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Home My WebLink About9211-z ~ O~ CLERK ~" ~ C~PL~ION OF THE WO~ AUTH~R~ZEb)~ Z % Dete Examined ,~....~....~. ......... , proved ........ ........ .......... IPOBM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. No..Z..X..LL ........... Application No. ~t.~ {j' (Building Inspectc~) APPLICATION FOR BUILDING PERMIT Date ......... INSTRUCTIONS a Th~s application must be completely f~lled m by typewriter or in ink and submitted in triplicate to the Buildir 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, areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this applicatio, c The work covered by this apphcation may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector wdl issue a Buildmng Permit to the apphcant Such perm shall be kept on the premises available for inspection throughout the work. e. N~ building shall be occupied or used in whole or in part for any purpose whatever until a Certmficate of Occupan~ shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of (3 Building Permit pursuant to t~ 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 describe. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and ~ admit authorized inspectors on premises and in buildings for necessary inspections. (Signature of?~a'l~plicant, or name, if a corporation) ........ .......................... (A~dress of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electric~an, plumber or budde Name owner prem,ses ....... ........ .................................................................. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............................................... Location of land on wh~ch~proposed work wdl be done. Map No ................................ Loh No ..................... ,I Street and Number ........ ,)..¥ ....... ~. ....... :.-,,. .................................................. , ...... ,.~,.. ...... .:..,.-~. ........................... Municipality State ex,sting use and occupancy of premiseslgj~d.~ intended use ~3nd occupancy of proposed construction' a Exisiting use and occupancy .................. ': ..... ..'~..,~...1 ..~.]..'..~..~.~ ............................................................................ b. Intended use and occupancy ........... ~ ~ ~,1 .............................................. bo,'¥ h 3. Nature of work (check which applicable). New Building ................ Addition ................. Alteration ............. Repmr .............. Removal ............ Demoht~or. .............. Other Work ....J..~. ~.~'.i...q-~'~.~-~ .................. cz , ........ tee .................................................................................... 4 Estimated Cost .............................................. (to be pa~d on filing th~s opplicahon) 5 If dwelhng, number of dwelhng umts .......................... Number of dwelling units on each floor .......................... If garage, number of cars ........................ 6 If business, commercial or m~xed occupancy, specify nature and extent of each type of use ........................... 7 D~mens~ons of ex~stmg structures, if any Front .......................... Rear ................................Depth .................... Height ........................ Number of Stones ........................................................................................................... D~mens~ons of same structure w~th alterations or addmons' Front .................................... Rear ....................... Depth .............................. Height ............... Number of Stones .............................. 8 D~mens~ons of entire new construction' Front ................. , ................ Rear ............................ Depth ...................... Height ............. Number of Stones ..................................................................................................... 9 Size of lot Front ........... ,;/ .................................... Rear ..... ~.....~...O.....-- ................... Depth .... '-;.~..c.....~::,.-.. .......... 10. Date of Purchase ....................................... Name of Former Owner ..................................................... 11. Zone or use d~str~ct in which premises are situated .............................................................................................. 12 Does proposed construction wolate any zoning law, ordinance or regulation ....... ~...~. ...................................... 13 W~ll lot be regraded ........................... Wdl excess fill be removed from premises. ( , ) Yes ( ) No 14 Name of Owner of prem,ses ...JTJ....C.".Y.~. ~) c.~...¥.~ ...... ~:.~....L..(.~Ac~ress ...'.~..C..~..?.~£.~....q/.. ..... Phone No. Name of Architect ................................... Address ................................Phone No ...................... Name of Contractor ...~...~..¢?.. ~2..~ ~ '.~. '~ .~'.T-)..~ .c). .... Address............. ~ ~'L ~c-j4 ....... o.~...L/....~... Phone No. ~...~...~..= ~.~...~. PLOT DIAGRAM Locate clearly and d~stmctly oil buildings, whether ex~stzng or proposed, and red,cate all set-back dimensions fron propcrty hnes Gwe street and block number or description according to deed, and show street names and indicot whether interior or corner Io~ STATE OF NEW YORK, ~S.S COUNTY OF ............. ........................................................................ being duly sworn, deposes and says that he ~s the applicon (Name of md~wdual s~gnmg contract0 above named He ~s the .......... (Contractor, agent, corporate officer, etc ) of so~d owner or owners, and ~s duly authorized to perform or have performed the said work and to make and fil th~s application, that all statements contained ~n th~s opphcahon are true to the best of his knowledge and belief; on. tha~ the work will be performed m the manner set forth m the apphcation filed therewith. Sworn to before me th~s ....................... day of ..................... , 19. Notary Pubhc, . ................................................... County (Signature of applicant)