HomeMy WebLinkAbout13436-z FO~'av NO. ~
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
N°,
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
~3~ z o,. ............ ~ ............... ,,,~..~
· ~,
at prem,ses located at ................. ~..'¥~ .........................................................
County Tax Map No. 1000 Section ..... .~....~.~ ......... Block ......... .~ ........... Lot No.....~.....-T.....~. ........
~.uo., ,o o,,,,~o,,on ~o,,~ ...~.~....~..~ ............ , ,,..t~...
ond
opproved
by
the
Building Inspector.
Building Inspector
Rev. 6/30/80
FORM NO. I
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N,Y, 11971
TEL,: 765-1802
Examined .~ .~..~., 19 ~..~
Approved .~ .~.., 19 .~.t~. Permit No. ~.ik..~..~.~..~..
Disapproved a/c .....................................
Received ........... ,19...
(Building Inspector)
APPLICATION FOB BUILDING PERMIT
INSTRUCTIONS
a. Tins application must be cmnpletely filled in by typewriter or in ink and submitted to the Building Inspector, with ?
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 street.
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 issued 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 Occupanq.
shall have been granted by the Building Inspector.
APPLICATION IS tlEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to th{
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances o
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 t(
admit auth°rized inspect°rs °n premises and in building f°r necessa~t~'[ts:O[ ~-*:'~
(Signature of applicant, or name, if a corporation)
r-~- [ (Mailing_ad,dress q~ applJ, c~[nt)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electric4'an, plumber or builder.
..... ' .......................................................
Name of owner of premises ~....~OO..~.-~k~...~;~. ...........................
( )
If applicant is a corfiomtion, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No ..... ~.1/.~.. ...............
Plumber s L~cense No ....
Electrici.'m's License No.. ~)/~. ...............
Other Trade's License No..~,?//~. ...............
1. Location of land on which proposed work will be done ............................... ; ...... h ..........
................................ ................. ..........
House Number Street Hamlet 0~)~000
County Tax Map No. I000 Section . .~).I.k DO ...... Block ...~.. 1 . .~. ~). ..... Lot...~?.(~. ~:n~O ....
Subdivision ...... ,~..~-~ .................... I:ilcd Mai:)No.. ~?~.'~r~,~. ...... Lot.
(Name)
2. State existing use amt occupanqy_o~f premises and intended usc and occupancy of proposed construction:
3. Nature of work (check which applicable): New Building .......... Addition ........... Alteration ..........
Repair .............. Removal .............. Demolition ...SA( ...... i... Other Work ...............
4. Estimated Cost ...................................... Fee ..........
5. If dwelling, number of dwelling units ............... Number of dwelling umSs 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 ...................... Rear ...................... ~Depth ......................
10. Date of Purchase ............................. Name of Former Owner . ............................
11. Zone or use district in which premises are situated ....................... .. I .. ..........................
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 of Owner of premises 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. iffdicate all set-back dimensions from
property lines. Give street and block number or description according to deed, and show street names and indicate whether
interior or corner lot.
COU TY OF .......
(Na~ne of individual signing contract)
above named.
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 daid 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 manner set forth in the application filed therewith.
Sworn to before me/._~ ~-~..tthis~~ .~.
Notary Public .....
¢*m~#hsn ,..,r*, M,rch :O, I"~ ; (Signature of applicant)