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HomeMy WebLinkAbout16390-zTOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y, BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLE'rlON OF THE WORK AUTHORIZED) ~.~.~.~..~.:~.,...u.~.?....~:.. ~o .~ ........... ~ .............................. ~t premises I~ofed ot ............ ~ ..... ;; .............. Coun~ Tax Map No. 1000 Section ..... l.~.~ .........Bl~k .......~ ....... Lot No ...... ~. .......... pursuant to application doted ..~~.~,.:,.....'~,-,~ Building Inspector. and opproved by the Building Inspector Rev. 6/30/80 'FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL BOARD OF HEALTH ...... 3 SETS OF PLANS ....... SURVEY .......... CHECK .......... SEPTIC FORM ............. : NOTIFY $OUTHOLD, N.Y. 11971 ~ TEL.: 765-1803 CALL ' ' ~ ' '-' '-4 ' ;, ..... f \ MAIL TO: ~ ~Ct~L D~sapproved ~/c ..................................... ¢ ' ' ' .. ................................. ...... % / -~ ~ ~ ~ TOWN O~U~HOLD (Building Inspector) INSTRUCTIONS a. This application must be completely filled in by Wpewriter or in ink and submitted to the Building Inspector, with ~ 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 th.e premises available for inspection throughout the work. e. No bnilding 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 apphcable laws, ordinances, building code, housing code, and regulations, and to adnfit anthorized inspectors on premises and in building for necessary inspections. (Signature of applicant, or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, p[qinber or builder. ' ' ~ ¢ ~ T~© //~ ~#/ ~Y~ .~? ~. .'. .... ......... "' .................. · ................... :' · .. Z.~c,b. ~.o~.(-~ N ~c of owner of premises ........................................ ~ .~ ~ .... (as on the tax roll or la~~,~V~ J, ~ ' ~' ~- If applicant is a corporation, signature of duly authorized officer. NOTIFY766_1fiO2~tLDING9 A~ TODEPART[g~T.~ PM ~¢M THENr .............................................. FOUiqt}A'qO~ 'YWO ~(IU~ED (Name and title of co,orate officer) , FOF ~*C~U~;~O ~0[~t¢~5. E ALL CONTRACTOR'S MUST BK~SUFFOLK COUNTY LICENSED [tOU~.5?.~ ,~A~q~4L~, & ~,,~.,L}M~iN(~ Builder's License No .................. 3, ff~.>H ,a~ ~0 Plumber's ~Jcense No ......................... B~ (,f);:~Fi Eft_ ~.(~t,;, C O Electrician's License No ....................... T~ RF[Z~®','-*~E~¢'~ R (~ t'He ~'~ Other Trade's License No. C{~'~¢~ ¢4~"~' ~:.:~'~:}~¢¢,.~.~.:0¢ I. Location of land on which proposedwork will be done .................................................. .... ............. .............................4¢c, .............. ltouse Number Street Hamlbt County Tax Map No. I000 Section .................. Block ................ Lot ................. Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy .... ~. ~./~. ~./.~..~ ~...T..-~..~'.~ ~/?, [ ................................. b. Intended use and occupancy ...~..-- ...................................................../~...~.~J~.~.~.. 3. Nature of work (check which applicable): New Building ..... ' ..... Addition .......... Alteration .......... Repair .............. Removal ..... ' ......... Demolition ............ Other Work ~..~.~.~. ...... ' Z/(./(. 7/, 0.? (Descrip~tion) 4. Estimated Cost ..... ~... ....................... Fee ...................................... · (to be paid on filing this application) 5. If dwelling, number of dwelling 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 ...................... Height ...................... Number of Stories ................. , ..... 8. 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 ............................. 1 1. Zone or use district in which premises are situated ..................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ............................ Will excess fill be removed from premises: Yes No 14. Name of Owner of premises ~ ~--YlS..[3}.~.Lt~: ..... Address/p.~.~..~.~¢~.S. fie. .qi4{-.~f(P~oten~No..~. ~.'7~.~.. ~.~... Name of Architect .... Address., , Phone No , . Nmne of Contractor 1. toil..~.O.,{~.~.~a4/. ~ ....... Address(/~)~.. ~t~/ff/./~..~gar( Phone Noo<'7?fl~.5 ?/.' ~.'~] ]] 15. Is this property ~ocated within 300 feet of a tidal wetland? ~Yes ..... No ~(... *If yes, Southold Town Trustees Permit maybe required. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all sbt-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. STATE OF NEW Y~.K.,fl~Tfl pff S S COU~N~rY OF. ~,f..~--"~'~. · .t~'t~- ..t~.(,, · .............. (Name of individual signing contract) above named. being duly sworn, deposes and says that he is the applicant (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 hisknowledge and belief; and that the work will be performed in the manner set forth in the application filed themwith] Sworn to before me this ............. ;,.c~...~...dayof..~.~4~. ...... ,19..?//~ {lutllIl~l ~'~,.~_ ~/~ , ~ (Signature of applicant) I