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Home My WebLink About10148-z FOI~I NO. 2 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? 10148 Z Date ............................................ ~ ......... , 19 ........ Permission is hereby granted to: I/~ ~, ~l~! ~ NP .~k' I ~ ' to ............... ~.fLL::...L~ .......................................................................................................... pursuant to application doted ................................................................ , and approved by the Building Inspector. Fee ....................... Building Inspector FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined .... / ....... ...................... ........................................... (Building Inspector) ~P¢klC~TIO~ FO~ BHILDI~G Application No./~ (.tr..?: ....... 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 thc 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 buildings for necessa~inspections. /~h (Signature of applicant, or name, if a corporatmn) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ............. ............................................................... ...... .... .... :: ........... (as on the tax roll or latest ee ~/ If 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 License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work,ill be done ......................... :.~? .................... . . :. . . .................. :. . .... :. ?. . . .:' . ......... House Number Street / County Tax Map No. 1000 Section .................. Block .................. Lot ................... Subdivision .................................... Filed Map No ............... Lot ............... (Name) b. Intended use and occupancy ...... ~~ ~ ............................ ....: ........ 3. Nature of work (check which a~plicable): New Building .......... Addition .......... Altera~ion, ../. ....... Repair .............. Removal .............. Demolition .............. Other Work../~...?~ ' (B6scription) (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. Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ........................................................ Dimensions of same structure w, ith alterations or additions: Front ................. Rear .................. Depth ................... !... Height ...................... Number of Stories ...................... 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height ............... Number of Stories .......... :~./_) .................... ~...~. ~ ............. 10. Date of Purchase ....... /.'~.rx(.~. .............. N~a~e of Fo~er Ow~_er c.~_a.. · '?) ...................... 11. Zone or use district in which p~emlses are situated .... /.7~.: ............................ 12. Does proposed construction~v.iq!~ate any zoning law, ordinance or regulation: . 13. Will lot be regraded .... .~7'.~..t-A~. ................... Will excess fill be removed from premises: Yes 14. Name of Owner of premises .. i .................. Address ................... Phone No ................ 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 number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW x~0R.l~,j., ,q /~-- c rYd 71 . s , .~f~.. ~..;~f~...~.., ...... being duly sworn, deposes ~d says that he is the applicant ~ (Name of individual sig¢ing contr~ above named. ~ ~ , He is the ' ~ (Contractor, agent, corporate officer, etc.) of said owner or owners, ~d is duly autho~zed to perform or have perfo~ed the said work and to m~e and file ~is application;that ~1 statements contained h this application are true to the best of his knowledge and belief; and that the work will be perfomed in the m~ner s~t-~rth in the application filed therewith. Sworn to before m~this / 1~ ..... ........ 19 NotaE ............ . . County ~ ~ ~ ~