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Home My WebLink About15623-zTOWN 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) $5623 Z County Tax Map No 1000 Section .. ,,Q~,..,,~...~, ....... Block ..... ,~.,,?,., ...... Lot No ..,,0,,.,.,~,,, ........ Budding Inspector. Fee $.~..,,~...:.~. 19.'~..~., and approved by the Building Inspector Rev. 6/30/80 FORM NO 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Dmapproved a/c .......... (Building Inspector) APPLICATION FOR BUILDING PERMIT Received ........... ,19. INSTRUCTIONS a Ttus application must be completely filled m by typewriter or m ink and submitted to the Buddmg Inspector, witl sets of plans, accurate plot plan to scale Fee according to schedule b. Plot plan showing location of lot and of braidings on premises, relationship to adjoining premises or pubhc stre or areas, and giving a detmled d~scnphon of layout of property must be drawn on the dmgmm whmh ~s pa~ of th~s catlon. c. The work covered by ~ apphcahon may not be commenced before ~ssu~ce of Building Pe~it. d Upon approval of th~s ap~hcahon, the Bmld~ng Inspector wffl ~ssued a Braiding Pem~t to the apphc~t Such pen ~ be kept on the premmes avadable for mspectmn ~rou~out tko work. e. No budding shall be occupied or ~ed m whole or ~n p~t for any purpose whatever ~td a Ce~fficate of Occup~ sha~ have been grated by the B~fldmg Inspector ~PLICATION IS HEREB~ MADE to the Budding Dep~tment for the ~ssuance of a Bmld~ng Pemit pu~uant to Bmld~ng Zone Ordmance of the Town of Southold, Suffolk County, New York, ~d other apphcable Laws, Ordm~ces Regulations, for the constmch¢n of buildings, add,boris or alterations, or for remov~ or demolmon, as hereto descdb The apphcant agrees to complyI w~th a~ apphcable laws, ordinances, building code, housmg code, and regulahons, and admit authorized mspectom on premmes and ~ budding for necessa~ mspect~ons .... (S~gnatu/~f apphcant, or ~e, ~f a corporahon) ................... Z .... (mazlzng address oT applzcant) State whe~er apphcant ~s own~er, lessee, agent, ~ch~tect, engineer, general contractor, elecmcmn, plumber or build. $~eof ownerofprem~ses ~ . %*k~,'~~ (as on the tax roll or latest deed) If apphcant ts a coTpo¢nq~; ~)a~re o~ ~ly aBthonzed officer (~iand t~tle of~ate ofdcer) Bmlder's Lmense No. - Plumber's L~censeN6 '" '. '_ ~-. .... Electrician's License No Other Trade's License No Location of land on whmh proposed work will be done ttouse Number Street County Tax Map No 1000 Section ~ '~ Block Hamlet 2 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 O~'>&~c~ l~r~ q:~ , b. Intended use and occupancy Cl.o,S'~- )~'¥ '~fvxe..g~ ~'41~ ~X'"k.~.~:~.v~..~t~,~X~ 3 Nature of work (check which applicable) Repair .~[~_ . ~[~emoval .. 4 EstunatedCost ~) O.t> .~.... 5 New Bmldmg ........ Ad&t~on ..... Alte rat_Bkon .... ..... Demohtlon ............ Other Work ~*-~.... (Desenptmn) .......... Fee o~ ~'.,. O. (D ............. (to be prod on filing thas apphcatlon) If dwelhng, number of dwelling umts ............ Number of dwelling umts on each floor ............ If garage, number of cars I 6 If business, commercial or maxed occupancy, specify nature and extent of each type of use .............. 7. Dtmenmons of exmtmg structures, ff any Front . .. Rear ........ Depth .......... Height ......... Number of Stones Dimenmons of same structure with alterations or additions Front .......... Rear ........... Depth .......... Height ............. Number of Stones .................. 8. Dnnenmons of entlre new cbnstructlon Front .... Rear ............. Depth ......... Height .... I Number of Stones .................................... 9. Size of lot Front .... Rear .............. Depth ......... 10 Date of Purchase .......... Name of Former Owner ............ 11 Zone or use district in whxch premises are situated ...................... 12 Does proposed construction violate any zoning law, ordinance or regulation ..... 13. Will lot be regraded ............. Will excess fill be removed from premises Yes 14 Name of Owner of premises ........ Address .......... Phone No ........... Name of Architect ........... Address ............. Phone No. Name of Contractor ............. Address ............... Phone No ........... 15. Is thzs property located withznl00 feet of a txdal wetland? * Yes ..... No ..... · If yes, Southold Tow~ Trustees Permit may be required. PLOT DIAGRAM Locate clearly and dlstmcffy all bufldmgs, whether existing or proposed, and. re&cate all set-back dnnenmons fro property hnes. Give street and block number or descnptlon according to deed, and show street names and in&cate whetl mtenor or corner lot STATE OF NEW YORK, COUNTY OF. SS (Name of individual signing contract) above named OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY being duly sworn, deposes and says that he m the apphc~ 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 t application, that all statements contained m thru apphcat~on are true to the best of hm knowledge and belief, and that work will be performed in the manner set forth m the application filed therewath. Sworn to before me this ....... ~... ~ day of... .., ...... 19(7 Notary Pubhc, '~. I~-~&D[V0E ~/:'' ~..E~U.~. County ...... .~ ~, ~ ~ PUStlC, ~ of ~w Y~ (Signatu~ of apphca . ~ 4707878. Suffol[ ~u~ ~v