HomeMy WebLinkAbout13038-z ]FOUM' ~qO. 0
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 13038 Z
Permission is hereby granted to:
..... ~...l..~..~ ...............................................
to ..... ~..~ ....... ~ ........ ~~
ot p~mi,~, I~ated ot .............................
Coun~ To~ Mop No. ,000 Sectio~.....L.~.~ ......... B,~k ....... .] .......... Lot No ....... 2 ..............
pursuant to application dated ...(~~.......~.... ..................... , 19..~....~., and approved by the
Building Inspector.
Building Inspector
Rev. 6/30/80
'FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
,~OUTHOLD, N.Y. 11971
TEL.: 765-1803
Examined .... '~..., 19~.~.1.
Approved ....... ~ ! .~...., 193 .q. Permit No./.:
Disapproved a/c .....................................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date ..... .~.~._:6~.. ...... ~ 19~..~
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted 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 issued 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 building for necessary inspections. ~
(Signature of applicant, or name, if a corporatio, n)
. .....
.. (M~i~ing. a¢~Lr~ess, o.f~ap, plicant)
State whether applicant is ow~ner, lessee, agent, architect, enoineer, general contractor, ele ' ' , p ' ·
Name of owner of premises ...... ~.c/4'~...~:..../~.d .~.o.'~ .,~.~.~. ~'~'..~. ..........................
- (as on the ta~rroll or late&Mccad) ~ AS 14OT~D '
If applicant is a corporation, signature of duly authorized officer. DATE: ~]Ia/?~L.B.P. ~ ~ '~o 3T%
' ' FEE:./~,-~' _ BY: ___0, (~.IL..~__.
(Name and title of c6rporate officer)
Builder's License No .... ~ ................
Plumber's License No .........................
Electrician's License No .......................
Other ~rade's License No ......................
NOTIFY BUll DJNG DEPARTMENT AT
765-18o2 9 AM TO 4 PM FOR THE
FOLLC~/VlNG INSPECTIONS:
1. FOUNrhATION - TWO REQUIRED
FOR P'qURSD CONCRETE
2. ROOGH - FRAMING & PLUMBING
2. INStJLAT~N
4. FINAl CON'STRU('TION MUST
BE C'~Mm m'E FOR C. O.
ALL CON57~JCT¢ON S~'Af./. MEET
THE REOt~RFMFNT5 OF THF N.Y.
1. Location of land on which proposed work will be done .............. STA,TE · CONSTRUC'T'ION · &' 'ENF~GY ......
.... ..~.,,.~... ,~_.~.~_7~.~.¢//,.~46.7~..' ...... ~.,.,, ~_/.~'.,,C~.C~ES. NOT RESPONSI~t_E FOR'
House Number Street "~"W"rY'~DIGN ~ffm~NSTRU~ION 'E~'~Oq~,' ' ' '
County Tax Map No. 1000 Section ...... ].~ .ST ..... 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 ..... ' .~-'/,~-.. ~[;:~../,~-/'~.~- ....................................
b Intended use and occupancy
3. Nature of work (check which apphcable): New Building Addition .......... Alteration ...... .~...
Repair .............. Rem~ovai .............. Demolition .............. Other Work ...............
4. Estimated Cost ..... ~ Fee
_...
i ~'. (to be paid on filing this application)
5. If dwelling, numbar of dwellingl units ............... Number of dwelling units on each floor ................
If garage number of cars '
6. If business, commercial or mixed occupancy, specify nature and extant 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 ................... i. · · Height .............. ........ Number of Stories ......................
8. Dimensions of entire new const!ruction: 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 .....................................................
12. Does proposed construction viqlate any zoning law, ordinance or regulation: ................................
13. Will lot beregraded...........................I . . 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, indicate all set-baak dimensions from
property lines. Give street and bloc[ number or description according to deed, and show street names and indicate whether
interior or corner lot. ~.~q~ ,(/ (-0~
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
w rk will be performed ~n the manner set forth in the application filed therewith.
Sworn to before me this ~
................. de, v~of, .... ~' ......... 1
Notary Public,J/ ~YLv,^ K. ~ous~. County ~'~.~ ~a~~~
~,~.~ ~,~ ~,~ :,, ~'~ (Signature of applicant)
I