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Home My WebLink About12625-z FOB.~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, No Y, BUILDING P EP,~,IT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 12625 Z Permission is hereby granted to: ~ .....~,~.....~..~. ......................................... ..... ~.~.~.~,....~.:~: ....... ~.~..? ...~. ,o ..... ~...~.~....~. ........ .~./....~.....~ ....... ~.~.~....~../..~..~....~....~../.. ..... et premises located at, ./,,~.~.... · · ~ .............................................................................. .................................. County Tax Mop No. lO00 Section ....~ .~..J ........ B,ock .....~....~.. ......... Lot No...(~.~......~...~.*. pursuant to application dated ...... ~.~.,~.......,/...~.. ......................... , 19.,.~.,.,, and approved by the Building Inspector. Fee $..~Z, ................... Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined...~/7. ........ ,1 Approved.?./ ........ , Pc=it j qppt, (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. Tiffs 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 inspections. . ............ -- (Signature of applicant, or name, if a corporation) (Marling address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. N~e or owner of p~emises :/....5'J"X..~.~,,,-~ ~.d.. ~ ~' i-,,.~'.~ ....................................... .. (as on the tax roll or latest deed) If applicant is a corporation, signature of dglly authorized officer. ,,-'" (Natme and ~ corporate officer) Builder's License No .......................... Plumber's LicenseNo ......................... Electrician's License No ....................... Other Trade's License No ........................ 1. Location of land on which proposed work will be done ........ . ./~O..7°.Oj~.. · ............ r,, ............... /~.. , ........ ,.Z.... House Number ~' ~-r (~Z7'___~.) Street Hamlet County Tax Map No, lOOOSection ...t,~.,. Subdivision ....... ~ Filed Map No. ~ Lot 'X'/ '// · (Name) 2. State existing use and occupancy of premises and intended use an~_ancy of proposed construction: Xa. Existing use and occupancy ...... ff~4,:~,. ~.~.~....~.....~...~..-. ,~.. ~ ............ .,,.,/) ........ .,)~ ....... b, Intended use and occupancy ...... $~0.0~.~. A..O°....'~..... ~/~~ · · · ' ,, '..7":'ZZ.. ,... ~ . ..: 3. Nature of.w.o~k (chedk which applicable): New Building .......... Addition .......... Alteratj.,~n ..;..~); .... Repair ............ Removal,' .............. Demolition .............. Other Wor~~ 4. Est~atedCost ...~.~...~ .... ' .................... Fee. ~..~.:~.(~,-~ .................... (to be paid on ~ling this application) 5. If dwelling, number of dwelling units ............. Number of dwelling units on each floor ................ If garage, number of cars ........................................................................ 6. If business, commercial or mixed oicupancy, speciy nature and extent of each type of use ..................... 7 Dimensions of existing structures if any: Front Rear Depth Height Numbe~ of Sto~es D~ensions of same structure with alterations or additions: Front ................. Rear ..... ~ .......... Depth ' ~Hei~t ' Number of Sto~es 8. D~ensions of entire new constmcfion: Front ............... Rear ............... Depth ............. Height Numbei of Sto~es 9. Size of lot: Front ...................... Re~ ...................... Depth .................... I0 Date of Purchase ' Name of Fo~er Owner 11. Zone or use district in which premises are situated ................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: 13. Will lot be regraded ........... ' ................. Will excess fill be removed from premises: ~s No 14. N~e of 0wner of premises ..... ,, .............. Address ................... Phone No ....~' ~. N~ae of Architect ........................... Address ................... Phone No ................ N~e of Contractor .......................... Address ................... Phone No ................ PLOT DIAG~ Locate cle~ly ~d dist~ctly ~I bu~d~gs, whether existing or proposed, ~d, indicate ~1 set-back d~ensions from prope~y fines, Give street ~d block n~mber or desc~ption accord~g to deed, ~d ~ow street nines ~d indicate whether interior or corner lot. OF NEwZ 5 __. CouNr¥ of.,_.)U ...... S.S ................................................. being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. He is the .. i ................... i ................................................................... (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly 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 ..........f ,.t'..: ...... da.,.,,,of ................ ....~L~.. · .'?~--,~-. · · · ~ ...... County .bio. 41.46809,20 .... ' Oornmlssion expires blarch 30, 198f