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Home My WebLink About16640-z I~OB~ NO. ~ 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) 1 No- ,6640 z Permission is hereby granted to: ~.~..~....~..........~..,~,~.....C~...,. ........................... .~~.._~.:~.,....t.t...~..~.t ........... ,o .~~......~..~.~......~......~~....O.....~~, · - ~ ~ ~. u.o.~.~..:...., ~....~~..~....~..~....~...,~., .............. ~~...~ ........ =t premises located at ../..l~...~..~......~...[,,*~,~ .................................................. ..... ..~..{,O...*i~} .... Block ...... .~t.) ....... Lot No / O. County Tax Mop No. 1000 Secti,o~ .......................... pursuont tO application doted ...~....~.~.......~....O., ............ , 19.?....~., and approved by the Building Inspector. Fee $~.~.'..~..~ .... Rev. 6/30/80 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined.~.~ .~'..o., 19 $ .~. Approved .~.~..~.o.., 19~. .~. Permit No..J.~.G..~..O.-?. BOARD OF HEALTH ...... 3 SETS OF PLANS ....... SURVEY .......... CHECK .......... SEPTIC FORM ............. : NOTIFY CALL ................ MAIL TO: Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. Th/s 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, bu~i~g code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessa .ry in~157~t~,n~ .~ ~r~ J /""~,,~ ,¢~ ' '7/' "' ', .... ~/ (Signature of ~pplicant, or~k~6, if a corporation) , ..... (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, .electrician, plumber or builder. Nameof owner of premises ...~ ./,.gc,~O¥c . .~...~~ .......................................... ~ (as on the tax roi1 or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) ALL CONTRACTOR'S I~UST BE SUFFOLK COUNTY LICENSED Builder's, License No ....... 5X~. ............... Plumber s License No ........ ~ ............. Electrician's License No ......... X~ .......... Other Trade's License No ............ ' .......... 1. Location of land on which proposed work will be done'....}.~..~/..O....~. . .~. &.. House Number Street Hamlet County Tax Map No. 1000 Section .... .C~..~.~ ...... Block ....... q~ .I ........ 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 3. Nature of work (check which applicable): New Building ..... ' .....~ Addition .......... Alteration .......... Repair .............. Removal .............. Demolition ............ Other Work ............... ]~ _~ (Descriphon) 4. Estimated Cost .... ~. 0~. .......................... Fee..~' ............................... · (to be paid on filing this application) 5. If dwelling, number of~welling units ............... Number of dwelling units on each floor ................ If garage, number of .ca~rs'x~.. ....................................... , ............................. 6. If business, commercial or fffi,~d occupancy, specify nature and extent of each type of use ..................... 7. Dimensions of existings c?re.' fr n_y_:Front ............... Rear .............. Depth ............... Height ........... / --.. Num. l~er 0~ries .......................... ~ ............................. Dimensions of same structure with a_!terat]~,? additions: Front .......... ~ ...... Rear .............. .... Depth ...................... Height .....'~ ................ Number Of Stories ....................... .... 8. Dimensions of entire new c~ion.:_Front ... ~... ..... Rear ...... ; ........ Depth ............... Height ............... Number of Stories ....... ~ ............... , ............................. 9. Sizeoflot: Front ................ ..... H Rear ...... ~ ............ i Depth ...................... 10. Date of Purchase ..... ~ ........... Name of"Twxrmer Owner ............................. 1 I. Zone or use district in w~.ed... ;.. ......... ~ ................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ..i ............................. 1 3. Will lot be regraded ............................ Will excess fill be removed from premises: Yes No 14. Name of Owner of premises .................... Address ............. i ..... Phone No ................ Name of Architect ........................... Address ............. ~ ..... Phone No ................ Name of Contractor .......................... Address .... : ........ ; ..... Phone No .......... , ...... 15. Is this property located within 300 feet of a tidal wetland? *Yes ..... No ~.. *If yes, Southold Town Trustees Permit may be required. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate 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. STATE OF NEW YORK, S.S COUNTY OF ................. ................................................. being duly sworn, deposes and says that he is the applicant J(Name of individual signing contract) above named. He is the ............................................................ i ............................. (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 work will be performed in the manner set forth in the application filed therewith. Sworn to before me this : .a. .o ................. .... day of.. ............. 19 .~. Notary Public ....... ?~...~.~....~.&..~..~.... County""-"l . /]~ ~ ~ NOTARY pUIiLIC. ~te of NOw Y0~kN0. 47078'/6, S~tolk Coualy ~ ol (,~ : ( ignature of appJJa'n'ti Term Expires M~ch 30,19,.,,~ · :