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Home My WebLink About15765-z I~OEM NO. ~ TOWN OF $O~THOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 15765 Z Permission is hereby granted to: ...i...].~~....~F~.....~... ...................... ................ _ _~ ,~.~.....~.~.r~..,...~m:,-.~..:~.:__., .... . ~~~~ ~ ~~ ~ .................. '~ .......................... ~ ............. ~ .................... ¢'~ ................. z ............................ ......................... : ....... .; .................. ; ...... ~ .......... . ............................... ~;~ .......... County Tax Map No. 1000 Section ...... l/...~.. ......... Block ...... ..~....~.. ....... Lot No....,~.~ .......... pursuant to application doted ...:.~.~......Z..~.. ................ , 19~..~.., and approved by the Building Inspector, Rev. 6/30/80 Examined ............N0/~ I~o 19 g... -/ Approved . .'~r~.~.. ! .b.., 1921. ~l. Permit No, ! ,~.".7.~ .~, ."~ 'FORM NO, 1 TOWN OF SOUTHOLD CItECK BUILDING DEPARTMENT :SEi"~IC TOWN HALL :NOTIFY $OUTHOLD, N.Y. 11971 CALL ,'TEL.: 765-1802 , ,, MAIL ~OARD oF HEALTH .~.,, 3 .. .S OF PLANS ..... ,, SURVEY .......... ': FORM ............. : TO: Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date .......... a. This application must be cmnpletely 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 t6 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 cmnply with all applicable laws, ordinances, buiidiag code, housing cod9, and regulations, and to admit authorized inspectors on pran]ises and in building for necessary in~ ~// (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of remises ~-,~- "~ '~. ~' ~.~- O - P ..... ;~' ........ 1' ........ , (a~ on If applicant m a corporation signature of duly author]zed officer. .............................................. (Name and title of corporate officer) - ALL CONTRACTOR'S MUS~/~ SUFFOLK COUNTY Builder's License No ...... .1~ ;~. - Plumber's License No .... Electrician's License No...i Other Trade's License No.. ~ 1. Location of,land on which proposed work will be dope: ...... .,t....~:~.:v.,.'.. :'. :'L. :¥~. ~:'::'~-.L'~:~ [.!i!t.O..R~. '.37o dM, .... House Nmnber Street Hamlet County Tax Map No. I000 Section .... l.I. .~. ........ Block.. '~'I ............. Lot...~..~ ......... Subdivision ..................................... Filed Map No ............... Lot ............... (Nmne) 2. State existing use and occupancy of premises and intended use and o/c4upancy of proposed construction: a. Existing use and occupancy ................................. b. Intended use and occupancy .... (~.}.LF0.1ll ........................................................ 3. Nature of work (check which applicable): New Building .......... Additto, Repair .............. Removal ............ Dernolition .......... ,,, ^l~orationcz' ........ ·. Other Work.,. ,'~.'~..-~-¢ ) property lines· Give street and block n}~lhbe'r or descrip,tion interior or corner lot. ~' ~ ~ ..d]t__' i (Description) 4. Estimated Cost ... .~ .............. Fee ......... I ............................ (to bp paid on filing this application) · " floor 5. If dwelling, number of dwelling units ............ Number of dwelling units on each ............... If garage, number of cars .......... , ............................................................ 6 If business commercial or mixed occupancy specify nature and exte,nt of each type of use : , , 7. Dimensions of existing structure~, if any: Front ............... Rear ...... : .' ................... NmnberofStories !.. .... Rear Dimensions of sa ne structure with alterations, or.,ad&tions:~ Front , ......... : ....................... Iteight ', ,, / Number of Stories Depth Dimensions of entire new construction: Front . Rear ; Depth Height Number of Stories 9 Size of lot: Front · Rear ' Depth 10 Date of Purchase Name of Former Owner i · 11 Zone or use district in which premises are situated ' J 12 .... or regulation: · Does proposed construction violate any zoning law, ordinance .......................... 13. Will lot be regraded ............................ Will excess fill be removed from premises: Yes 14. Name of Owner of premises .................... Address ............. I ..... Phone No .......... Name of Architect '. Address , Phone No Name of Contractor Address ' i Phone No 15. Is this property located within 300 feet of a tidal wetland? *Yes . No · If yes, Southold Town Trustees Permit mag be required. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and, indicate all set-back dimensions froJ according to deed, and show street names and indicate whethc STATE OF NEW YeP, K, S,S COUNTY OF ................. being duly sworn, deposes and says that lie is the applicar (Name of individual signing contract) ",, above named, x'~,, , He is the ...................................................................................... (Contractor, agent, corporate officer, etC., ) of said owner or owners, and is duly authorized to perform or have performed th6 said work and to make and file th application; that ali statelnents contained in this applicl~tion'are true to the best of his knowledge and belief; and that t!~ work will be performed in the manner set forth in the application filed therewith. Sworn to beforq m~ this HELEN tL DE VOE .... , ' ' 'tNOTARY PUBLIC, ~ate of New Y~k No. 4707878, Suffolk C0unt~ '7 , (Signature of appliean Term Expires M&mh 30, 19----- r