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Home My WebLink About12174-z(THIS PERMIT MUsT BE COMPLETION OF THE ~? 12174 Z ~e~'miss~On is hereby granted t~q~ BUILDING: D£PA~TI ~a~uant :: to application dated B~i!dlng jnspecto~ W and approved by the FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 76§-180:3 Examined ................ ,19 ... .3/219. . Pe Approved ............. ~., . . rmit No ............ (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Application No..../..'2. ;. ? ./... a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with ~ets of plans, accurate plot plan to scale. Fee according to schedule. ~ b. Plot plan showing location of lot and of buildings on premises, r~lationship to adjoining premises or public street~' ~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 may not be commenced bcfdl'e issuance of Building Permit. ~-) d. Upon .approval of this application the Building Inspector will isSue{t 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 used in whole or in part for any purpose whatever until a Certificate of Occupancy ;hall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pumuant to the luilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or legulations, for the constraction of buildings, additions or alterations:, or for removal or demolition, as herein described. ['he applicant agrees to comply with all applicable laws, ordinances, l~uilding code, housing code, and regulations, and tot tdmit authorized inspectors on premises and in building for necessary inspections. ............ (Signature of applicant, or name, if a corporation) (Mailing address of applicant) grate whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. (as on the tax roll or latest deed) :f 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 LicenseNo ....................... Other Trade's License No ...................... Location of land on which proposed work will be done .................................................. ............................................ /.d. q~.d. .~Z~,."/.(. . . I. /~ ? /. ....................... ltouse Number [ Street Hamlet County Vax Map No. 1000 Section .... ~.~..~. ......... Block.· i. J./.. ......... Lot ..... .~. ........... Subdivision ..................................... Filed MapI, N~ ............... Lot ............... (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy .... .~./V.~.-. ./..~.~.~..~ .~.../?.~.,.z~*./~././?.~.,." .. .................................. b. Intended use and occupancy .. fi.W<`.../~./.~.~. 5.z~/.../.-k../-P'.~'.' ./-2./.~,.~ ........ . .'... i ..... i ................... 3. Nature of work (check which applicable): New Building ....... Repair .............. Removal ........... 4. Estimated Cost /~ .~.-Z~,. ~o ... Addition .......... Alteration ......... Demolition .............. Other Work. f~.~.,Y. C./.,~. ?~.. s~ (Description) ....... Fee .. d.~. '.q~~. ............................ (to be paid on Filing this application) $. If dwelling, number of dwelling uti/ts .............. Number of dwelling units on each floor ............... · If garage number of cars 6. If business, commercial or mixed ~ccupancy, specify nature and extent of each type of use ................... 7 ...... Rear · Dm)ensmns of ex,sting structures~ If an]/: Front ..................................... Height ............... Numbler of Stories ........................ i i ........... Dimensions of same structure with alterations or additions: Fro~i .... Rear Depth ..................... i. Height ...................... Number of Stories .................... 8. Di.mensions of entire new construbtion: Front ............... Rear ............... Depth ............. Height ............... Number of Stories ................... 9. ' //~' .... Size of lot: Front ........... [ .......... Rea; . i ././.~· ' ..'. .............. Depth .... O?.~"; .............. ............ 10. Date of Purchase ............ i ................. Name of Former Owner ............................. d .... h pm' '!uat d 11. Zone or use mnct in whlc re sses are si e ..................................................... 12, Does proposed construction violate any zoning law ordinance or regulation: ........................ 13. Will lot be regraded .......... i ...... : ............ Will excess fill be removed from premises: Yes No 14. Name of Owner of premises . .~.~.,?P....//,,?.'K .~../../~. Address ?. 9.q .~...~..,.'FO. q .a.... Phone No. ??.5. ~7..o,,?.o:~. ,~.'-... N,'Lme of Architect ........... ! ................ Address ................... Phone No ................ Name of Contractor ........................... Address ................... Phone No ................ PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and, indic'ate all set-back dimensions from property lines. Give street and block ~umber or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, COUNTY F u.~{¢,~//C :S.S ~ ....... ..O~:...,~..eC.~:~.',,..,7.~' ....... , ................ being duly sworn, deposes ~d says that he is tho applicant (Name of individual al~ng contract) above n~ed. (Contractor, agent, corporate officer, etc.) of said owner or owne~, ~d is duly autho~zed to perform or have perfo~ed the s~fl work ~d to m~e ~d file this application; ~at ~1 statements contained ~ th~s application ~re true to the best of Ms knowledge and belief; and that the work will be perfo~ed m the m~n~r set forth in the applicahon filed therewith. Sworn to before me this Notary Public,~~~ :~ ~x ounty NO. ~2.4e6~406 ~ · . ~U~IlFI~D INSUFFOLK COUNTY ~ (S~ature of apphcant) COMM,'~S/q~ ~xmaes MARCH 30, t9 ~