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HomeMy WebLinkAbout9587-z FOBM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Disapproved a/c .............~ ...... ,~ ............................. ._~.,,~.~. ~.. ............................ .......... 7' ................. APPLICATION FOR BUILDING INSTRUCTIONS a. This application must ~e completely filled in by ~ypewriter o~ in ink and submitted in triplicate to ~he Building InspeGtoG with 3 sets of plans, acourate plot plan to ~ale, Fee according to schedule. b. Plot plan showing Iocadon of lot and of buildings on premises, relationship to adjoining premises or public streets areas, and giving a detail~ description of layout ofproper~ must be drawn on the diagram which is pa~ o~ this application. c. The work cove~ed by this application may no~ be commenced before issuance o~ B~Hding Permit. d. gpon approval o~ this application, the Building Inspector will issue a Building Permit to the applicant. Such permit shall be kept on ~he premises available for inspection throughout the work. e. No building shall b~ 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. to the Building Department for t~e issuance of a Building Permit pursuant to APPLICATION IS HEREBY MADE Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. The appJican~ agrees to comply with all applicable laws, ordinances, building code, housing code, and ~egulations, and ~o admit authorized inspectors on premises and i~ buildings for n~essa~ inspe~ons. (Address of appricant) / / 77~ State whether applicant is owner, lessee, agent, architect, eng~nee c lectncton, plumber or builder. Name of owner of premises ~ ~ ' ~.~.~.~ I~ applic.,ont is ~flcorporote, signature of duly authorized officer. ....... ....... ............... (Name and tit of corporate officer) Builder's License No ..................................................... Plumber's License No. Electrician's License No .................... 7-~c'0-/3 (o /ooo -- 9/f/- ~ -- / o Other Trade's License No ............................................... Location of land on whicF/proposed work w be done. Map No ............................. Lot No .......... Street and Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ...... ~...~...~...~... ................................... SOUTHOLD, N~Y. BUILDING I~EI1,N~IT (THIS PERMIT MUST BE KEPT ON THE P'REMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 9587 Z ;'/'~(~"~ C, /5 19..:?.?., and approved by the pursuant to application dated ........................................................ , Building Inspector. property lines. Give street and block number or description according to deed, whether interior or corner lot. / 3. Nature of work (check which applicable): New Building' .....'.~5.......... Addition .................. Alteration ................ Repair .................. Removal .................. Demolition .................... Other Work ................................................ (Description) .... _., .............................................................. 4. Estimated Cos~ ...~...-..f.l~.O.~...:...':5~... ............................ 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 .......... /~.fl./~'~.... ................................................................................................................. 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 ..;~.O...~. ............... Depth ..."~.....~.. .............. Height ..~,.~ ............ Number of Stories .................................. [ ............................................... ; ....... .j .................... 9. Size of lot: Front ...~.0. I ............................................ Rear .~'.~.0.. .................................. Depth .~...~... ...................... 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 ...~.~ .................. Will excess fill be removed from premises: ( ) Yes (t~) No 4. Name of Owner of premises .................................................... Address ................................ Phone No ....................... Name of Architect .............................................................. Address ....... S.~ ............... Phone No ....................... -/_ Name of Contractor ~ .~...~.~.....{5...~...~-o..~'N..: ....... Address~.'lTl~.~t~.. :~t~ ...... Phone No. ~..~..~.~.Zl.~..... PLOT DIAGRAM locate clearly and distinctly ali buildings, whether existing or proposed, and indicate all set-back dimensions from and show street names and indicate STATE OF NEW YORK, COUNTY OF ..... ~-~ ........................ fo.,, ....... .~..t.[...~.. ........ ~./~.....~....f~'.....?.....'~.. .................................... being duly sworn, deposes and says that he is the applican, (Name of individual signing contracf) above named. He is the .......................................... ~ ....... ~ ............................................................................................................... (¢ContracWagen,, corporate officer, etc.) of said owner or owners, and is duly~-- ~auihuri~ to perform or have performed the said work and to make and file this application; that ali statements contained in this application are true to the best of his knowledge and belief; and tha~ the work will be performed in the manner set forth in the application flied therewith. Sworn t} b~?re me this [h~. ~otory~~ ~ ~~¢ublic'. ................................................... Coun~ ......... NOTARY PU~tlC. State al New York Term Expires March 30, LIC. LAND SURVEYORS.GREENPORT, N. Y. TELST HOL~E ~[::~,.,,oil ~ o' ";7;~'~. , .... ~,~, 17' SUFF. CO, DEFT. O...__F HEALTH FOR APPROVAL OF CONSTRUC:TION ONLY APPROVED: --, STATEMENT O~ INTEH~T THE WATER SUPPLY AND SEWAGE DISPOSAL SYSTEMS FOR THIS RESI. DENCE WILL CONFORM TO THE STANDARDS OF SUFFOLK CO, DEPT. ' APPLICANT LLE~ ~ APPRovED AS NOTED 1 L,~ ~,/ A -[' ON',,,] .? uP l~E' ~°. ~ 4©