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FORM NO. !
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
.............
Application No..?...?E...,.~-.../.. ...........
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Buildi.
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 gwmg a detmled description of layout ofproperty must be drawn on the diagram which :s part of this applicahc
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 will :ssue a Building Perm:t to the apphcant. Such pern
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 Occupan
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 ti
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances
Regulahons, for the construction of buildings, additions or alterations, or for removal or demolition, as hereto 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 applicant, or name, if a corporation)
(Address of applicant)
State whether apphcant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or build.-
........... .............................................................................................................................................................
Name of owner of premises .......... ~.~.~-..~ .............................................................................................................
If applicant is a corporate, signature of duly authorized officer.
............... iKi~;~;.-;;~f~f~x~.- .........................................
of comorate officer)
Builder's Lic~se No ........ ~~.:: ................. --~ ~ / ~ 7- ,-- [7
Plumber's License No .................................................
Electrician's License No .............................................
Other Trede's License No ...............................................
1. Location of land on which proposed work will be done. Map No ........ .~ ........................... Lot No...~ ..............
s re , N,m e .......... ..... ..........
' Municipali~
2. State exmtmg use and occupancy of premises and intended use and occupancy of proposed construction:
a Exisiting use and ~cupancy .......... ~.~.~ ...............................................................................................
b ,. e.dedu e .doc u..nc ....... ...... ...... ...... .......................
3. Nature of work (check which applicable) New BuHd,ng .... ~ .... Add~hon ............... Alteration ............
Repmr ............... Removal .............. Demolmor ......... Other Work .........................................
.-.. ~ (Description)
(to be pa~d on filing this apphcahon)
5 If dwelling, number of dwelhng umts . ...~.. ............. Number of dwelhng umts on each floor .........................
If garage, number of cars ................................
6 If business, commercml or m~xed c~:cupancy, specify nature and extent of each type of use .... ../~..~../~.. ............
7 D~mens~ons of ex~stmg structures, if any' Front. . .~'..}.'~ ........... Rear ~':"~-- / Depth ~ r'
sa~/~ structure w,th alterations or addlt,ons: Front ........ ...'f~.~ .................. Rear ....~./("~. .........
D~menslons
of
Depth ............. ..'~./~.. ........ He,ght ........ ..~.Z~ .......... Number of Stories .............................
8 D~mensio,~s of entire new construchon Front ......... ~.....J~.. ................. Rear ..... ../'.>~.~. ............. Depth. ..
11 Zone or use d~stnct in wh,ch prem,ses are s,tuoted .../~..~.~. ~.~. .............................................................
12 Does proposed construchon violate any zoning law, ordinance or regulahon ..... ...,':¢~.~.~ ......................................
13. W~II lot be regraded .......... ...'~.~. ........ Will excess fill be removed from premises' ( ) Yes ( ) No
Name of Architect ........................................ Address ................................ Phone No ......................
Nome of Contractor ........................................... Address ................................ Phone No ......................
PLOT DIAGRAM
Locate clearly and dmtmctly all buildings, whether ex~stmg or proposed, and red,cate all set-bock d~mens~ons fror
propcrty lines Gwe street and block number or description according to deed, and show street names and ind~cat
whether mter~or or corner lot
~TATE OF NEW ~R~,.- ,/. ~ S S
COUNTY OF ...~.~L~2~/~. ........ J
..~'~./~.......,~...'...././.~.~..?......~... .................................... being duly sworn, deposes and says that he ,s the apphca
(Name of md~wdual s~gn~ng contract)
above named
He ,s the .......... .~'~ ........................................................................................................................................
(Contractor, agent, corporate officer, etc )
of sa~d owner or owners, and ~s duly authorized to perform or have performed the sa~d work and to make and
thru applicahon; that all statements contained m thts apphcahon are true to the best of h~s knowledge and belief;
tha~ the work w~ll be performed m the manner set fonh m the apphcation filed therewith.
Sworn to before me this
..... /~ ..... day of ....... ~_ . ............ , 19-~.Z Z ,~, /, . ~/
~ota~ Pubhc, . .......~ ............. ~~~. Coun~ ............ ~ ........ ~..C~..~~ ............
~~~ {Si~netu re o{ opplic~nt~
ELIZAS~H ANN N~ILLE
~0TARY PU~LI~, State of New Yor~
No 52-8~25850, Suffolk Count~