................................. Address ................................ Phone No ....................... Nome 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 interior or corner lot. STATE OF NEW YO~I(,//,. ~ ,/ tS S COUNW OF ' ................................................................................................ being duly swam, deposes and says that he is the applicam (Name of individual signing contract) 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 file this application; that all statements contained in this app]icotion are true to the best of his knowledge and belief; and thor the work will be performed in the manner set fo~h in the application filed therewith. Sworn to ~e me this ........ .., ........ N ota,'y Pub l,~ ~C~~..~ ~ .~~.. ~.....~~ ................. ~ ~" (Signature of applicant) Comn~ssl0n Exp:res ~arch 30,