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Home My WebLink About12752-z FO~ NO. ~ TO~VN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. ¥. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 12752 Z County Tax Mop No. 1000 Section ..... .(~...~....-). ...... Block ....... ..-~..'~. ......... Lot No ........Q..,.~... ........ pursuant to application dated ..... ..~...(~.~...~..~...). ................... , 19.~..~,, and approved by the Building Inspector. Building Inspector Rev. 6/30/80 Examined .~..t~bt~L~ .~...~,. ?. Approved .0 .~....~ .~.~. FORM NO. TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y, 11971 TEL,: 765-1802 ., 19~. Permit No. Received .......... ,19... Disapproved a/c '. .................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This 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 Fart f0Fany purpose whatever until a Certificate of Occupa~ncy s~all 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 regulation.s, and to admit authorized inspectors on premises and in .10_~..~ .~ ~ ~.a building for necessary ins ctions. }, (Signature~f ap¢ ant~~) (Mailing address of applicant) j! ~ ~ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. . ........................... Name of owner of premises .... ~.a ~ .E'Y~...~'.....~/ .... ~. O./,~q-< ..~./,.J-~ 5-~ ....................... (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 ...................... 1. Location of land on which proposed work will be done..(/O~../../~r~. 7.~...~4tt~'.~....g? .~. ~... .... .... House Nmnber Street Hamlet County Tax Map No. 1000Section.....O..~...~. ..... Block ..,.........( ..... . Lot......~. ........... Subdivision .~ ! ~.~ ~7.~..... ~. ,~g,~/.~. .......... 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 .... .e~.7..~.I~:1~t. ~.. ~-..rff.~. ff~. .............................. b. Intended use and occupancy ~g.~.~.~---~/~..~..-~..~4~.~'..~. · .'~./'f.~. ~...~ ~. ~v,5"b~ 10. 11. 12. 13. 14. Nature of work (check which applicable): New Building .......... Addition Mt ....... arreranon .......... Repair .............. Removal ............ Demolition .............. Other Work ............... ~ ~ ~ ~ (Description) Estim0ted Cost .. ~., .~ ................... Fee .J.Qt ~ ................................ : (to be paid on filing this application) If dwelling, number of dwellingiunits ~ Number of dwelling units on each floor. If garage, number of cars .... ~...~ ..... i'. ............................................. ' .......... If business, commercial or mixe~d occupancy, specify nature and extent of each type of use~...~.~.~.~ Dimensmns of existing structures, if any Front ..... ~. ~ .... Rear ...~ .~ ..... Depth .... He ......... Nu er o ones ............................................... D~ehsions of same structure with alterations or additions: Front ... ~.~ f ....... Rear .... ~ f .......... · · ...... ~ ~ ............ Number of Stohes ....... Dimensinns of entire new constmctmn: Front .... /~.~ ~ .... Rear .../~ .~ f .... Depth ... Height .. .~ .... Number of Stories ................................................. Date of Purchase .......... ; ............ ~ ..... Name of Fomer Owner ............................. Zone or use district in which premises are situated.. ~ ~ ~./... w.. ~ ~ ......................... Does proposed construction ~ioJate any goning law, ordinance or regulation: ... ~ ............... ~ ...... Will lot be regraded ...... ~.~.~ ............... Will excess fill be removed from premises: Nme .of Architect ......... } ................. Address ................... Phone No ............... Name :of Contractor ' Address Phone No PLOT DIAGRAM Locate clearly and distinctly ali buildings, whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and blocki number or description according to deed, and show street names and indicate whether interior or corner lot. (Name of individual sig~ing contract) above named. 'being duly sworn, deposes and says that he is the applicant He is the ' : (Contractor, agent,corporate officer, etc.) of said owher or owners, and is duly authorized to perform or have performed the said work and to make and file this applicationI that all statements contained in this application are true to the best of his knowledge and belief; and that the wqrk will bi performed in the mannor set forth in the application filed therewith. S~)orn to b~fore me this : ............ day of ~ ~, 19<~ NotarvPublic, . ............... . ~. ~01~q~RY PUBLI~, Stete ~ft ~lew York ti ! No, 52-~1125_850, Suffolk 19~'~,~