Loading...
HomeMy WebLinkAbout16366-z IPOII~ NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT CT'HIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 16366 Z Permission is hereby granted to: . .... ~.~,...~.:~..,. JJ...'l..~....-z. .................... ,o ¢'-'° '~ 6/- o ~ ' at prem's s I~ ted at .~.M....&~ ...~..~ .......... ~~ .................................... ......................................................................................... CounW. Tax Map No. 1000 Sectio~.~..~ ....... Bilk .....~..~ ........Lot No...).~.~..~,q... pu~uan' to application dated ...~.~....L.~ ........... , 19~.3.., and approv~ by the Building Inspector. Fee $...~....: ............. Building I~tor Rev. 6/30/80 BOARD OF HEALTH ...... 3 SETS OF PLANS ..... · FORM NO. 1 SURVEY . · TOWN OF SOUTHOLD CHECK - BUILDING DEPARTMENT SEPTIC FORM ............. : /OWN HALL NOTIFY SOU/HOLD, N.Y. 11971 TEL.: 765-1803 Examined~(~.~..~..~.., 19~ ?. Approve~..~o. ?'..~..~. ., 1967. Permit No.]..(q.~. ~.~..~... Disapproved a/c ............................. .....--~ (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS CALL ................ MAIL TO: Date ,....~/..~.~.~.-., a. This application must be completely fiiled 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 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 for necessary in tio s. admit authorized inspectors on premises and in building - /(Signature of atglglicant,~or nam_d01f a corporation) (Mailing address ot appticant) v State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises. ~'~'~t~ '~'~' ~ '~' "' '" D' ~~'*~"~ ....................... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No. ~'~11~..~ ........... Plumber's License No. ' Electrician's License No ....................... Other Trade's License No... ................... .~.,i.,i.,i.,i.,i.,~ ~ ~ 1: Location of land on which proposed work will be done..~. ~.~. ~..:..~4~.~. .... ~.t ~,-a~,. ~.~. ..... 'oH~usel~:~l~'~}'~a'~': '~' ~' '' '~;r;;; ~~e.. ,~.. .... ,~.,..~ ....... : ............. mum Der Hamlet County Tax Map No. 1000 Section ...... .~.~ ......... Block ....~ ............. Lot...].~...'P..~. ......... Subdivision ..................................... F}led Map No ............... Lot ............ :. · · (Name) 2. State existing use and occupancy of premises and intended Use and occupancy of proposed construction: a. Existing use and occupan.cy .... ~.~. ~.~ .~ .... r,~. ~. ~,..~... ~. ~. l~['d~.~]~. .... b. Intended use. and occupancy .: ....... ~,~ ~-, ........... : ........' ......... 3. Nat~re of work (check which applicable): New Building ..... ' ..... Addition .......... Alt,e. ration .......... ......... . ..... Removal .............. Demohtion .  ' (D ripli ) , esc on 4. Estimated Cost ........... ~.~.iI~., .~.~P ............. Fee ...................................... ' (to be paid on filing this application) 5. If dwelling, number of dwellin~ units ...... ~.. ...... Number of dwelling units on each floor ................ If garage, number of cars .... ............... -~-. . ~ ................... : ..................... 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ..... ; ............... 7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ........ ] ............................................... Dimensions'of same structure with alterations or additions: Front ................. Rear .................. Depth ................... i... Height ...................... Number of Stories ...................... 1 1. Zone or use district in which p~emises are sit"~t~ated ......... ~..--. ~., ................................. 12. Does proposed construction vi61ate any zoning law, ordinance or regulation: ...... ,~.41~. .................... 13. Will lot be regraded..........................i . . . Will excels fill be removed from premises: Yes No Name of Architect ......... i ............. Address .. Phone No ............... 15. Is this property locatedlwithin 300 feet of a tidal wetland? *Yes ..... No *If yes, Southold Town Tr0stees Permit maybe required. PLOT D~AGRA~ Locate clearly and distinctly al! buildings, whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. FOLLOWING ~N~P~CTIONS: ROUGH ¢~AMiN~3 ALL CO~SY~tJCT~Om T~ REQ(J~Fi~NTS Of- ~E N.Y STATEOFNEWYO~RK...~ i~,. ./9/ .aa~;.,~. a~..__e~7. ~ .,. ~ ¢~. ~ ~ .'.. ~. ..... bezng amy sworn, deposes and says that he is the applicant -- (Name ~individuaI sig~ contract) above named. ; He is the ..................... ~ ........ . ............ , (C~, corporate officer, ~.) of said owner or owners, ~d is du~y authorized to perform or have perfomned the said work and to m~e and file this application; that all statements contained ~ this application are true to the best of his knowledge and belief; and that the work wHl be perfo~ed in the m~ner set forth in the application filed therewith. Sworn to before me this ......... / 7 ............. o,.. Nota, mublic~ ~~ .-.~ . NOTA8Y pUBLIC, State . -- Commission Exptres ~ C ©'o~ 0'~o7~/ it t~ 0 U