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Home My WebLink About9947-zTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN GLERK'S oFFIGE SOUTHOLD, N. Y: BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE P~EMISES UNTIL F~JLL COMPLETION OF THE WORK AUTHORIZED) Permission is hereby granted to: -)r~/~/ ~0~' ~_ ....~.~.~.~ ........... .~.~, ......................... at premises IO~atecl or ..... Building Inspector. Fee $ ........................ FORM NO. 1 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE E amined. '- ............ ......................... ................. ............................................................... ~XT~J~ .......... ~n~ ..... ..................... ...... ......... {guildin~ Inspector) Application No..~.L../....~... ........... APPLICATION FOR BUILDING PERMIT Date .~g.u~.~..~8~lg.~.8 ............. , 19 ............ INSTRUCTIONS a. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate to the Building Inspectgr, 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 o~ areas, and giving a detailed description of layout ofproperty must be drawn 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 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 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 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. ]-he 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. (Signature of applicant, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ¢ o~t i*&e t o~' Nome of owner of premises .......... I'I~l~'.~'...]Rms~ .................................................................................................................. If applicant is a corporate, signature of duly authorized officer. .................. ~....De~3~i.oene ........................ ;......~ ......... (Name andtitle of corporate ofricerJ 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 ......................... Street and Number .-Gl~tb.wot~i...Ro~d......ICe~..B'~'~.£.oi~.....~T.;.¥.; ................................................................. Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a Exisiting use and occupancy o~.~ b. Intended use and occupancy ......... n.x.r i.iz....dw .iiim ......................................................................... 3. Nature of work (check which applicable): New Building'. ................. Addition .................. "Alteration ................ Repair .................. Removal .................. Demolitior, .................... Other Work ...~.~..~ ............................. (Description) 4. Estimated Cost ....~..~.~.?..0..0. ........................................ Fee ...~..~...,..0...0. ......................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ............................ Number of dwelling units on eocl~ 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 ................/..~...o.. ................................. Rear .......................................... 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 Iow, ordinance or regulation: ........................................................ 13. Will lot be regraded . ........................... Will excess fill be removed from premises: ( ) Yes ( ) No 14. Name of Owner of premises .....~.~,~'.~.~....R..~II.~. ........................ Address ....~.~tr~t~ .................. Phon~ No.Z~I,,-..~J~.~.~ .... Name of Architect .............................................................. Address ................................ Phone No ....................... Nome 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 YORI(, COUNTY OF ........... g.~,..~.~..~'.~.e.O~ ......................................................... being duly sworn, deposes and says that he Js the applicant (Name of individual signing ~contrac~) above named. kle is the ......... ~.~zl.t~.~O.~,O~. .............................................................................................................................................. (Contractor, agent, corporate officer, etc.) of .~;aid owner or owners, and s du y authorized ¢o perform or hgve performed the said work and to make and fil~ this application; that all statements contained i.n this applicatio~ are true to the best of his knowledge and belief; tk, a'r the work will be performed in the manner set fo~h in the ~plication filed therewith. Swam t~re ~ this / J ~..- ~ co.. ........ ..... ..... ~ ' -'""["1 ............. ~~ /7 ~ ~ '~(Sigpa~r~ of~pplicant)