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Home My WebLink About15702-zTOWN OF SOUTHOLD IUILDII~ DEPARTMENT TOWN HALL SOUTHOLD, Iq. Y. BUILDING PERMIT CTHIS PER/V~IT MUST BE KEPT ON THE PRE/VIISES CC~MPLETION Of: THE WORK AUTHORIZED) JLL DQte Permission Is hereby granted to'. County Tax /~ap No. ~ursuant to Rev. 6/30/80 OU~DATIO.~ ( 1 st) OUNDATIO~ ( 2nd ) OUGH FRAME & FLUMBING NSULATION ?ER N. Y. STATE ENERGY CODE FINAL ADDITIONAL COMMENTS: Dmapproved a/c ..... BOARD OF HEALTH ...... 3 SETS OF PLANS ....... FORM NO I SURVEY .......... TOWN OF SOUTHOLD CHECK .......... BUILDING DEPARTMENT SEPTIC FORM ............. : TOWN HALL NOTIFI $OUTHOLD, N.Y. 11971 TEL..765-1802 CALL ................ MAIL TO: Permit No. /.~-~ ~)..~---~ (Bu'W&ng Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date a This application must bt completely filled m by typewriter or in ink and submitted to the Budding Inspe~ sets of plans, accurate plot plan' to scale· Fee according to schedule b. Plot plan showing location of lot and of bmldmgs on premises, relationship to adjoining premises or pubhc sh or areas, and giving a detailed description of l~4~t~t of property must be drawn on the diagram which is part of this a, cation. I .,f%~ c. The work covered bg. lhiOl~l~t~,~$ ma~r~b~ommenced before issuance of Building Permit. d Upon approva~f~t/.~l[E~_G.ntttlle ~t,~g~l~ect.gj~lll issued a Bufldmg Permit to the applicant. Such pe shall be kept on the prlghl~l"ava~ti0e~[c~o}i'_hbSqtl~h~[5~_e work. e. No bufldmg shat1 (~cu~'~t ~%~.~l~i$t~l[~[b'~T6r any purpose whatever untzl a Certificate of Occup~ shall have been granted [1~ . .t~ll~n~_ ~ "~-- _~.~~P~%~'~ APPLICATION IS Ht}~I~N~d]~ t'o..~K~,~i~l.i~g Department for the issuance ora Bmlding Permit pursuant tc Building Zone Ordinance ~t%.* T.~o .~[.~I~..1~. tlffolk County, New York, and other applicable Laws, Ordinanc Regulations, for the consti2xotiori ~.I~ ,l~iJ/'galfgg, additions or alterations, or for removal or demolition, as hereto descn The applicant agrees to co~.'p~y ,l~l~a[1 apphcable laws, ordinances, bufldmg code, hou~ng code, and regulations, an admit authorized inspectors ~n premises and m building for necessary iFl~pecti, o,np I . .~ .~. :.~. ,~r(~ ................ i /J~Slgr~ture of appt}cant, or. amc, if a corporation) (Marling address of applicant) State whether applicant is owner, lessee, agent, architect, enlgneer, general contractor, electrician, plumber or buff f?~t . /~" ~,~ 3/7 ............ ' ~/~,/ i',,':~6(,L;'~; ~L~:' .... Name of owner of premmes ,r~'~'~ ~ ~f(-/Jf ?',/~4.q ...................... If applicant is a corporation, signature oftduly authorized officer FE~ ....... ~¥ . , - iName and title of corporate officer) ALL CO};TRACTOR'S MUST Builder's License No Plumber's License No. Electrician's License No Other Trade's License No Location of land on which proposed work wllJ be c}oaej House Number Street County Tax Map No 1000 Sechon ~ ~. BE SUFFOLK COUNTY LICENSED Block tNSUL~ rtO~' COOE~ ~Ol ~S~S~ ~ ~ fz~ ..... Hamlet ..... not . .? ........ 2 Subd~v~sion .. Filed Map No Lot (Name) State ex~snng use and occupancy of premises and intended use and occupancy of proposed construction a Exmnng use and occupancy . /~,fq.r] ............... b Intended use and occupaimy ~/~,72'~ ... 3 Nature of work (check which apphcable) New Burldmg .. Add~tmn ..~ Repair ... Removal . Demoht~on ...... 4 EstlmatedCost ')~O~) [ .... -Jfm ................... Fee .,-%~z~. ,. ..... .... Alteratmn Other Work ........ (Descnptmn) (to be prod on fihng thru apphcatmn) ·.. Number of dwelhng units on each floor .......... 5 Ifdwelhng, number ofdwelhng'umts If garage, number of cars .. ~ ...... 6 If business, commercml or m~xed occupancy, specify nature and extent of each type of use ........ 7. D~menmons of exmtmg structures, ~f any Front . .. Rear ...... Depth .. . Height ....... Number of Stones ................................. Dm~enmons of same structure vClth alteratmns or add~tmns Front ........... Rear Depth ........ ~ Height ............ Number of Stones .............. 8. Dunenmonsofent~renewconstmchon Front ..... ~/. R~r ..~,~,./ .... Depth ......... 9. S~ze of lot Front ..... ! ........ Rear ...... J7 .... t-Depth .............. 10. Date of Purchase ~ .... F ......... Name of Former Owner ...................... 11 Zone or use district m which premises are mtuated ........................................ 12 Does proposed constructmn vldlate any zomng law, or&nance or regulation .......................... 13. Will lot be regraded ..... ~ .......... 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 ...... I ........ Address ............... Phone No .............. 15. Is this property locatedI withzn 300 feet of a tidal wetland? *Yes ..... No ..... ~If yes, Southold Town Trustees Permit maybe required. , PLOT DIAGRAM Locate clearly and d~;tmctly ali buddings, whether existing or proposed, and red,cate all set-back dnnenmons from 9roperty hnes G~ve street and block number or descnphon according to deed, and show street names and indicate whether ntenor or corner lot. iTATE/QF NEW ~'(~j~RS,.,..~/d ~ ~ 2OUNTY OF..~2 b ~ ,.~----~.,,,~1~ ..... be,ng .u,~ .worn, ...o~.~ .n. says fl, a, ~ //''~ (Na~ ~n&wdual mgmng contract) tb~named Is the ............. ~ ................... ~ ..... ~ ........... (Contractor, agent, corporate officer, etc.) smd owner or ownem, ~d m duly authomed to peffom or have perfo~ed the said work and to m~e and file pphcatmn; that all statements cont~ed m th~s apphcatmn are true to the best of bm knowledge and behef, and that the york w~l be perfo~ed m the m~ner set for~ m the apphcation filed therewith. ,worn to before me thru ....... ~ .... dayof...~r ~.t.~.. ,19~ .... Coun ,,, ~ , rtL'A~HANNN~ILLE ' ~/- ~ .............. ;2 '~ .... ~'' · -- ~. ~,~, ~ State of New York / / // t~arure ot appncanr) N~ 52-8125850, Suffolk ~ ~ ~erm E~res ~er ~, 19 ~ ~