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HomeMy WebLinkAbout12158-zperfnission is hereby granted to: BUILDI (THIS PERMIT MUST BE KEPT ON C~PL~ION OF l~58 Z purSjUont ~o application'doted ........ ,.....,~....., ....... ~ ........... ,~.. BUilding I~,pector. and approved by e FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by Wpewriter 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 insj~c_tioxts. , ~ . (Signature o f_glat~i~e'ant, or name, if a corporation) (Mailing address of applicant) t' .-~ H-7 7.- /'¢c.s" State whether applicant is owner, lessee,(agen~ architect, engineer, general contractor, electrician, plumber or builder. (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. ~ Pl~'~,/,~r-'~ Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... Location of land on which proposed work will be done. /~.O..~.~.~.....~..~.~.,~'...O.f./.~../,~.../(~'~. .... ~.~',,//,,///,,r~.. ~../.2...~...'./.v~.~r.~,,,<..~. ~./....~7....~:.~,...~..,,../.~.-~.,:..~.,..-- :~.9:... .......... itouse Number Street Hamlet ~ County Tax Map No. 1000 Section . .~.~. ............ Block ... a~. ............ 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 .... ~..,~).~..."~.~,.~.....~....~....~.~.. ...................................... b. Intended use and occupancy ............................ .~.~..~'~(....~.4~r-.,~..~*~'fd%~-. .......... 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Wot 4 Ftimat dCost .~. ~. ' Fee..~../~._.~.~ (Description) : (to be paid on filing this application) 5. If dwelling, number of dwelling !units ............... 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. 1)imensions of existing structure?, if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ........................................................ Dimensions of same structure wlth alterations or additions: Front ................. Rear .................. (~tDepth .................... i" Height .... l .............. ~' .... ~Number of Stories ...................... imensions o~f entire new construction: :~l*t- ......................... . I~ .... ............ "ze'ght ............ , 9. Si e of lot: Front . .~..~....~ ................. Depth,~i~.' i~'.' ~.'~ .......... 10. r)ate of Purchase ........... .................. Name of Former Owner ............................. 11. Zone or use district in which premises are situated ..................................................... 12. Does proposed construction vioiate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ......... ' ................... Will excess fill be removed from premises: Yes No 14. NameofOwnerofpremises ... ................. Address ................... PhoneNo ................ Name of Architect .......... ................. Address ................... Phone No ................ Name of Contractor ......... i ................. Address ................... Phone No ................ PLOT DIAGRAM Locate clearly and distinctly all! 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. ~ ~_o-~ o~ STATE OF NE~-~RK,./~ ./~ COUNTY OF~f/~.~.&'{.. ~'a.~.. (Name of individu~Jigmng contract) above named· He is the ............. ~ ....................................... , ~ / .. ?~tractor, agent, corporate officer, etc.) of said owner or owners, ~d is duly authorized to perform or have perfo~ed the said work and to m~e and file this application; that ~l statements contained ~ this application are true to the bes~t of his ~owledge and belief; ~d that the work will be perfomed in the m~ne~ set forth in the application filed~ therewlih}- Sworn to before me this ~ ' ........... ~..~-. · -~ :=~:.':aay of!. Notary lc, ~IOT~Y r · '¢' ~ignature of applicant)