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HomeMy WebLinkAbout10666-z FORM NO. 2 TO~N OFSOUTHOLD BUILDING DEPARTMENT TO~N CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT Ol'-! THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 10666 Z Date ..HLI't........Cr.....,............,.., 19JtJ. Permission is hereby granted to: Tit -;f,. -- c: ' .... ..tu.l.A..!...f::cr.l.C.. ..l'::IE/w{C!L. .0...".. \' A - ....-'tZJ.(./.N~... ... ."'<&...~...... .......... 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".' ~_ ~ _*. ~"~ "_~^'., ^~" 'e . - FORM NO.1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD. N.Y. 11971 TEL.: 765-1802 Examined 114/... .?., 19 J!? Application No. !O'b.~ . . . . . . . Approved &.-q~. .r...., 19~Pe~itNo. .!(J)6,(i, ~ Disapproved a/c . . . . . . . . . : . . . . . . . . . . . . . . . ........ ....... ..... ...... .... ..... ... , ..~~ , APPLICATION FOR BUILDING PERMIT Date .Apr.d. . . .~r . . . ., 19 'l.Q 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. Plat 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 Pennit, d. Upon approval of this application, the Building Inspector will issue a Building Pennit to the applicant. Such pennit 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 Penn it 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 applieant 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 inspections. ,.' . . 'Twj().. F.Q!.~.. F~.~ ~ . .. ..... . .. (Signature of applicant, or name, if a corporation) ~t)I~~. .4?.4... M.lt-nfT~~J>1.. N..~. /l9~~.. (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. . . . . . ~l9.r'I+ffi~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , Name of owner of premises"K~ [Y.I~nd . . . t.<.~.~w.. f?1< i . . . . . . . . . . . . . . . . . , , . . . . . . . . . . . . . . . . . , , . . . . . . . (as on the tax roll or latest deed) . If applicant is a corporation, signature of duly authorized officer. .,.. .... ~.-.?~~~\~9.':"I~.. . .,. . .. .. ....... (Name and title of corporate offIcer) Builder's License No. ...1f-: . If(!( .. . . ..... ., .. Plumber's License No. ......,............,.... Electrician's License No. ...... ........... ..... . Other Trade's License No. .............,...,.., , i I. Location ofland on which proposed work will be done. ...........................................,..... . . . .A..\.~.'f:!~ . h ~O<:::.. . . dr. . .cj.:r.~~Q. . . . . . . . . . . . . . . . . . . . . . . .h..~I. . . . . . . . . . , . . , . . . . . . . . . House Number Street Hamlet County Tax Map No. 1000 Section ..,.!.~ q. , . . . .. Block ... Q. ? . . . . . . , .. Lot. ,0: ! .S;. . . . . . . . . . . . Subdivision. . . . . . . , . . . . . . . . . . , . . . . . , . . . . . . . . . . . . Filed Map No. .............. Lot............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction. .. E,,",,"", Md "o,"p'", ... .<>=.c X_i.li . . d """,II, ~l" . .. . . . . .. .. . . .. . . .. .. . . . . .. .. . . b. Intended use and occupancy ... ~,~:-.. ~m..l~... d.\M~d.J In l' . . . . . ',' . . . . . . . .:. . . . . . . . . . . . . . .. j >!, ,.,',lI;;'], I!, I. 1 J ,', L. . 3. Nature of work (check which applicable): New Building .......... Addition. . . . . . . . .. Alter*an . .-. ,. . .'. . . Repair .............. Removal . . . . . , . . . . . . .. Demolition .............. Other Work . ~1('\~tY)~. . . . i .Sf (Descript n) 4. Estimated Cost . . . ~ .1?om '. k,. . . . . . . . . . . . . . . . . . . . . . . . Fee . . . . /(i', PD.. . . . . . . . . . . . . . . . . . . . . . . . . . (to be paid on filing this application) 5. If dwelling, number of dweJling' units. . . . . . . . . . . . . .. Number of dwelling units on each floor. . . . . . . . . . . . . . . . If garage, number of cars .... ~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . 6. If business, commercial or mix~d occupancy, specify nature and extent of each type of use . . . . . . . . . . . . . . . . . . . . . 7. Dimensions of existing structures, if any: Front. . . . . . . . . . . . . . . Rear .............. Depth. . . . . . . . . . . . . . . , Height ............... NuJj1ber of Stories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimensions of same structure with alterations or additions: Front ................. Rear.................. Depth. . . . . . . . . . . . . . . . . . . I. . . Height. . . . . . . . . . . . . . . . . . . . . . Number of Stories. . . . . . . . . . . . . . . . . . . . . . 8. Dimensions of entire new construction: Front. . . . . . . . . . . . . .. Rear............... Depth ............. .,. Height ............... NuIj}ber of Stories. . . . . . . . . . . . . . . .,. . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . 9. Size oflot: Front.... .~OA I.. ... . ... ... Rear..... .~~Q. ...... ..... Depth ... .~R9.... .......... 10. Date of Purchase ............................. Name of Former Owner ...........................:. 11. Zone or use district in which p~emises are situated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Does proposed construction violate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ...,'..~.. 'rrl' ~ ". . . . . ',' . . Will excess!ill be reJ::oved frrm premises: .;es No p 14. Name of Owner of premIses ,1)'1f!.. .\.I.o.f"P~.K,. Address I:}/Jrl~ 14, C!-I(...e.<. Phone No, ~.q f. . 9H ,,"1. . . Name of Architeet ..............,..,......... 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 blocl<j n~mber or description according to deed, and show street names and indicate whether interior or corner lot. .......""," ,-- - tL ;<- ;< ~~ { ?"'- !( - r' )( I ~ I , >'- 't.pl 77Y~~ , . '- STATEOFNEW~R~ ; ss j-Ltt,'C 1-1 LA- COUNTY OF . . . . . .~~ . . . . " . I ~~' , .. ...... .'.... .n....\.C:-O.I';'.~. .i... .. .. . " ... . . . . .. " being duly sworn, deposes and says that he is the applicant (Name of individual sigping contract) · above named. " He is the. . . . . . ~Y.\+r~ . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . ., . . . . . , (Contractor, agent, corporate offieer, etc.) . of said awner or owners, and is d~ly authorized to perform or have perfonned 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 manrier set forth in the application filed therewith. Swom to before me this , . .. .. .. . .. .f.ffJ<f:. . . .. .. .day ~f.. . ... . .. ~ .. . .. ., 19 .~?' \ 1 ~ Notary P blic, ...... . . .... , .... ,'" Coupty II ' I, HO~R PUBLIC. 51'1' 01 Nf..r~ N4. 52-8125850. sun: l' I T"m E.pl~' M'ro~. , I