The URL can be used to link to this page

Home My WebLink About12392-z FOF, M NO. ~ TOWN OF $OUTHOLD BUILDING DI:PARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING FElt, MIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 12392 Z Date ..................... . ..~.~. ............... ;.~......, 19...~..~ Permission is hereby granted to: D- ~o. ~ .~. ~. ............ at premises located '"' ~5 ~ ~ ~ County Tax Map No. 1000 Section ........... ...ff..~,~...... Block ........... ..~.... ..... Lot No ...... ~ ............. pursuant to application dated ...........................~.~...~...., 19.~ and approved by the Building Inspector. Fee $....fff..~ .... Building Inspector Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined .......... .~..57~.., 19...~ Approved ............. ,2~ ............ Disapproved a/c . . ~ .... ~_ .................. APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. Tins application must be completely filled in by typewriter or in ink and submitted 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 issued 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 building for necessary~ections. ~.~ ~ jj .~ ~ ~J ~..~~..~/.~.~~ ............. (Sig~ture of applicant, or name, if a corporation) (M~iling address of applicant) ;~rS~~ State whether applicant is owner, lessee, agent, architect, eno~neer, general contractor, electrician, plumber or builder. Name o~ o~er of premises .~.~' ./.~.~~ ~,~..~:. ~.~..~.~,~. ...... (as on the tax rop/l~r latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ....... .d~..~~. ......... Plumber's License No ......................... Electrician s License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed wor~k will be ~one .................................................. ,~. ~., ~. ~?.., ~~.~~.. ~., ............................ House Number Street ~ ~ Hamlet County Tax Map No. I000 Section...~. ?.~.. .......... Block...~ ............ Lot ..... .?. ........... Subdivision ~2 Filed Map No. Lot (Name) 2. State existing use ~nd occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ....................................... b. lntended use and occupancy ..... ~i i .~'.' i~.'~i .~ .~.~-~ ." 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration .......... Repair .............. Rembval ........... Demolition .............. Other Work ............... 4. Estimated Cost . ,</.d~'.~..2~ .... ~ .............. Fee ~ (to be paid on filing this application) 5. If dwelling, number of dwelhngumts ............... 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: Front ............... Rear .............. Depth ............... Height ............... Nun~ber of Stories... ' .............. ' ............................... I)imensions of same structure with alterations or additions: Front ................. Rear .................. Depth. .................. q;. Height ...................... Number of Stories ...................... 8. Dimensions of entire new const[uction: Front ............... Rear ............... Depth ............... Height ............... 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 ..................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ................................ 13. Will lo:t be regraded ............................ Will excess fill be removed from premises: Yes No 14. Name Of Owner of premises .. i ................. Address ................... Phone No ................ Name 9f Architect ......... ; ................. Address ................... Phone No ................ Name of Contractor .......................... Address ................... Phone No ................ PLOT DIAGRAM Locate clearly and distinctly allI buildings, whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and ]escription according to deed, and shgw street names and indicate whether interior or corner lot. ~ue¼ S ~l~e~ ~ ~£vct STATE OF NEW YORK, COUNTY 0r...~?.q. ,P~.~.~/../c. .... S.S ....~ ~ ~~¢~. · . .~ .'.. ~/~.~.~. ............ being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. He is the ...................... i ................................................................... (Contractor, agent, corporate officer, etc.) of saki owner or owners, and is dul~ authorized to perform or have performed the said work and to make and file this application ;~ that all 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 forth in the application filed therewith. Sworn to before me this ........ . .<~. ~...'~. ........ day ofi.....'2-~..~..,Z.~. ~.'. ....... ,19 ~ Notaw Publ,ic ... "~+-' ; ,, Cc-,. NOTARY PUBLIC State of Now Yo~ . · No., 52.4524,771 Qualified in Suffolk County ~ / Commission ~xpires March 30, 19&~" (Signature of applicant)