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Home My WebLink About11671-z FOE~ NO. TOWN BUILDING DEpARTMENT~ TOWN HALL SOUTHOLD, N~. Y, BUILDING :FERMIT (THIS PERMIT MUST BE KEPT ON THE PREMIS[~S UNTIL F~LL · coMpLETION OF THE WORK AUTHORIZED) Perth ssion is hereby granted to:f~}~-/~/ "~ ~'~ BOil~ ling Ihspector. Fee Rev: 6/30/80 Memorandum from.... BUILDING INSPECTORS OFFICE TOWN OF SOUTHOLD TOWN HALL, SOUTHOL~:', N. ¥. 11971 765-1802 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y, 11971 ~ (0.,,0 ,~" TEL.: 765-1803 ,: Examined ............ : · ·., Approved ............ - ..... Disapproved a/c ....... ~..'. ':~ ..... (Building Inspector) APPLICATION FOR BUILDING PERMIT Application No. I1 ~ '7 / INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate 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 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. The applicant agrees to comply with all applicable laws, ordinances, budding code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary~ CBignature of applicant, or name~, if a corporation) (Mailing address of applica~lt) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ................................................................................. Name of owner of premises .C'..O. ...... .'CF... ~ .................................... (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 ...................... [ '7 G ~- Location of land on which proposed work will be done. ~.~ .~% .~..~. · .C~.~. · · .~(~. ~. ?.c¢..~. it.c/ ............... House Number Street Hamlet ' C~>hnty Tax Map No. 1000 Section /~gT.d....~..~. ...... Block ...~.~. ............. Lot..c:~....O. ............. (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ............. : ' ' 'Li" ' ................................. use and occupancy ....................... --(~... ~ ~ .............................. b. Intended 3. Nature of work (check which a plicable): New Building .......... Addition .......... Alteration .......~ .~.. Repair .............. Removal ... ~ .......... Demolition ............... Other Work .~..~¢.~.~ ...... - ~ ~/0 ~ (Description) 4. Estimated Cost . . .~..cg.q :.c~. ?. ...... } .................. Fee ....... .............................. (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.It' business, commercial or mixed occupahcy, specify nature and extent of each type of use .................. 7 .... if any:' Front Rear Depth · Dunenslons of existing structures, .......................................... Height ............... Number of Stbries ...................................................... Bimensions of same structure with alteraiions or additions: Front ................. Rear .............. De th . . . .Heit p .................... git ...................... Number of Stories .................. 8. DimenSions of entire new construction: ~ront . ~..a.'(~..o_~Rear ............... Depth ........... Height ............... Number of Stbries .................................................... 9. Size of lot: Front ........... : .......i .... Rear ...................... Depth .................. 10. Date of Purchase ................... i ........... Name of Former Owner ......................... 1 1. Zone br use district in which premises are situated ................................................. 12. Does proposed construction violate any zbning law, ordinance or regulation ............................. 13. Will lot be regraded ......... i ...... ~ ........... Will excess fill be removed from premises: Yes .. 1~o 14. Name of Owner of premises . (~, .~o[ ~), .~.o..~.b ~.~.Address ..~.~[ff~.OT'..77. PhoneNo. 2~.~..Z~.. ?.0. ?.. Name of Architect .......... ; ............ .Q~.. Address ................... Phone No ................ Name of Contractor ......... i ...... , ......... Address ................... Phone No ................ PLOT DIAGRAM Locate clearly and distinctly all buildingsi whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and block number o~ description according to deed, and show street names and indicate whether interior or corner lot. ~ (Name of individual s~gnmg ~ontract) above named· being duly sworn, deposes and says ttFe is the applicant e is the ~tor ' ( ~ , agent, corporate officer, etc.) of said owner or owners, and is duly au. thorizedt to perform or have performed the said work and to make and file this application; that all statements contained in this iapplication are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth inithe application filed therewith. Sworn to before' me this · No~t a. ry Public ............. t~ qOl~gY ~qJBUG,~ ,$~.~ f~A~. ~$*li~e * ....... ,/ ,/