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HomeMy WebLinkAbout12699-z FOBM NO. ~ TOWN OF $OUTflOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 12699 Z Date ...~.. ...... ' ........... , Permission is hereby granted to: ....... County Tax Map No./1000 Section ..... .~..~ ......... Block ...... ~ ......... Lot No..~.3.:.~.~......~...,.~, to application dated ..~...~.V:~..~......L~. ............. ..., 19.~..~., and approved by the pursuant Building Inspector. Fee $ ........................ Building Inspector Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.; 765-1803 Approved .~..~......~.~., 19~..~. Permit No. I ~.[o.~.~.~i~,. Application No .................. 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 ;ets 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 )r areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- ;ation. c. The work covered by this application ~nay 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 ;hall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or usedjn whole or in part for any purpose whatever until a Certificate of Occupancy ;hall have been granted by the Building Inspector. .~,PPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the 3t~ifding Zone Ordinauce of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances pr R~e~ulations, for the constraction of buildings, additions or alterations, or for removal or demolition, as herein des~,ribed. D:e applicant agrees to comply with all applicable laws, ordinances, building code, housing code~ and regulations, ditto ~dmit authorized inspectors on premises and in building fornecess~,~,~ _~, _~.._ _~ ~_. ~ (Signature of ap l~nt, or name, if i~rporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. gains of owner of premises...,~. ~. ~. ~ ~ .T.. ~. 'b' S~"~' ~ ~'~' ......................... (as on the tax roll or latest deed) If applicant is a corporatiou, signature of duly authorized officer. (Name and title of corporate officer) Buihler's License ~o. ~ ................ Plmnber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... Location,S)land on which proposed work will be done. ......... House Number Street · ......... Hamlet Couuty Tax Map No. t000 Section .................. Block .., ................ Lot ................... ............ ............... State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing usc and occupancy ..... ~ .~.~..~.~. ~..~ ..... B~g[/~ .~. ........................... b. Intended use and occupancy ~ .~". ~ ~ .~..~ .~... ~.~.~.R~ .~..~ .... ,~. ~.~ ............. 10. 11. 12. 13. 14. Nature of work (check which applicable): New Building . ,'~. · · Addition.. Alteration .... , ..... Repair .............. Rembval .............. Demolition .............. Other Work ~ . q~ (Description) Lstimated Cost .... 1~, ~. ,.~}..O. ............... Fee ..................................... ' i . (to be paid on filing this application) If dwelling, number o f dwelling !units .... ~ ...... Number of dwelling units on each floor...,¢~¢.,I~ ...... If garage, nuinber of cars ..... i ....~ 'O ....................................................... If business, commercial or mixe~l occupancy, specifkknature and extent of each type of use ... i ................. {!i .mensions o~f ex{sting structures, if any: Front.. ~.~. y ....... Rear .... ~.~ .~.... i Depth freight . . .__,2~_ ~,. ?. .... Number of Stories ........ ~ ~.~,,.,,~ ......... ~[?m.e, nsions of same structure w!th alterations or additions: Front ... i ]i] '. ] '. ] ]i ii ]i /~J..eptu .. ...... ~... ........... ;...Height ...................... Number of Stories .............. . ..... r,nnens, ons of cut,re new construct,on: Front .... ~ ~.. f .... Rear... ~.~..' ..... Depth ... ~i~..' ..... Height .... /,,~' ....... Numb. er of Stories ... ~. ..... . Sizeoflot Front ,,~ ~. - ~,,. .¢'~'~,,; 'i ......... ~."'..' .... ';'&'~'i .......... Date of Purchase .¢¢~¢~.~'~../.~'.~.. lJ~ .......... Name_of Former Ownere~ .~ .... Zone or use district in whicb pr0mis~s are situated ~. ~,i~.~,. ~,,~ ~,~ 1, .,~.~Z...~ .~...~ f..~., .~. Does proposed construction violotg any zoning law, ordinance or regulation: ....... ~¢.~. ................... ~ill lot ~b~regrad? ..... ~. g~-¢~-~._...~. ;.. ;...~_. Will exce~ fill be removed from premises: Yes ,~a,ne m owner m premise~Zo.~..,...g~.~..~.~.¢~..~/~iJ[ddress . ~lt~'l~' r.,~, ]¢, Phone No Name of Architect .. ~ I~¢1~.~ Addr .... ' ' ' '" ~ ' ' ' - ~'' Name of' Contractor . ..... ~. !1,O ~ ~.~. ..... Address ................... Phone No ................ PLOT DIAGRAM Locate clearly and distinctly all i buildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. Give street and block number or description according to deed, anti show street names and indicate whether interior or corner lot. He is the ........ : (Contractor agent corporate of said owner or owners, and is duly iauthorized to perform or have performed the said work and to make and file this applicator all statements contaified in this application are true to the best of his knowledge and belief; and that the work will be Performed in the manner ~et forth in the application filed therewith. Sworn to before me, t~his ........................ day of ..... 7. ...... 19 Notary Public (~([.'(.~..X '~ ~'~Z~'{-'/C~/ Tv ~ LINDA F. K ] .... ~. ......... \ ...... ,NalA~y POllL~C, ~t~o ot ~e~ No. 52-4524771 Qu,alili~d In Suffo k Cou.~ ./ ~ '~ ~ ~ '- ~' ~'' ''