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Home My WebLink About11640-zTOWN OF $OUTHOLI BUILDING DEPARTME ~IT TOWN HALL SOUTHOLD, N~. Y; BUILDING P,ERMIT (THIS PERMIT MUST BE KEPT ON THE Pi~EM SES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) ~: ' N°. 11640 Z Date '"'"",:'"!i ............................... ' ....... Permission is hereby granted to: : .. Co ~ Tox ~op ~o. 1000 Soctio~ ..... : BI~ ...... > .......... ~ot ~o ......... ~ .......... pumo~nt ~o application datod ............................................. ~/...[~...., 19....,.., ~nd Opprov~ b~ tho ' Buildin I~to~ Building I~spector. Fee $...,;..,; ............... FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N,Y. 11971 TEL,: 765-1802 Examined ........../ "r.~.;,..,19... Disapproved a/c ......... .~ ............ ~-~ (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Application No .................. a. This application must be completely filled in by typewriter or in ink and submitted.-g,~t,d_:._~t-to the Building 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 or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- cation. 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 w/ll 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. The 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) , .... (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plu~nber or builder. ....... ............................................................................... Name of owner o£ premises . . ./.~..~ .~ .~.../.~.~ '.~.~-.~ !~.~ E.~. ................................................. (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... Itouse Nnmber Street ~ Hamlet County Tax Map No. 1000 Section ......... ~... Block .......... ~. .... Lot... f.'~,.~.~.. Subdivision ..................................... Filed Map No. .~ ........ Lot~...~". ....... (Name) , 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy .. .~.~:~7'....; ............................................ b. Intended use and occupancy 3. Nature of work (check which applicable): New Building .......... Addition ........... Alteration .......... Repair .............. Rem~vall .............. Demolition ~...,; ........ Other Work../~'~'~" 5(Description) ..... · ~//~o~, i ~ ~ .~? ........ 4. Estimated Cost ............. ~ ......................... Fee ........................... ~ (to be paid on filing this application) 5. If dwelling, number of dwelling Cnits ............... Number of dwelling units on each floor ................ If garage, number of cars ..... ; .................................................... ' ............... 6. If business, commercial or mixeO occupancy, specify nature and extent of each type of use ..................... 7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............... Height ............... Numlber 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 .../..~.Y..~ ....... Height .... d'./ ......... Numlber of Stories ........................................................ 9. Size of lot: Front ..... 7,~.~..r ........... Rear ...................... Depth .../.~.~... .............. 10. Date of Purchase ........... i .................. Name of Former Owner ............................. 11. Zone ~r use district in which premises are situated ..... .~.Z ./ ........................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ............ ~t~...~2. ............. Will lot be regraded ......... ~ ........ , ........... Will excess fill be r~empved from premises: 14. Name of Owner of premises . ?~.~.~r:'.,~.~f.~?.,A"/~.... Address . .~Z...../~..o., ...... Phone No. Name of Architect ...... ~r.' .~x'..~: ................ Address ................... Phone No ................ Name of Contractor .... .5~r~. ~,.l..e_ ................ 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 humber or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF N,,EW,,5~)RJ~,,,~/~ I° S COUNTY~~ ~0~ .... ~ o.~,~ }~ .,:~. ~~-::'-:". ~x.j..~../~ being duly sworn, deposes and says that he is theapplicant . (Name of individual sign~ng~cofitco tract) above named. Heis the . . . (Contractor, agent, corporate officer, etc.) of said owner or owners, ~d is duly authorized to perform or have perfomed the said work and to m~e ~d file this application; that all statements contgined ~ this application are true to the best of his knowledge and belief; and that the work w~l be perfomed in the manet set forth in the application filed therewith. Sworn to before me this ............... ........ , . .~ County No~ Public, .... ~. ~..~ ...... :~ ' '~f~f/ k . (Si~ature of app~c~t)