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Home My WebLink About12766-z ~0~ NO. ~ TOWH OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N, Y, BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 12 66 z County Tox Mop No. 1000 Section ...... i..~.....~.. ....... Block ....... ~ .......... Lot No....,~., .............. pursuont to opplicotion doted ..... ~....b~...~..~.~.....~..~'. ............. , 19.,~...~, ond opproved by the Building Inspector. Fee $.)...~.., .............. Rev, 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Approved }00'lJ,~..~...~.}.., 19~.~. Permit No. l .~..~. k.{q.. ~ Disapproved a/c ..................................... (BtuI&ng ~hspector) APPLICATION ,~R BO1LDING PERM IT Date .~. 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 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.~.]..__ ~ ~. t~./'~ ~dlgnatum ol(3/pplicant, or name, if a corporation) W.: ............ . .(Mail.i~fig a.ddres, s of. ap~olkcant) State whether applicant is owner, lessee, agent, architect, enoineer, general contrac~tor, electrician, phimber or builder. Name of owner of pre,nises . .MJ..~.../gtCO......~..'...~'..~ .................................. (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 ...................... I. Location of land on which proposed work will be done.. ~./... /0, jto ............ M .... ............. ........... /.... House Number (~ ~.O~w.~r ~?~a.) Street Hamlet County Tax Map No. I000 Section ....... 7.Q ....... Block ......... ~ ...... Lot ..... ~ ~/ Subdivision k' Filed Map No. )c Lot -~ J (Name) 2. State existing use and occupancy of p.r. emises and intended use and occupancy of proposed construction: b. Intended use and occupancy .... .~....~.........~...~.~ ..................................... 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration) .......... Repair .............. Removal .............. Demolition .............. Other Work..~..~. .... (~)E ti ated Cost s m ee ............... (to be paid on filing this application) 5. If dwelling, number of dwellingiunits ............... Number of dwelling units on each floor ...... .......... If garage number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ..................... 7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............... lteight Number of Stories Dhnensions of same structure With alterations or additions: Front ................. Rear .................. (~) Depth ...................... Height ....... >~ ._. ~. ......... Number of Stories ...................... Dimension. s~f entire new construction Front ... ~..~. ....... Rea[ ............ ~oth .... 9(g2 Size of lot: Front .,~¢.~. ~,~... Rear~. .' .~......~... Depth .~..c~. ................. !)ate of Purchase .......................... :.. Name of Former Owner ............................. . Zone or use dis.tri~,t in. .which premises are situated. ~>. ~ .'~ ............................................ f2 Does proposer c6~struction violate any zoning law ordinance or regulation' . .......... ,~. Will lot be r~'g'{~d~d ...... : ....... . .............. Will excess fill be r;n~;~;~ ~{om premises: ' ~ Name of Owner of premise~. ~J,.C.~P~-~ .~..~...t~...~. ~t, Sk~ .~7~[~/}6h~ ~,).. ~..~./~. ~.~ Name 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 block.number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW 5~OR~', ~Z S.S COUNTy_OF .~n~;~.. .... ~~.~ .............. being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. He is the ~ ~' ",,? (C ' ontractor, agent,~corporat~ offi~r, 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 Notary Public ........ JUDITH T. TERRY Notary Public, State of New Yorl~ · ' · ~ · .~ ' ' "h'''~' ........... NO. 52-0344963 Suffolk Count~.--~ Commission Expires March 30,