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Home My WebLink About10050-zBUILDING DEPARTMENT''. TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined ................... ; ....... : ............ , 19''r'''';'/ Application No ............................. / ," /' ' f' ~ '"7' ~proved ~ ¥ ' ' ' '~ ~ ............................ ~z'.: ........ 19 ........Permit No ..................................... Disapproved a/c .......................... ~v ............................................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT Date ..~[..~0 ....................... ] 9.~.~ ...... INSTRUCTIONS o. This opplicotion must be completel~ filled in b~ t~pewriter or in ink ond submi~tod n tripl c~t~ to th~ Bu Idin~~ Inspector, with 3 sets of plans, occurote plot plan to ~o1~. Feo ~ccordinfl to echedule. b. Plot plan showln~ locotion of lot ond of buildings on premisos, relotionsh~p to ~d oinin~ premises or pub c streets o ore,s, ond 0ivino o detoil~ doscription of layout o{prop~rtg must Be dr~wn on Ihe dia~rom which is p~ o{ this *pplicoHon.~ c. The work covorod by this opplication moy not bo commenced before issuonce of Buildin9 ~ermit. d. Upon opprowl of this opplicotion, the Buildin~ Inspector will issue o Buildin~ Permit to tho oppllcont. Such permit sholl be kept on the premises awil~ble for inspection throughout the work. e. ~o buildin~ sh~ll be occupied or used in whole or in port for ony purpose whatever until ~ Co~ificote o{ ~cuponcy sholl have been ~ranted by the Buildino Inspector. APPklCATIOM IS HER[BY ~ADE to the Buildin~ Dep~rtment for the issuance of o Buildin0 Permit pursuont Buildin0 ~one Ordinonce o{ tho Town o{ Southold, Suffolk County, ~ew Yor~, ond other opplic*blo kows, Ordinances ReOulotions, {or the construction of buffdinos, odditions or alter~tions, or {or removal or demolition, os horein describod!~ The ~pplicont ogrees to comply with all op~licoblo I~ws, ordin~ncos, build~no codo, hou~inO codo, ond ro~ul~tions, ~nd to odmit outhorlzed inspectors on premises ond in~ buildings for n~esso~ inspections. (S~gnatu~e of apphcant, or name, if a corporation) ......................... (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electnclan, plumber or buiJder.~ ......................................................................... .................................... Name of owner of premises I{ ~pplic~t is ~ corporoto~ signature o~ duly ~uthorizo officer. ........ . (Name ~d title of corporate officer) Builder's License No .... Plumber's License No. Electrician's License No .... .~..~...~..'...~. ............................. Other Trade's License No ...... :~J~,J,..'~ ........................... Location of land on which proposed work will be done. Map No.: ko~ No ......................... Street and Number ......................................................... ~D~ J~t~a .~..~...~,,~,,,~.~..l~.....~...~..~.~.~...~... ~....~....O~'...~.. ................................. Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy J~eJ~ll~ll;~J . b. Intended use and occupancy ...................... ~.~.[~1~.~..~ ................................................................ m Nature of work (check which applicable): New Building'. ................. Addition ............. ..'~... Altbratlon ......... ' Demol itibn,: .................... Other Work ..... ...~.,.,,~.....~...~....~.~ .................... ~ Repair .................. Removal .................. (Description) ~ 4. Estimated Cost . Fee ....... i~J~O0 ..................................................................... ...... Ijt:J';'~',OO ................................ (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: Fr6nt ............................ 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 ........................ I-bight .................... Number of Stories ..................................................................................................................... 9. Size of lot: Front ........................................................ Rear .......................................... Depth ................................ 10. Date of Purchase ........................................................ Name of Former Owner ........................................................ 11. Zone or use district in which premises are situated ................~IISJ, tt~I~,~iI:L .......................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ......... I~O ......................................... 13. 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 ....................... Name of Contractor ............................................................ Address ................................ Phone 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 or corner lot. STATE OF NEW ~¥ORI<, ; ~ ~ ¢ COUNTY OF ....x..~.~(f~z;..~...r~ ........ ~¢'¢ ................. &....¢~})l~..~l~l~...~., ...................................... being duly sworn, deposes and says that he is the applicam (Name of individual signing contract) above named. He is the (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or hove performed the said work and to make and file this application; that oil 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 foRh in the application filed therewith. Sworn to..~efore me this ......... I..J.~.:~..Z. day of ....... ,,k"'/~'~'~'C: ............. , 19~.S... Notary Pub lic,~l&~..~ ... ): ~-~. &.;5~g~u n~ ........ ~....~ ........ ~,....~ ......................... ~",~'EtEWJCZ J '~' (~ /Signature of applica~ MARY B F~,t~' z 0 52-8261950 ~ SUFEOL~ COUNT~ ~ ' ~., EXpiReS MARCH 30, CDMM%SSlU~