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Home My WebLink About13059-z I~OBM NO, ~ TO~VN OF Sou'rHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. ¥, BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Building Inspector. ~, ,..../..~ ..... Rev. 6/30180 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 7654802 ~xa,nined . "d//~q% 19..~. ~ ,pl, ..... , l ..Permit R e c e .i, v e d. ~""/'/,~' )isapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 :ts 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 ,r areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- ation. 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 hall 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 hall have been granted by the B!ailding Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the luilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or {egulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. ?he applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to tdmit authorized inspectors on premises and in building for necessaryjnspections. //'/2 ! _ ~ ,g/~r .......... . ......... .. ......... : ...... * ,~..Cy'~ff~,~ ~','~,~ Z~A~',~'. gi';~a~)~ f apphca/~r name, ifa corporation) ................... y ............. ./. (Mailing a~dd~ss of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ame of owner ofpremiaes .... ................................................ H (as on the tax roll or latest deed) If applicant,..g~/,~/, .is'a -"'~--.c°rp°r~'gti°n'~ ~a~, o f~ ~ duly_, authorized officer. · .~.-.. ,~,~' -='-~: .-'-"../., ..'5'.~.. l ............. (Name anfftitle of 4orporgfl5 officer) Builder's License No .......................... Plmnber s License No ......................... Electrician's License No ....................... Other Trade's License No ...................... Location of land on which proposed work will be done .................................................. }louse Number Street Hamlet County Tax Map No. 1000 Section t~ ff 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 .. ~./..'~..~../fl../..~ ..................................................... .- . . : ...... 3. Nature of work (check which applicable): New Building ..... ' ..... Addition .. ~ ....... Alteration ..; ....... Repair .............. Removal .............. Demolition ........... 4. Estimated Cost .... '"~.7; .~.~..~.T7 ........................ Fee 'ff~., ........ f~ ........................... '°' (to be Paid on filing this application) 5. If dwelling, number of dwelling units ............... Number of dwelhng umts 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 ............ l ..... Rear .................. Depth ...................... Height ...................... Number off'Stories ...................... 8. Dimensions of entire new construction: Front ............... Rear ................ Depth ............... Height ............... Number of Stories ................. . ....................................... 9. Sizeoflot: Front ...................... Rear ...................... Depth ...................... 0. Date of Purchase ............................. Name of Former Owner ............................. 1. Zone or use district in which premises are situated ...................................................... 2. Does proposed construction violate any zoning law, ordinance or regulation: .... i .... ~'~' ................... 3. Will lot be regraded ........................... Will excess fill be removed from premises: Yes ' No of premises Address Phone No ' 4 Name of Owner ' Name of Architect ..; ........................ Address ............... i ....Phone No, ...... ~ ........ Stone of Contractor .......................... Address ............... i ....Phone m~tfl).ff~.~'. .~.~!.~. · PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and, re&cate all set-back dimensions from street names and indicate whether .roperty lines. Give street and block number or description according to deed, and show lterior or corner lot. TATE OF NEW YORK, S.S :OUNTY OF ................. being duly sworn, deposes and says that he is the applicant hove named. le is the ............................................................ ~ ............................. (Contractor, agent, corporate officer, etc;) f said owner or owners, and is duly authorized to perform or have perfomed the lsaid work and to m~e and file ~is pplication; that all statements contained in this application are true to the best of Kis knowledge and belief; and that the /ork w~l be perfo~ed in the m~ner set forth in the application filed therewith. ;worn to before ma this .......... ...... or .... 4ota~ Public, ...... 2~. ~ ~R~ ?[IBL~, State e~ ~ 4707878 S ~ l0 k '-6 20 179~b . N.75' Gilbert ~' ' ;~ ' '~ (o[~E°' ~' ~ I formerly. Mrs put -, F 0 i_ 3 7/~'_L3d7