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Home My WebLink About10997-z1'0997 Z FOR~ ~0. 2 TOWN omi SOU~HO:L~ BUILDING DEP.~RTMEI TOWN HALL OLD, N ¥ SOUTH' BUILDING PERMI~T (T~IS PERMIT MUST BE KEPT ON THE PREMtSES UNTIL FULL cOMPLETION OF THE WORK AUTHORIZED) Permission is hereby granted to: Buil~Jing Inspector. Fee ~$..~'.. ,~-~. .............. 6/30/80 Rev FORM NO. 1 TO VN or SOOT.OLD SOUTHOLD, N.Y. 11971 ~,., .,~..~. TEL.: 765-180~ ~~ ~, ~,~ ~ - ~ Examined ~../.~%.., 19 ~ ~~ O ~'7 Application No..~./. ~ ..... / Disapproved a/c ........ ;~ ...~ .......... .~ ........ / APPLICATION FOR BUILDING PER~IT Date ./~J[~. ........ , 19 ~. 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 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 inspe~~z~_~~ · .~../~- -- (Signature of applicant, or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner o f premises.. ~..~... ~5~..d~ ............................. (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 N~,:5 ........... Other Trade's License/No. ......... 1. Location of land on Which proposed work will be done.....~. ~/~.....F"F~...~...~..~ . House Number Street Hamlet County Tax Map No. 1000 Section .... .~..d'..~ ....... Block....O.. ~ .......... Lot.. ~..~d..'~.'~.~Y..O..Q .~.. Subdivision ..................................... Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy.../. ~2~... ~ ......................................... b. Intended use and occupancy .~(~.....w~.../~....~.....~,. .... .~...~... ........................ 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration__ .......... Repair .............. Removal ............ Demolition ............ Other Work.. ~ ..... ' ~[Description) 4. Estimated Cost. ~ Fee ,' (to be paid on ~fling this applicatioh) 5. If dwelling, number of dwelling finits ............... 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 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. Size of'lot: Front . ~2~/~..~ .&..z!? .......... Rear ...................... Dej~th ...................... 10. Date of Purchase .... /...., .................. Name of Former Owner .~..7~.~ ....... 11. Zone or use district in which premises are situated .................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: 13. Will lot be regraded ....... ~ .................... Will excess fill be removed from premises: Yes No 14. Name 0fOwner of premises ~ .*.~k~. (,d~'t~ddress ~ .~:~...ff~.~.~)~. 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 humber or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW yO~, ~, COUNTY OF .)~e~. .... ~1S'S (Name of individual signing contract) above named. being duly sworn, deposes and says that he is the applicant He is the ......................................................................................... (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 b~fore me this otaryPu ... o JUDITH T. TERRY Notary Public, S~ate Of New Yorl[ No. 52-0344963 Sulf~olk CountYtT/ Commission Expires March a0~ (Signature of applicant)