HomeMy WebLinkAbout7800-z FORM NO. 2
~'OWN o~ sou~.sOLo
BUILDING DEFARTMEHT
SOUT~O, N~ Y.
· BUILDING PERMIT
(THIS PERM~T MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 7800 Z ~5 ....
e~ect feneing: on farm 1~ a~ .~.e~ ..a.p.~lieatio~ file~,
at premises I~ated at ..... $~,.~.~. ............. ~.;.~.~ ........................................................
....... ~ee~or~ ~.~, .
Oursuont to oppllcofion dated ................ : ........ ~.~[ ....... ?(. ....... , 1~...., ~nd opproved by the
Dui[ding Inspector.
~ ~ - , Bulldm'~ Inspector/
Approved ........................................ ,
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERKJ$ OFFICE
SOUTHOLD, N. Y.
,9.2?
............................
App,co,on .............
APPLICATION FOR BUILDING PERMIT
.......... ......
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building
Inspector, with 3 sate 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 or
areas, and giving a detailed description of layout ofproperty must be drown 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 o 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 port 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 i~suonce 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 necessary inspectior~.
(Signatur0 of applicant, or nome, if a corporation)
(Address of applicant) li7 t~6
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises ....~../..~E. xt~......~.~.~.~./~...~.C~/(/.~..//../ .....................................................................
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 Zrade's License No ...............................................
1. Location of land on whic~,pro, posed~~~~work will be done. Map No.: ....... ~ ......... ~_~ot No....~.~.
Street and Number .. ~F..,iJ=~;i~f~./~C'~~~..-
2. State existing use and occupancy of premises and in.~ended use and occupancy of proposed construction:
Exisiting use and occupancy ..............~..~ ................................. , ..........................................
Repair .................. Removal .................. areal'tie ..................... Other Work ~..~/'~...~,~....~ ......
L/(DeJ,~ription)
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 .................................................................................................................
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., .............................
Date of Purchase .......... ~/'~...~.....~...~..~.. ......................... ,,~~ __~'~ame ,of Former Owner "J~,~ _ r/ .,~- ...................
Zone or use district in which premises ore situated .J[.~,~J~...~.....~ ~'~f.~4~¢~~ .........
11.
12. Does proposed construction violate any zoning law, ordinance or regulation: ........................................................
3. Will lot be regraded . ........................... Will excess fill be removed from premises: ( ) Yes ( ) No
14. Name of Owner of premises .................................................... Address ................................ Phone No. ......................
Name of Architect .............................................................. Address ................................ Phone No .......................
Nome of Contractor ............................................................ Address ................................ Phone No .......................
PLOT DIAGRAM
Locate clearly and distinctly ali buildings, whether existing or proposed, and indicate oil set-bock 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.~O~// I S S
COUNTY ........
//!
(N~"~"~":'":~ualu,.~ ~..--~...~ signing contracf) being duly sworn, deposes and soys that he is the applicom
obow.~ named.
He is the ................................ ~.~ ...............................................................................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, end is duly authorized to perform or have per~ormed the said work and to make and file
this application; that ail statements contained in this application are true to the best of his knowledge and belief; end
that the work will be performed in the manner set forth in the application filed therewith.
Swam to before me this
................. · '~..,. day of 19'Z.~... ....... .....~_ ~/~ .,~,~" ~/~ .
Notary Public, ~ (Signature of applicant)
\\
FORM NO. x �
TOWN OF SOUTHOLD ' C.
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE r 0
SOUTHOLD, N. Y. -7
,w
Examined ....� .. Application No. ................... : ....., �Approved .............. :. ...........!.!..... 19. .: Permit No. .. �17.
Disapproveda/c ............... ...., -. .........................................................+............ Z
..................................................G�.�r '.'. .. - ..................... :: • • - �'.
F
d. .EBui�drrrg'Insp or ...............................
APPLICATION FOR BUILDING PERMIT
r Date. ......... .. ..... .... ..41
INSTRUCTIONS
a. This application must be completely filled in by typewriter or 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 or
areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this application. — j
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 cd
r7
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 il)I
'Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws; Ordinances or a
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 necessary inspections:
.....'E:k / : ...............................................................
(Signature of applicant, or name, if a corporation)
3 1.... ... ... . . . . _\ --
(Address of applicant)
I l 7�b
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
...................... .... ......................................p.......,........... .................................:.....:..............
Name of owner of premises ..V.�hICEI :I......�.f.��.lS.1��.��?..0 .k1.S�.�I..0...................................................................
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.
Streetand Number ....... }............... V......... ...............t.
.� ..... n'''. L"^-"'` z'.'; " . pj 1„0^'"'`,7,,,,ak7-""._•f r(4 •r � r"�..s?�,. , ,�ipal............
� MUI'IlGlpallty
2. State existing use and occupancy ofopremises and intended use'and occupancy of proposed construction:
a. Exisiting use and occupancy �j
b. Intended use and occupancy ............... 1� .... .... {, i2f. ; ""� .......
13. Nature of work (check which applicable): New Bui|dihg. ------ �dAddition ----- Alteration �� -.
' Repair .................. Removal ------ Demolition.................... Other \A/ork �,�����
&� ��^ ° �
zi Estimated Cost _.-_.-��.�----���--------�ee ..����/t-- ......................................................................
` (to be paid on filing this application)
5. If dwelling, number of dwelling unhs.�--.��.----�Nun�bor of dwellingunds on each floor .--,-----`--
'
Ifgarage, number ofcars _----_-'—'-.---'-----------------------.--------------.
6. If business, commercial or mixed occupancy, specify nature and extent of each type of 'use ............................
7. Dimensions of existing structures
ngstructurms if any: Front ............................ Rear ................................ Depth .....................
Height ................-.-- Number of Stories ---------_-----.-------------__-_-------.
Dimensions of oome structure with alterations or additions: Front .................................... Rea .............................
Depth ................................ Height --.-------Nun,ber of Stories ------..----
8. Dimensions of entire new construction: Front .................................... Rear ............................ Depth --------
Height ------' Number of Stories ------.----.-----------------------.----.--
� 9. Size of lot: Front ....................... �--.----.- Kao ..
X.3)7^�
10. Date of-Purchase --./cf^ ��--------. o .�
11. Zone or use district in which premises are situated -.A
12. Does proposed construction violate any zoning low, ordinance or regulation: ........................................................
13. Will lot be ragnodod ---------. Will excess fill ba removed from premises: ( ) Yes No
14. Nome of Owner of premises ..................................................... Address ................................ P6one.h�o. .......................
Nome of Architect -------- .................................... Address ................................ .Phone No. ......................
No,ne of Contractor ............................................................ Address ................................ Phonci 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 orcorner |c^. ' _
~
`^
� v
- K
'
'
---,N � _
-------_' -----_-_----_--------.--boing duly sworn, deposes and says that. he is the opp|icon/
' (Non"�bf in6ivk�uo| 'o.iggi�g contract). _
above named. '
Heis the ----------. --.^_.'------.-----_.______________________
~- (Uont oQant 'co rpo rate 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 nfhis knowledge and belief; and
thor the work will be performed in the nnonnbr set forth in the application filed therewith.
Sworn tb before me this
............... ~ �
Notary Public -.-..xc�./'�z-'�-+:-�-----_'.-------^�--`�.-^----.
� � (Signature of ��|�o�)
` `
ELIZAB
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