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HomeMy WebLinkAbout16394-zTOWN OF $OUTHOLD 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~- 1 ~3(~4 Z Dote ..... Permission is hereby granted to: .... ..c.......~,..!~.:.~.~ ........... ~~...~.~..~.,..z,.~.~.. C~nW T~x Map No. 10OO Sectio~.J.~.~ ....... Bilk .~.~ ....... Lot No. ~.~. .......... Building Inspector. Rev. 6/30/80 BOARD OF HEALTH .... 3 SETS OF PLANS ....... 'FORM NO. 1 SURVEY · TOWN OF SOUTHOLD CNECK .......... BUILDIN(~DEPARTMENT SEPTIC FORM ............. : TOWN HALL NOTIFY $OUTHOLD, N.Y. 11971 TEL.: 765-1802 CALL ................ MAIL TO: Examined ~Q~~..~.~., 19~. 3. Approve~%'~'~7..~.~., 19 .~.'~ Permit No..~ .~..~.c}.q ..~. Disapproved a/c ~~ (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by type,~:iter 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 d, escrip~ 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~ Ordinm~ces 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 hou~ingwO)de, and regulations, and to admit authorized inspectors on premises and in j0~il.d~/ecessary i00"~ctions:// ~, .~.~ ./?.~ · '" i'~gr~ir'~'~iJpli"a~nt;or name,)~'a, orpor: ' ) / State whether applicant is owner, 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 corporation, signature of duly authorized officer. (Name and title of co.orate 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 of Iand on which proposed work will be done ................... House Number Street [Iamlet County Tax Map No. 1000 Section .{...O..~.: :; . .: ..... Block ....... 7 .......... Lot... , ........ Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premix{ and intended use and occnpancy of proposed constrnction: 3. Nature of work (check whictl applicable): New Building ... dition .......... Alteration .......... Repair .............. Removal .............. Demolition ......... ~. .. Other Work ............... ~ (Descrip.tion) E§timat~d Cost Fee ' ~ (to be paid on filing this application) 5. If dwelling, number of dwelling units ............... Number of dwelling finits on each floor ................ If garage, number of cars .......................................... i .............................. 6. If business, commercial or mixed occupancy, specify nature and extent of each !ype 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 .......... I ....... Rear .................. Depth ...................... Height ...................... Numberiof Stories ...................... 8. Dimensions of entire new construction: Front .......... ..... Rear ...... . ......... Depth ............... Height ............... Number of Stories .......................... : .............................. 9. Sizeoflot: Front ...................... Rear ..................... !. Depth ...................... I0. Date of Purchase ............................. Name of Former Ownerl ............................. 1 1. Zone or use district in which premises are situated ....................... ~ .............................. 12. Does proposed construction violate any zoning law, ordinance or regulatiou: . .! ........................... :.. 13. Will lot be regraded ........... p~. ............... Will excess fill be rem6ved from premises: Yes No 14. Name of Owner of premises ...~L....,~. .......... Address ............. i ...... Phone No ................ Name of Architect ........................... Address ............. . ...... Phone No ................ Name of Contractor .......................... Address .~ .... Phone No. 15. Is this property located within 300 feet of a tidal wetland? *~Yes ..... No ..... *If yes, Southold Town Trustees Permit maybe required. PLOW DIAGRAM Locate clearly and distinctly, all b~i}dings, whether existing or proposed, and.iindicate all set-back dimensions from property lines. Give street and block nu'mber or description according to deed, and show street names and indicate whether'+ interior or corner lot. STATE OF NEW YORK, S.S COUNTY OF ................. ................................................. being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. lte is the ........................................................... ' .............................. (Contractor, agent, corporate officer, et~.) of said owner or owners, and is duly authorized to perform or have performed thh 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. Sworn to before me this Notary Public, .'.~. ~.-...~...~...~/..,~-~. f. ..... County y No. 4707878 Su;fo k ~ Term Exp~;es ~a~ ~ ~0 ....