HomeMy WebLinkAbout10458-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)
N? 10458 Z
Permission is hereby granted to:
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at premises located at ........................................................ -~ -
pursuant to application dated ..~..--..~.~..~.(C ...... ~..~.. ........ , 19.~...~.., and approved by the
Building Inspector.
Building Inspector
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1802
Examined-.~..CT. 7~..~ .... , 197.q
Approvec~ .77..~. ..... 14~..~ Permit No../~.....~.. · .fi?5
Disapproved a/c ................. .' ' ~ '. ~... '../~ i/
(BulldOg Inspector)
APPLICATION FOR BUILDING PERMIT
Application No./(.(~).~. · .fi-?. · ......
Date ..... .Qe.~...2.4. ......19.7.0.
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, Or&nances 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 buildings for necessary,- ~inspecti°ns' ~/' ./~/.~./
.... . ...........
(Signatur[ ofl]~plica~t, or name, if a corporation)
Main Road, Southold, N.Y. 11971 Box 566
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
''' .................................................................
Name of owner of premises,.. ~.~/~?.~.zq~.., .~./., ~'.~.., '.~. ............................................
(? ~ (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 L~cense No .........................
Electrician's License No ......................
Other Trade s L~cense o.
I. Location of land on whmh proposed work wall be done ...........................
53545 .Main l~oaO ~. ~-~- ,xT-Ti~ ~ ~, ~ /
............. / ..............c? .............
House Number 5~245 Street Hamlet
County Tax Map No. 1000 Section .Q~ .............. Block ... 9.1 ............. Lot..~ ............
Subdivision .... None Filed Map No. Lot
(Name)
2. State existing use and occupancy of premises and intended use and Occupancy of proposed construction:
lense to be erected on west line, rear of property
a. Existing use and occupancy ............................. . ........................................
b. Intended use and occupancy ....................................................................
10.
12.
13.
14.
~ ' fence
Nature of work (check which applicable): New Building .......... Addition .......... Alteration ..........
Repair .............. Removal .............. Demolition .............. Other Work ...............
' (Description)
$300 i Fee
Estimated Cost ............. ~ ...............................................................
~ (to be paid on filing this application)
If dwe ling, number of dwelling ~nits ............... Number of dwelling Knits on each floor ....... . .........
If garage, number of cars .........................................................................
If business, commercial or mixe¢ occupancy, specify nature and extent of each type of use . ~. ...................
Dimensions of existing structures, if any: Front ............... Rear .............. Depth ...............
Height ............... Number of Stories ........................................................
Dimensions of same structure with alterations or additions: Front ................. Rear ................
Depth .................... 1.. Height ...................... Number of Stories ....................
Dimensions of entire new construction: Front ............... Rear ............... Depth .............
~ Number of Stories '
Heightl ..........................................................
Size of lot: Front ........... i ........... Rear ...................... Depth ....................
Date of Purchase ............ . ................. Name of Former Owner ...........................
Zone Or use district in which pr~mises are situated .....................................................
Does proposed construction violate any zoning law,. ordinance or regulation: ................................
Will lot be regraded ......... I ................... Will excess fill be removed from premises: Yes No
fp '
Name of Owner o remises ...~ ................. Address ................... Phone No ................
Name of Architect ........................... Address ................... Phone No ............ ' ....
Name of Contracto~ .......................... 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 Iced, and show street names and indicate whether
interior or corner lot.
STAT'E OF ,NEW Y~RK- . --
· ~ .~,~-~.:~.~.~ being duly deposes and that he is the applicant
....... ~~l'si~nlng ..... contract)
sworn,
says
above named.
He is the ~
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 ,
....... ....... dayo . . ......
Nota~.Pu,b!~c, .... · ..... ~ .... ~ .... ~6unty'
' ....... ............
£L~StTH AI?N' ~tV~tLt ' / / (Signature of applicant)
NOTARY ~U~LIO, State of New York
No. 52.8125860, ISuffolk C~_.n~
Term Eal)ires Maq~ch