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Home My WebLink About10165-z F~RI~I NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLE~,K'S OFF;CE SOUTHOLD, N. Y. BUILDING PERklIT (THIS PERMIT MUST BF KEPT ON THE P~REMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 10165 Z Permission is hereby granted to: pursuant to application dated ............. ...~...~..../...~ ..................... , ]9.7,.~.~., and approved by the Building Inspector. / Buildm~~j FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined...,"~. :..Z Approved.. ~. Disapproved a/c ........ '~... ....... :,/~,,..~~ ......... ~pplication No. a. ~is application must be completely filled ~ by typewriter or in ink and submit~ in triplicate to the Building Inspector, with 3 sets of plans, accurate plot plan to scfle. 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 ~ving 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 Pe~it. d. Upon approvfl of ~is application, the Building Inspector will issue a Building Pe~it to the applicant· Such permit ~all be kept on the premises ava~able for inspection throughout the work. e. No building shall be occupied or used in whole or in pa~ for any purpose whatever until a Certificate of Occupancy shall have been granted by the Budding Inspector· ~PLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Pe~it pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Re~lations, for the construction of buildings, additions or flterations, or for remov~ or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordin~ces, building code, housing code, and regulations, ~d to admit authorized inspectors on premises and in buildings for necessaw inspections. _ ( 'g pp ' , , ' p ' ./~.. i;.~.. ~ c~,,.~...~¥~, :3-...~'- , ., ........ (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises .. t.,)~\ :3 ~..':~ /\'\, .Q~.{~. ,..}.. ~ .c. ....................................... (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 License No ........................ Electrician's License No ...................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done .................................................. · ./.o. ~ .z.o. ................... :~,,,~,q~. ,~ ~-~.. ' /~/.77.~.(,,.~.. House Number Street Hamlet County Tax Map No. 1000 Section .../.2-']~-~ ........ Block . .(~ ............ Lot... O..t{/...~..(J./..O. .... Subdivision ................ ~ .~. · ............... Filed Map No. ....~m%~... ....... Lot .... ~ ....... (Name) 2. State existing use and occupancy of premises and intended use and occUp&ncy of proposed construction: "' Dw~.It/.,~.~ a. Existing use and occupancy . ...-~.~.l..~/9..~Z~ . ~.V'12~./~.~3/V~iZ..~.. , , . ................. b. Intended use and occupancy ' '~'~'' '1~t' '4~'~27'"4dC~"~' ..................................... 3. Nature of work (check which applicable): New Building .......... Addition .. . Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work...[~..~..~.~. .... ~ ~ .~[ (Description) 4. Estimated Cost -¢' S (J.~. 0 (~. Fee ] .~". ............................ I (to be paid on filing this application) 5. If dwelling, number of dwelling,Units .... ]. .......... Number of al.welling units ?n each floor ................ If garage, number of cars ... ~ .............................................................. 6. If business, commercial or mixe'd occupancy, specify nature and extent of each type of use ..................... 7. Dimensions of existing structures, if any: Front ............ /' · Rear .............. Depth ............... Height ............... Number of Stories ..... ONe,,...~T.O.c.q ....................................... Danens~ons of same structure w~th alterations or addmons: Front .. ,~.t3.rr, .......... Rear .................. Depth ...................... Height ...................... Number of Stories ...................... 8. Dimensions of entire new constFaction: Front..7. ........... Rear ............... Depth ............... Height ............... Number of Stories ..................................... · .......... ..~ ~ ....... 9. Size of lot: Front ...,.I. qOF:~i..., ........ Rear ...... .~,~.. ?.~' ......... Depth .. ~..~,4~.O...,.f~t-... ,-',' ' 10. Date of Purchase &/.~/. 1- .~.].~]'] ....... Name of Former Owner 1 1. Zone or use district in which premises are situated 17. ~ 5 d~ ~ .c~\ .............. 1 2. Does proposed construction violate any zoning law, ordinance or regulation: .... hr. iD. ........................ 1 3. Will lot be fegraded ........ i.N..0 ................. Will excess fill be removed from.psemises: Yes No 14. Name of Owner of premises .. D....C,<x.s ~.eF. ..... Address . [~,.0 ~¢.o.~.. I O.b .~.. (h.t'Pl~one No. ¢?A.q ~'.'.gff..,~..~. Name of Architect .... ~'7... ~ ................. Address ................... Phone No ................ Name of Contractor -- ... i .................. Address ................... Phone No ................ PLOT DIAGRAM Locate clearly and distinctly ali buildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. Give street and bloc~ number or description according to deed,~ L~d~.how street names and indicate whether interior or corner lot. ' _. ' ,---x ' o STATE OF NEW,.V~ulL _ COUNTY O~t~/~'... ' S.S ~)' p.~,~.~,~, a~'-----~ being duly sworn~' deposes an'd says that he is the applicant (Name o~ inctiviauat signing contract) abow~ named, i (Contractor, agent, corporate officer, etc.) of said owner or owners, and is dEly 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 man~er set forth in the application filed therewith. Sworn to before me this I ................. day Of ..... r~ ....... ,1 /~' NOTARY PUBLIC, Stat~ af [~ow York ............... ~o 52-B~5BS0. Sulm~ .Cou~ly (Signature of applicant) i Te'rm Expires March