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HomeMy WebLinkAbout11359-zTOwN HAL[ SOUTHOLD, NJ. Y.~ BUILDING P'E~IT (THIS PERMIT MUST BE KEPT ON TH,~ PREMISES COMPLL~'ION OF THE WORK ^UTHOR!ZED) Pertnissiorl is hereby grorlted Date ........... (,% FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 --'~..Y..-/', 19.,. ermitNo. [ ¢ ~ 59 7 . Approved (Building Inspector) .. ~h APPLICATION FOR BUILDING PERMIT Date. ~"t)~q.a, .~' ..... ,19~' ~ INSTRUCTIONS a. This application must be completely fried in b~t typewriter or in ink and submitted in triplicate to the Buildi ~k. 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 stre~ or areas, and giving a detail6d description of layout of property must be drawn on the diagram which is part of this apl: 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 pern 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 Oecupan 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 t Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as her~in descritn The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and admit authorized inspectors on premises and in buildings for necessary inspections. (Signature of applicant,.or name, if a corpor/~l ' ) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or buildt Nam~prem~ses ................ ~~ ............................. ~ i(as on t e tax roll or; latest ........... '~deed)''~ If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) u er s License ....................... Plumber's License No ......................... Electrician's License No.' .~ .C.~LC.~ ~ ~ ....... Other Traders License No ...................... Locatio~ of land on which proposed work will be dohe ................................................ ......... .V..?..o. ........ o.c ............ d ................. House Number Street Hamlet / County Tax Map No. 1000 Section.... ..~..~.. .......... Block ..... '. ............ Lot ................. 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 ...~ ~-,.~ i C~.C~c~O~, ............................................. b. Intended use and occupancy ........................................ 3. Nature of work (cheek which applicable): New Building .......... Addition ...... ' .... Alteration .......... ............ Other Work ....... : ....... .'. ' .':. Repair .............. Removal .... ' ......... '.. Demolition · ~ ~ ~ - (De nption) t. Estimated Cost ...... .O. .......... i... Fee ..................... ~ ........ ~. ~' (to be paid on filing this application) L If dwelling, number of dwelling units ............... Number o f dwelling units on each floor ................ If garage, number of cars ........................................................................ L If business, commercial or mixed occupancy, specify nature and extent of each type of use ..................... 1. Dimensions of existing struetures, ifany: Front ............... Rear .............. Depth ............... Height ............... Number of Stories .............. : ......................................... Dimensions of same structure with alterations or additions: Front ................. Rear'. ................. Depth ...................... Height ...................... Numl~r of Stories ............. . ......... g. Dimensions of entire new construction: Front ............... Rear ............... Depth .... :-. ......... ;. Size oflot: Front ...~7.O ............... Rearii~i~i'~iiiiiiiiiiill ~)~3[1~ i~)z~;: ...... ..... ). Date of Purchase .... l.~ .6.7. ...... , ......... : Name of Former Owner . .~.0 .~ .~. !.t.~ ....... 1. Zone or use district in which premises are situated ........................... [ ......................... L Does proposed construction violate any zoning law, ordinance or regulation: ................................ I. Will lot be regraded ........ ; ~ .................. Will excess fill bo removed from premises: _Yes ~lo L Name of Owner. of premises ~."~-~,] .~..~.,i.,'. Address ~.~.~ .~ ........... Phone No..7.~;f. 7.~.q.~..~... Name of Architect . ~..~].~,! ........... ~. ........ Address ~..~l hl, i ~41 ~i,~ ~. Phone NONo.~.e~ ........ ~.. ff.~..~./. ...... .~. Name of Contractor ~.4~.~ .[~e). ,'f~ .... Address .Phone PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from :operty lines. Give street and block number or descnptzon according to deed, and show street names and ,nd~cate whether ~terior or comer lot. ./ ~ove named. being duly sworn, deposes and says that he is the applicant e is the ........................ : ._ ................... . .................................... . ~ (Contractor,~gent, corporate officer, etc.) f said owner or owners, and is ~u~~ ?,~r..orm or have performed the said work and to make and file this · pplication; that all statements c~talned in this application are true t° the best of~fi~wledge and belief; and that tho 'ork will be performed in the manner set forth in the application filed therewith,,,/ ...... ...... .... ( ~-""~'~~r'~'a'''~'''''''~ X S Of N~ ¥0~ · · · · ~ .... .m . . ~ ..............