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Home My WebLink About12758-z FOP, M NO. ii TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 1275S ,z Building Ir~:~'tor Rev. 6/30/80 FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Approved .~...g}~....~...~:-..~.., 19 ~.~. Permit No. ] ~--).~'~ ."~-.. Disapproved a/c ....... ' ............................. ~. (Building Inspector) APPLICATION FOR BUILDING PERMIT Date . .. / ............. 19.~ INSTRUCTIONS 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,i accurate plot plan to scale, Fee according to schedule. b. Plot plan showing locatton of lot and of buildings on premises, relationship to adjoining premises or public stre~ or areas, and giving a detailed;description of layout of property must be drawn oil the flia~am which is part o£ this apF cation. c. The work covered by this application may uot be commenced before issuance of Building Permit. d. Upon apprc.'al of this application, the Building Inspector will issue a Building Permit to the applicant. Such pern shall be kept on the premises available for inspection throughout the work. ' e. No ' ' ~ ' bufl(hng shall be ocCupmd or used m whole or in part for any purpose whatever until a Certificate of Oceupan stroll have been granted by theBuildipg Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance ora Building Permit pursuant to t Building Zone Ordinance of ttie Town ~f Southold, Suffolk County, New York, and other applicable Laws, Ordinances Regulations, for 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, hojm'ttg code, and regulations, and admit authorized inspectors oni premises and in buildings for necessary ~~~j (~~'a~t, o' t' t' t' t' t' t' t' t~r na;u'e', 'i~ ~'c;;porat~on) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or build .... .Co. .................................................................. N,'une of owner of premises.. ~t~l'~./0g-~/. , (as on the tax roll or latest deed) If applicant is a corporation, signature of duly author zed officer. (Name and t~tk; of corporate officer) Builder's License No...~. ~ .~.. ................ Plumber's License No ......................... Electrician's License No.' ...................... Other Trade's Liceuse No ...................... 1. Location of land on which proposed work will be done ................................................ House Number ~! Street Hamlet County Tax Map No. !000 Section ..... I.O..~ ......... Block ...... '~ i Lot.. .'71. '. Subdivision. a .ut,~'l~.o~ ..... . ...~...~..~..-~.. .........Filed Map No. · .~.~,'~ ~ Lot . .~.~.. · (Nmne) .............. 2. State existing use and occupancy of premises and intended use and occopancy of proposed construction: a. Existing use and occupancy ............. b. Intended use and occupancy 1. Nature of work (check whicl, applicable): New Building .......... Addition .......... Alteration .......... Repair .............. Removal .............. Demolition ........... ~. Other Work..~",gncd-,, ...... .~.]/~. 0.O' ,~ ..~... (Description). Estimated Cost ............................... Fee .................... ~ ......... (to be paid on filing this application) ;. I/dwelling, number ofdwelling units ............... Number of dwelling units on each floor ................ If garage, number of cars ........................................................................ L If business, commercial or mixed occupancy, specify hature and extent of each type of use ..................... t. Dimensions of existing staictures, if any: Front ..... ; ......... Rear .............. Depth ............... HeiSt ............... Number of Stories ........................................................ Dimensions otsame structure with alterations or additions: Front ................. Rear .................. Depth ...................... HeiCtt ...................... Number of Stores ......... : ............. ~. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height ............... Number ot Stories ............................... ' ......................... ). Size of lot: Front ............ ;... ........ Rear ...................... Depth ..................... '. ). Date df Purchase ............................. N~e of Foyer Owner ............................. 1. Zone or use district in which prenfises are situated..~$,' .................. , ........ ~:. ............... L ~,~es proposed const~ction violate any zoning law, ordinance or regulation: ~ ................ / ........... L ~i~ lot be reg[aded .. ~ .... ' .................. Will excess fill be removed from premises: ~es No ~.Nasne of Own.r of premises .~. ~f... ..... Address .~.~..~one No. ~. ~ .... Name of Architect ......................... '.. Address ................... Phone No ................ N~e of Contractor ~.~ .~ .... Address~.~l~ ~4. Phone No,~.~'~q ~ .... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from roperty lines. Give street and block number or description according to deed, and show street names and indicate whether ~terior or corner lot. }400 I}*-. OUNTYOF ...... ... ' _ '" l si ning cont;ddt) .... being duly >ove named. sworn, deposes and says that he is the applicsnt e is the .......................................................................................... (Contractor, agent, corporate officer, etc.) t said owner or owners, mad is duly authorized to perform or have performed the said work and to make and fire this ~plication; that all statements contain.ed in this application are true to the best oftfis knowledge and bel.~, and that the 'ork will be performed in the manner s,:t forth fl~ the application filed therewith. worn to before me this . / .......... .... Notary Public, S;ate of N~,,v ,, (..,/ _ a~.~L~,~/..// NO. 52-0344963 Suffolk County ., : ..... ,.~.. ~,. ~r'r....o.,,,',-v'v'w/r ..... ............... Gommission Expires Mar6,h 30, 19..., (Signature of applicant)