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Home My WebLink About16363-zTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y, BUILDING PERMIT CTHIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~- 16365 z Permission is hereby granted to: /~ ~ ! / .... ,...~....~~.~,~,,,...~ ~~....~...~..,....~.....~.~:...~. _, ,o.~~....~~., ....... ~......~~....'.~ ...................... pursuant ,o application dated ...~.~.~...J....~... ............ , 19.?...~.., and approved by the Building Inspector. Fee $....~....:......../'..... Building Inspector Rev. 6/30/80 BOARD OF HEALTH ...... 3 SETS OF PLANS ....... 'FORM NO. I SURVEY .......... TOWN OF SOUTHOLD CHECK .......... BUILDING DEPARTMENT SEPTIC FORM ............. : TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1803 Examin ~4.~..~..t"v., 19~ .~ Approve~M~ .~..?'...~?.., 19~?. Pe=it No].~ .3~ ~ Disapproved a/c ............................... .....~ (Building Inspector) APPLICATION FOR BUILDING PERMIT NOTIFY CALL ;j ............ MAIL : ~ ~~~ Date ................... 19... 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 adjoining premises or public streets or affeas, 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 premises and in building for neces~ryf//~ ~ -~/~/*/~/f ~inspecti°ns'D ~ ~) fi(Signature of app i ; , ' p ' ) (Mailing address of applicant) II~..~. State whether applicant is_owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. (as on the tax roll or latest If applicant is a corporation, signature of duly authorized officer.' ~,~T~: ................................................ (Name and title of co,orate officer) . ~:NOTI~W ........ ~fLD~4 ~7'., ALL CONTRACTOR'S MUST BE SUFFOLK COUNTY LICENSED 7~$~.~O2 Builder's License No. ~ ~ ~ ¢ Plumber's License No ......................... FOB ~(tU~?, Electrician's License No ....................... & NS~JLAr, Other Trade s License No ...................... ~,"~ ALL O' 1. Location of land on which proposed work will be done ......................... "~,~S'~x~ .................... ~.~ .Gr¢~t,~lt%~ House Number Street ~amlet County Tax Map No. 1000 Section .. ............ mo~ ...N ............. 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 . ~.~ ~ .~ .~.~....~ ~.,~' ./.%~-r...&k~: ~. [~ ~. r~..~...~.~ ...................... b. Intended use and occupancy . · · .57. C.' ...................................................... 3. Nature of work (check which applicable): New Building .· Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work...~--'.~ c~c_~., .... (Descrip~tion) 4. Estimated Cost ..................... Fee ..... ..~ .O ........................ ' (to be paid on filing this application) 5. If dwelling, number of dwelling!units ............... Number of dwelling units on each floor ................ number of cars If garage ........................................................................ 6. Ifbusiness, commercial or mixed occupancy, specify nature and extent ofeach type ofuse .:....'...'.. ......... 7. Dimensions of existing structures, ffany: Front ......... I .......Rear .............. . Depth. ............... Height Number of Stories Dimensions of same structure With alterations or additions: Front ................. Rear .................. Depth ................... ,.. Height ...................... Number of Stories ...................... ---8. Dimensions of entire new constructmn: Front .......... ' ..... Rear ............... Depth ............... Height ............... Nun~ber of Stories ...... .................................................. 9 e. ofl t Fro } R ' Depth · olze o: nt ................. ear ........ ~ ....,.. ............................. 10. Date of Purchase .......... , .................. Name of Former Owner ............................. 11. Zone or use district in which pr~mises are situated ..................................................... 12. I)oes proposed construction violate any zoning law, ordinance or regulafion: ................................ 13. Will lot be regraded ........ ; ................... Will excess fill be removed from premises: Yes No 14. Name of Owner of premises .. T ................. Address ................... Phone No~gr.q.$.7.7 ...... Name of Architect ......... , ................. Address ................... Phone No ................ Name of Contractor ........ ~ ................. Address .... : .............. Phone No ................ 15. Is this property locatediwithin 300 feet of a tidal wetland? *Yes ..... No ..... · If yes, Southold Town Trdstees Permit maybe required. ~ PLOT DIAGRAM Locate clearly and distinctly ali buildings, whether existing or proposed, and. indicate all set-back dnnenmon~ from property lines. Give street and block number or description according to deed, and show street names and indicate wh6ther interior or corner lot. STATE OF NEW YORK, i!S.S COUNTY OF .................. (Name of individual signing contract) above named. ...... being duly sworn, deposes and says that he is the applicant 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 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. Sworu to before me this ........................ day of .... ~ ........... 19o~. · Notary Pubhc ...... ~. .. .................. N0[.AI~. PIIIII. I¢, 8bl~ dJ~w.Y~ /1 /'~ (Sienature of ao¢licant . ~ 4707,878, Suffelk ,'~uWTo // .... ) i ferm Expires I~rch $0,