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Home My WebLink About8468-z FOE~: NO. ~ TOWN OF ,~0UTHOLD TOWN CLI~i~K'$ OFFicE SOUT,OLD, N~. Y. BUILDING pERMIT (THIS PERMIq' MUST BE KEPT ON TI~t.E PP, EMISES 0NTIL FULL COMPLETIoI~I O~THE WORI(AUTHORIZED) ':~ ! Pe~-missioh i~ I~rel~y gmn't~cl t~i FOBM NO. ! TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. proved .................. /. .................... , Pe,mit Nb. ...................... Disapproved alc .~...<.:~;..~.. ............ ~.~.,:~ ........ ...~.~.~,..~ ........ ::~.~.~,.?.,. ~ .......................... ::.U.:::j .............................. (Building Inspector)~ APPLICATION FOR BUILDIN6 FERMIT Date .............. ~,~ ~, ~ >~. ....... .)~ .......... ¥ INSTRUCTIONS Application No. ~'~" a. This application must be completely filled in by typewriter o~ in ink and submitted 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, relationship to adjoining premises or public streets o~ 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 Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances o~ 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 ir~ buildings for necessary inspections. (Signature of applicant, or name, if a corporation) ........... .......... ................................................. /z ,- (AddreSs o~ 6pplicant) / State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. 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 ~wi be done. Mop No.: ......... ~'../..-i)'/./~ ....... ,Lot No. '~.~ ................ 2. State ex st ng use and occupancy aT p~mises and in.ended use and occupo cy of proposed constructton: b. Intended use and occupancy .................................../~ ....... ~,.../ ........................................................... 3. Nature of work (check which applicable): New Building.. ................. Addition .................. Alteration ............... Repair .................. Removal .................. Demolitior. .................... Other Work ...,~....'2~..,.-.~ .......... ,r ................... (Descril~tion) 4. Estimated Cost ............................................................ Fee ...... /./t. ...... ~ .............................................................. (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 ...................................................................................................................... 9. Size of lot: Front ........................................................ Rear .......................................... Depth ................................ 10. Date of Purchase ........................................................ Nome of Former Owner ........................................................ 11. Zone or use district in which premises are s~tuated "~'"'"t~ -~"¢': ....................................................................... ,/~ i2. Does proposed construction violate any zoning law, ordinance or regulation: .......... .~.d./ ................................. 13. Will lot be regraded ...... --'/~'"0"'t ......... ~W, ill exce~ fill be removed from~pre~K~,e~;~( ) Yes ( ) No 'L.~,'/ ' '/ ?" '-~- "" .-~ ..... Phone No 14. Narre of Owner of prem ses.[/.~.,..(: "~'w',",' ..'h,'~" Address~.p~',-.....~,.~..:....~... Name or 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 frorn property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner couNw ................... r"'" ......................... ~'./-_. ............................................................... being (Name of' 'individual signing/~,~rocf) abow~ named, f,.~>"---r~, ] ~ ' -_. duly sworn, deposes and says that he is the opplican~ 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 performed in the manner set forth in the application filed therewith. Sworn to befor, e me this r~ ~ ~ '-~2/' ........................ cloy of .......... ................ ........ . Notary Pubhc .............~ f./..M.r..,~ ....... ~..' ........... Coun~ ............................................................... ..~ ............................... (~ / (Signature of applicant) // ' , ,/ JUD'TH T. BOKEN Camm'ss'on Expires March 30, I¢~1