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Home My WebLink About10190-z FORM NO. 1 TOWN OF SOUTHOLD ~¢.'~"-~- BUILDING DEPARTMENT,/ SOUTHOLD, N.Y. 11971 TEL.: 765-1803 Disapproved a/c ............. ~: ..................... ....................... APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Applicat,on No. /0/Ct 0 ~-~ 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 streetSr~ 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 th~s 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 permi~ 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 q~ 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~L' 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 on and in buildings for necessary ih~ections. admit authorized inspectors premises .... ~~ '~e{i~ ~'c~a'tio'~)''' ? Zr2?;' ~...&x.. ~...o?..,.. ~..~.../X4'/.,...,(.~.r...-...~, (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrici,an~ plumber or builder. Name of owner of premises ...~.~f~. ~..~'....¢'..~..~.~. r'.~.. 5~c..~.'~.~.~ .¢./'. ..................................... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of ,c. orporate officer) Builder's License No ......... . .~..~. ~ Plumber's License No ......................... Electrician's License No ....... . ................ Other Trade's License No ...................... Location of land on which proposed work will be done. ¢.4 .~.~.6p.~{d.,/~ .~.~.. ~./~.~.t~.~.~..~.g..~o. ~ .yr/~./.,;~.~./?~.~,}: .,~.~ .~. _. House Number Street Hamlet County Tax Map No. 1000 Section ........ /.~.?; .~.... Block .......... ! ! ...... Lot ..... (.~..~-.. ........ Subdivision .................................... Filed Map No ............... Lot .............. (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed constructmn: a. Existing use and occupancy ~ ~rfY~/.Q~.. ....... . ......... ~'~"' ~ {/'~.. ~.?.¢/~'~.....,.... ~..(~?..F..~..~f...~.f;t.~.{<~.'~. ........... b. Intended use and occupancy 4'. XX :; .) ....................... 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration .......... Repair .,. Removal ,.. Demolition .............. Other Wgrk.../~. ......... 4. Estimated Cost Fee (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 mixeld 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 with alterations or additions: Front ................. Rear .................. Depth ................... !... Height ...................... Number of Stories ...................... 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height ............... Number of Stories ........................................................ 9. Sizeoflot: Front ...................... Rear ...................... Depth ...................... 10. Date of Purchase .......... ~ ................... Name of Former Owner ............................. 11. Zone or use district in which p~emises are situated ..................... 12. Does proposed construction vidlate any zorti,ng law ordinance or regulation: 13. Will lot be regraded ........ 1 .................... Will excess fill be removed from premises: Yes 14. Name of Owner of premises .. 1 .................. 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. Gwe street and block number or description according to t s street names and indicate whether interior or corner lot. STATE OF NEW~ORK,, COUNTY .......... OF. '~4 individual.~/~/~.~:~.~.:~.:~((g~,,~,,~ ~'~'~'~being duly sworn, deposes and says that he is the applicant (~ame of above named. He is the ~ ..................................................... (Contractor, agent, corporate officer, etc.) of s~,id owner or owners, and is drily authorized to perform or have performed the said work and to make and file this application;that all statements corttained in this application am true to the best of his knowledge and belief; and that the work will be performed in the manger set forth in the application filed therewith. Sworn to before me this .................... day Cf ........... ,19... Notary Pu'blic, . ................. CountyQ~ . ,ff~ff_~ I,~2~d~nY pullLm, ~e,~o ot }Iow ¥orl~ (Signature of applicant) REVISIONS YOUNG 400 OSTRANDER AVEN ALDEN W. YOUNG SURVEY FOR: JOH/V G,4~'US/ ~ E/El'd/