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Home My WebLink About13238-Z "FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined . .~(~'..'-3-P:~... ~ .... 19 ~.~. .~__~....e:v. 9 .... 19 .~.~. Permit No..J. '.~..~..~-?..~. Approved Disapproved a/c ..................................... ................................ iV'i'2 i . g ....... (Building Inspector) APPLICATION FOR BUILDING PERMIT Received ........... ,19.,. Date ................... 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, x ......c_.,:. ......... (Signature of applicant, or name, if a corporation) · .~, .~....~ ~... ¢~l... ~.,.7.:, .U. ~..~..v.,, (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ... ~..o¢.,¢..~.%~. ................................................................................... Name of owner ofpremises ...deNE.,~....~.':..&({~.~ ............................................... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ........................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... Location of land on which proposed work will be done .................................................. ..... .~..~..~..ss ........... ~,o~ ~. ~. ~/.od ........... .~...~.~..4. .......................... ttouse Number Hamlet County Tax Map No. t000 Section .... /.."Ir..~. ......... Block .... ~.0~.. ......... Lot..C).~ .fy ............ 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 .... /~¢ '~q-d~ c. b. Intended use and occupancy ...... ~. ?' '~r' .C ........................................................ 3. Nature of work (check which applicable): New Building ..... ', ....'Addition .......... Alteration . ..~.. ..... Repair .............. Removal .............. Demolition .............. Other Work ............... ~h cf'0 ~s,,¢./os~ 'tE~. ~'~,ja? ~c~-. t:~,~ ~,. ~,~ U~ (Description) 4. Est~ated Cost ............. ~ ~P ................... Fee .~.~.:...~ ........................... ~- (to be paid on filing this application) 5. If dwelling, number of dwelling units ...... { ........ Number of dwelling units on each floor ................ If garage, number of cm ........................................................................ 6. If business, commerci~ or m~ed occupancy, specify nature and extent of each type of use ..................... 7. D~ensions of existing structures, if any: Front ................ Rear .............. Depth ............... HeiSt ............... Number of Stories ........................................................ D~ensions of same structure with alterations or additions: Front ................. Rear .................. Dep~ ...................... HeiSt ...................... Number of Stories ...................... 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ......... ' ...... Height ............... Number of Stories ........................................................ 9. Size of lot: Front ...................... Rear ...................... Depth ....... : ............... 0. Date of Purchase . ~g~.~ ....................... Name of Foyer Owner ~:~q~ Q...~.r.;~qt.~: ........ 1. Zone or use district in which premises are situated ..................................................... 2. Does proposed construction.violate any zoning law, ordinance or regulation: ............................... 3. Will lot be regraded .... t~O ..................... Will excess fill be removed from premises: Yes No 4. N~e of Owner of premises ./~. ~ ~/~¢cJ. Address ...~4~.~.( ....... Phone No. ~.~.'~'q~ .... Name of ~chitect ........................... Address ................... Phone No ................ Nme of Contractor .......................... Address ................... Phone No ................ PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from ,roperty lines. Give street and block number or description according to deed, and show street names and indicate whether lterior or corner lot. FATE OF NEW YORK, 3UNq'Y OF ................. ................................................ being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) love named. is the (Contractor, agent, corporate officer, etc.) said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this .plication; that all statements contained in this application are true to the best of his lmowledge and belief; and that the xk will be performed in the manner set forth in the application filed therewith. yom to before me this ........... · ~?.. ~ .... '.day or ..... ~. ......... 19 )tary Public ........ ~..~-.. ~. ¢-:..~..~...~/'" ' County \ r~o 470~s.,a. sufrc~ c~,,,,,~. (Signature of applicast)