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Home My WebLink About15776-z FOBM 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 ^UTHORIZED) N_o 1577~,z County Tax Map No. 1000 Section ..... .L./.....~.. ........ Block ...... ..~.....~'... .... Lot No ....... ~....~ ........... / pursuant to application dated -~Ou~LeJ~. Ig~..l., and approved by the Building Inspector. Building Inspector Rev. 6/30/80 Examined ................. 19... BOARD OF HEALTH ...... ~ 3 SETS OF pLANS ....... 'FORM NO. I :' SURVEY .......... ~ CHECK ~ ' TOWNOF~SOUTHOLD · ....... ' · BUILDING DEPAR~'MENT SEPTIC FORM · TOWN HALL NOTIFY $OUTHOLD,'N.Y. 11971 CALL ................ TEL.: 765-1802 MAIL TO: Approved ................ ,19.., Permit No ............ Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR, BUILDING PERIVHT 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 a'djoining 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 preI~/iises and in building for necessa~ns. .~..~ .~.., (Signature of applicant, or name, if a corporation) (Mailing address of applicant) State whether applicant is pwner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ... ~ ............................................................ (as on the tax roll or latest deed If applicant is a corpo[ation, ~ignature of duly authorized officer. (Name and title of corporate officer) · ALL CONTRACTOR'S MUST BE SUFFOLK coUNTY LICENSED Builder's License No ..... ~ ................ Plumber's License No ...... ~'. · · ."~. · · ·; ........ Electrician's License No ......... ~. · Other Trade's License No .............. ~ · 1. Location oflarid on which proposed wor~ will be d0ne] .~. ............................................... ..... .... ..... ...................... House Number Street l-lamlet County Tax Map No. 1000 Section ...... /./..,~ ....... Block ...... .(~...~,. ...... Lot .... ]..7. ............ ' Subdivision ............................ ; ......... Filed Map No ............... Lot ............... (Name) 2. State existing u~e and occupancy of pj~mises and intended use and occu~pancy of proposed construction: a. Existing use and occupancy ...~....'.~.~..~....1 ............................. b. lntendeduseandoceupancy .*'.'" - ~.,L~.'.~..~.'.~.~' ~ ~ ........... : .......... New Buildl ' Addition" ' Alter tion Nature of work (check which applicable): ng .. ............i ...... a .......... Repair ............ Removal ....: .......... Demolition ........ ....' [. Other Work ............... ~ .... , .... ~ ~, . ~ ~ i (Description) Estimated Cost .'. · · (to be p~id on filing this application) 1 f dwelling, number o f dwelling units .............. Number of dwelling units ion each floor ................. If garage, number of cars ..................................................................... If business .................... commercial or mixed occupancy, spe~if~/nature and extent of each typei of use l)imensions of existing structures, if any: Front Rear ' l)epth lleight ............... Number of Stories ............................. i ......................... Dimensions'of same structure .... 'Front ' ' ' ~ R~ar wxth alteraQons or add~tmns: .............................. l)epth ...................... Ileight ...................... Number of Stories .................... Dimensions of entire new construction: Front ....... . ..... Rear . . ~ Depth lteight ............... Nmnber of Stories ............................. i .......................... Size of lot: Front Rear " Diepth Date of Purchase ............................. Name of Former Owner .. i .......................... Zone or use district in which~premises are situated Does proposed construction violate any zoning law, ordinance or regulation: ..... i .......................... Will lot beregraded............................' Will excess fill be removed from premises: Yes No Name of Owner of premises Address ' Phone No Name of Architect · Address i Phone No Name of Contractor Address : ~ Phone No is this property located within 300 feet of a tidal wetland? *Yesi ..... No ..... ¢{If yes, Southold Town Trustees Permit maybe required. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indiCate all set-back dimensions from perty lines. Give street and block number or descripf!on~according to deed, and show ~treet names and indicate whether .rior or corner lot. t.,TE OF NEW YORK, S.S JNTY OF ................ .-. (Name of individual signing contrac named. .......... being duly sworn, deposes and says that he is the applicant s the .............................................................. ~ .......................... (Contractor, agent, corporate officer, etc.) i aid owner or owners, and is duly authorized to perform or have performed the said work and to make and file this ication; that all statements contained in this application are true to the best of his l~nowledge and belief; and that the k will be performed in the manner set forth in the application filed therewith. ,rn to before me this ............ ....... da× of ..... .... , ?.7. ary Public,. ~-~.'~f... ~:. ~..g<..~/..~.: ........ CountY ~~~'~~~ .... ~10 ~t£LE~ ti. D£ V0~. (Signature of applicant) TAllY PLSLIC, State of New York No, 4707878 Su~lolk C~tmtlq.-~ Terro I:xp re~ M~ch ~0,