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Home My WebLink About12713-z FOU~W NO. ~ TO~'N OF $OUTHOLD BUILDING DEPARTMENT TOWN HALl. SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permission is hereby granted to: ............... .....~..~.~..J..u...~.~.. .............................................. .......... ,o at premises located at ....~..~..~. .......~;..Z~x~,~...~,~.~.~...~-~ .......... ..~.~.~L..~"l~..wF;.~'~ ~ ~ .............. County Tax Map No. 1000 Section ........ ?...~.. ......... Block ...... .J....,'~.. ........ Lot No ........'~.. ............... ~ i t . . , 19~., pursuant to application doted .... .(~ ..................................................... and approved by the Building Inspector. Fee $..1 ..................... Rev. 6/30/80 FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL,: 765-1~02 Approved O...~..~....~..I .... 19~.~. Permit No/..~.']J.'~.~.. Disapproved a/c ....... ' .............................. (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date .................. , a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Buildi 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 stref or areas, and giving a detailed description of laybut of property must be drawn on the diagram which is part of this apg cation. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon apprc.'al of this application, tile Building Inspector will issue a Building Permit to the applicant. Such pen~ shall be kept on the premises available for inspection throughont the work. e. No build/ag shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupan shall bare been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for th~ issuance of a Building Permit pursuant to t Building Zone Ordinance of the Town ~f Southold, Suffolk County, New York, and other applicable Laws, Ordinances Regulations, fbr the construction of buildings, additions or alterations, or for removal or demolition, as herein describe The applicant agrees !~ comply with all applicable laws, ordinances, building code, housing code, and regulations, and admit authorizeS inspectors on premises and in buildings for necessary inspecflJpons..~¢ ~,,, ~//7 .~ (Signature of applicant, or name, if a corporation) . .e ...Sox .m..re..,. ,,¢?. ...... (Mailing address of applicant) State whether applicant is o~vner, lessee, agent, architect, engineer, general contractor, electrician, plumber or build .... ................................................................... N,'une of owner of prexnises .. ,T~¢.,~i~...~.. a.., .~.~/Ot~'. .............................................. (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 Ns ........ ' ................. Electrician's License No.' ...................... Other Trade's License No ...................... Location of land on which proposed work will be done ................................................ /d · 3t ................... ................ .$.,.0. ....................... House Number Street Hamlet County Tax Map No. t000 Section ....... :7..0. ....... Block .. J ~ Lot. Subdivision ..................................... Filed Map No ............... Lot .............. (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy. . ~.$t ~ta~:.~. ...................................................... b. Intended use and occupancy ..... .......... ~'~-~.g~.......7~.../ ..................... ~..O~..~..~ ~-- .~-- ........ ~,. x. ). Nature of work (check whicl, applicable): New Building .......... Addition ..... Alteration Repair .............. Removal .............. Demolition .............. Other Work...~'.~ ¢.~ ...... Estimated Cost . .. Fee . -r .......... (to be paid on filing this application) ;. If dwelling, nmnber of dwelling units ............... Nmnber of dwelling units on each floor ............. If garage number of cars i. If business, commercial or mixed occupancy, specify hature and extent of each type of use ..................... I Dimensions of existing stn~ctures if any: Front ' Rear Depth Height ............... Number of Stories ............... ......................................... Dimensions of same structure vitb alterations or additions: Front ................. Rear .................. Depth Height Number of Stories I Dimel~sions of entire new construction: Front Rear Depth Height Nu :nber of Stories ' Size of lot: Front '. '. ·. Rear Depth Date o'f Purchase .......... .................. Name of Former Owner ............................. Zone or use ....... : d strict ~n which pre roses are s~tuated ................................................. Does proposed construction vi61ate any zoning law, ordinance or regulation: ................................ , Will lot be regraded ....... :..' .................. Will excess fill be removed from premises: Yes No Name of Owner of premises .~.ko~. R, ,'Tt~t/~.... Address ~,5.~..~a.~, Al~,~..19g!, . . Phone No ................ Name of Architect ......... i ................ '.. Address ................... Phone No ................ Name of Contractor .~.t~.! .~,~..,%)tSq~¢*~, .... Address ~}17: ~ t'~".~. ~'~4'~/d. Phone No..~..~,~.,'~ ..... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from roperty lines. Give street and bloc: number or description according to deed, and show street names and indicate whether .terior or corner lot. ....... i)~qgl .~............. ;.......... being duly sworn, deposes and says that he is the applicant (Nanie of indMdual sigifing contract) ~ove named. e is the ............... ,... i (Contractor, agent, corporate officer, etc.) f said owher or owners, and is drily authorized to perform or lmve performed the said work and to make and file this >plication; fi~at all statements coniained in this application are true to the best of his knowledge and belief; and that the 'ork will be performed in the manner set forth h~ the application filed t!,erewith. worn to before me this ! - . t~m IExplres M;~reh 30. IO._~F ,,,~,,ature o[ appncantj