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Home My WebLink About10323-z ]FORM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 10323 -Z Date ............................... 19 Permission is hereby granted to: ...... .~::~.....~........~.y..~:'~ ~...~... ........ ~:~,'~. ~.. ,Z;. Z~2.~.~..T../~Z..:...~.: ................. ,o ..... C~.~..~.~.~b.~. ...... ~.~.~.r ~....~c.~.~:..~.~~ ........ ....... ~i~....~ ....... ~...~.~.~.~......~.~.~L~.G ........................... at premises located at~ ~ ~ ~ ~/~ ~-- . .......................................................................................................... ~/o~..~....~,~ .... the Building Inspector. Fee $,,~,....~,.-.~ Building Inspector Examined FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 , Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate 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 issue 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 braidings, 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 buildings for necessary inspections. ? ~ (Sign{iture of applicant, or name, if a corporation) ....... /F..' .......... e (Mailing ~ddress of applicant) State whether applicant is owner, lessee, agent, architect, en~neer, general contractor, electrician, plumber or builder. Name of owner of premises . .. ~.. ~'.~...~/ ...... (~. f:~..~. · .~.~. ...................................... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and t~tle of corporate officer) Builder's, License No .... ~.-~-~]~: ............. Plumber s ~icense No Other Trade's License No... ] .................. 1. Location of land on which proposed work will be done .................................................. .... :. :.?-. .......... :. :. . : .... .......... :. ...................... House Number r Hamlet County Tax Map No. 1000 Section .. ~ .?.-.~.. ......... Block . ~?, ~. ............ Lot .~.(...C: .~..~. ....... Subdivision .................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy....~.~q..~: ./~/ ~__ /~ g~~'J/ ............................................... b. Intended use and occupancy , 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work ............... ~,2_;/ f~ [ ~ (Description) 4. Estimated Cost ..................................... Fee ...................................... (to be paid on filing this appliqation) 5. If dwelling, number of dwelling ufiits ...... /. ........ Number o f 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. Dhnensions of existing structures,'if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ............... J ........................................ Dhnensions of same structure with alterations or additions: Front ................. Rear .................. Depth ..................... i' Height ......... ? ............ Number of ,Stones .............. ~ ....... 8. Dhnensions of e~re new construction: Front ...~../' .......... Rear .... ~.f.. ~. ......Depth ...2..Z_..~. ....... Height ...... e ........ Number of Storied ........................................................ 9. Size of lot: Front ......... L./Y?. ......... Rear ....... /. 72~-. ........... Depth .... .?..~.~.~. ............ 10. Date of Purchase ............ ' ................. Name of Former Owner ............................. 11. Zone or.use district in which premises are situated ..................................................... 12. Doespr0posedconstructi, o,n violate any zoning law, ordinance or regulation: .../k/ff. ......................... 13. Will lot be regraded .../!/~... ~ .................... Wdl exce~ss,filJ,be.,removed from premises: 14. Name of Owner of premises . f~e.)/~,r~'.. ~..,5~'$, .e.~/~Address ~?fi..~.~././~.,ffK/.e...~.'... Phone No. ~.~:/fl..2~. .... Name of Architect ........................... Address ................... Phone No ................ Name of Contractor .......................... 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 npmber or description according to deed, and show street names and indicate whether interior or corner lot. STATE, OF NEW Y, ORt~,/ -- .... ................. (Name of individual signipg contract) above named. being duly sworn, deposes and says that he is the applicant He is the ...................... i .................................................................. (Contractor, agent, corporate officer, 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 manne~ set forth in the application filed therewith. Sworn to before me this ~ ............ /~...~.. .... day of~~ ...... ,19..~f JUDITH T, TERR~ ........... Notary Public, State of New ¥ork~ No. 52,03449631 Suffolk COunt~ (Signature of applicant) Commission Expires March $0, 19P'~