HomeMy WebLinkAbout12356-z FORM NO*
ToW. o0 .o,
BUILDING DEPARTM
TOWN HALL
SOUTHOLD, 'N.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON ~HE PREA
COMPL~ION OF THE WORK AUTHORIZED)
permission is hereby granted to:
at premises located at
......................................................................................... t'"'~ ................. ? ............ ~ ..........
County Tax Map No. 1000 Sect,on ../. ......... Block ~.. ..;...t...~L0t No ..... , ..........
purs0ant to application dated ..... : . ....¢....~ 19 and 0pproved by the
Bull~llng Ig$pector. i ' ~
Rev. i6/30/80
BUilding Inspecto('
~, COMMENTS
FIELD INSPECTION
FOUNDATION (1st)
(2nd)
FOUNDATION
ROUGH FRAME &
PLUMBING
INSULATION PER N.
STATE ENERGY
qODE
FINAL
ADDITIONAL COMMENTS:
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1803
Disapproved
a/c
APPLICATION FOR BUILDING PERMIT
INSTRUC*IONS
a. This application must be completely tilled in by Wpewritcr 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 properW 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 thc Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for thc 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 necessarv_..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, plumber or builder.
Name of owner of premises . .~. ?. (~.(/.~.~.d...~:.~./.~.~.~..~.~e~ .~. ..............................................
~..&~ ~' (as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
...... ......................
(Name and title of co,orate officer)
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 ..................................................
coo . .:'?. . . .<-: ., ./ : : . .........................
t~;~e' N~;r ....... Street ...... Hamlet
County Tax Map No. 1000 Section ........ ( .2r .~. .....Block ...... :.~.. ........ Lot .... 2. .~. ............
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
b. Intended use and occupancy
3. Nature of work (check which ap'plicable): New Building .... ..... Addition .......... Altaration~ ..........
Repair .............. Removal .............. Demolltionl ............. - Other Work. ~...2~..,~..,,~'.Q ....
' (Description)
4 Estimated Cost ~--- Fee
i (to be paid on filing this application)
5. If dwelling, number of dwelling units ............... Number of dwelling units on each floor ................
If gara§e, nmnber of cars ..... . ...................................................................
6. If business, commercial or mixe0 occupancy, specify nature and extent of each type of use .....................
7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth ...............
Height ............... Numbar 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 ............... Num. ber of Stories .................
' ' ....................... ""i ............
9. Size o£1~)t: Front ...... i ........... Rear ....,(..O.?' ............... Depth ./.O~ ..........
10. Date of Purchase ........... i .................. Name of Former Owner .............................
11. Zone or use district in which premises are situated ............. i ....... .. ...............................
12. Does proposed construction violate any zoning law, ordinance or regulation: ................................
13. Will lot be regraded ......... : ................... Will excess fill be removed fLqom premises: Yes No
14. Name of Owner of premises ,fJ, J(('~..~ .~:-. ~./.~.".~.,r.".~..,~-Address .f_,) .~....2~..t~.-....~...~.. Phone No...2.~. ~. 77...~".-~..~..
Name of Architect .......... i ................. Address ................... Phone No ................
Name of Contractor ........................... Address ................... Phone No ................
PLOT DIAGRAM
Locate clearly and distinctly alii buildings, whether existing or proposed, and, indicate all set-back dimensions from
property lines, Give street and block aumber or description according to deed, and show street names and indicate whether
interior or comer lot.
STATE OF NEV~¥ORK, S.S
COHNTY OF ~.~tF~ .......
· ~ ~~ ·; ....... being duly sworn, deposes and says that he is the applicant
(Name of individual si~g contract)
abov~ named.
He is the ..............................................................................
':' (Contractor, agent, corporate officdr, etc.)
of said owner or owners, ~d is duly authorized to perfom or have perfo~ed the said work and to m~e ~d file this
application; that all statements cont~ned ~ this application are true to the best of his knowledge and belief; and that the
work will be perfomed in the m~ner set forth in the application filed therewith.
Sworn to before me this
.......... , ....