Loading...
HomeMy WebLinkAbout15975-z ~'O~E NO. il TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, H. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 15975 Z Permission is hereby granted to: ..~...IJ..~ ..... / ..................... ....~i~...-..~...L..!..~ ................................................ .... ~~,~_......~.~.:...!.~.~.~.~.. . ................. ...............__ pursuant to application dated .... ~.......~,..~. ............... , 19 .~..~.., and approved by the Building Inspector. Fee ~...~:.....,~.... ...... Rev. 6/30/80 Disapproved a/c . . BOARD OF HEALTH ...... 3 SETS OF ~L~ANS ....... FORM NO. I SURVEY TOWN OF SOUTHOLD CHECK :~':~ BUILDING DEPARTMENT SEPTIC FORH ............. TOWN HALL ~O~IY~ SOUTHOLD, N.Y 11971 TEL.. 765-1802 CALL ................ Pem~t No. l.q.s t~ ~ ~:~J ~ Ill I ........... I · [ (Bmldmg Inspector) APPLICATION FOR BUILDING PERMIT Date ..... 19... INSTRUCTIONS a. Tins application must be completely filled m by typewriter or in mk and submitted to the Budding Inspector, with 3 sets of plans, accurate plot plan to scale Fee accor&ng to schedule. b Plot plan showing location of lot and of buddings on premises, relationship to adjoining premises or pubhc streets or areas, and giving a detmled description of layout of property must be drawn on the diagram winch m part of tins apph- cation. c. The work covered by tins apphcation may not be commenced before issuance of Buddmg Permit d Upon approval of this application, the Building Inspector will ~ssued a Budding Permit to the applicant Such permit shall be kept on the premises available for inspection throughout the work. e. No budding shall be occupied or used m 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 Buddmg Department for the issuance of a Budding Permit pursuant to the Braiding Zone O~dlnance of the Town of Southold, Suffolk County, New York, and other apphcable Laws, Ordinances o~ Regulations, for the constructton of buddings, addltsons or alterations, or for removal or demolition, as hereto described The applicant agrees to comply with all apphcable laws, ordinances, budding code, housing cod~ and ;~egulatlons, and to admit authorized inspectors on premises and m budding for necessary insp~ejtlons. (Signature of applicant, or r/(,~e, if a corporation) t x l. 9. (Mailing address o¥2apphcant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder ........... OVEO_., L, AS OTm N~eofownerofprem]ses ..~O~1~ . / s . ~.eS~Cf< (as on the tax roll or lat~~~' If apphcant m a corporation, signature of duly authorized officer .... (Name and title of corporate officer) ALL CONTRACTOR'S MUST BE SUFFOLK COUNTY LICENSED Builder's Lmense No ...... Plumber's L~censeNo ......... Electrician's License No Other Trade's License No .... 15?S ~0~ ~, 1. Locatmn of land on winch proposed work will be done House Number Street .. Block .. County Tax Map No 1000 SecUon [ .0 ~ Fded Map No Subdxwmon ~)O ~)]0wa~ C0 .v:g.~ (Name) 51OTI~Y i~UILD h G DCPgtr~TMENT AT ?e6 1802 0 A~n ~O" ~M FOR THE FOL[OW'N~ tN~PFC FtO~8' FOUNDArlO~ TW~ c.~ :~'~RED FOR ~O{JR~I~ ,~O~'t ~- ~ THE ~F(]t;ff'~,~*~, ~ ~ ~ ~Y ....... Lot..~ ............ . Lot ./~ .. 2 State exmt~ng use and occupancy of premises and intended use and occupancy of proposed construchon a. Exlsttng use and occupancy b. lntended use and occupancy . 3. Nature of work (check which applicable) New Building Repaxr ........ Removal ... 4. Estimated Cost .'--.'~./.gO, OD ..... 5. If dwelling, number of dwelhng umts . ...... Addition ........ Alterahon . ....... Demolition .... Other Work .. fff~"2~. C~ (Descnphon) ......... Fee ................................ " (to be prod on fihng this apphcatmn) ....... Number of dwelling units on each floor ........... If garage, number of cars ........................................................... 6. If business, commercial or m~xed occupancy, specify nature and extent of each type of use .... 7. Dunenmons of ex~shng structures, ~f any Front .... :. .. Rear ............ Depth ............. Height ...... Number of Stones ............................... Dunenmons of sam~str~re~th alterations or addltmns Front ...... Rear ............ Depth ............ Height ............... Number of Stones .................... 8. Dunenmons of enhre new construction Front ........ Rear ............. Depth ........... Height ........... Number of Stones ............................................ 9 Size of lot Front ................ Rear ................. Depth .................. 10. Date of Purchase ............. Name of Former Owner .................... 1 1. Zone or use distnct in which premises are situated · 'c ................................. 12. Does proposed constructmn v~olate any zoning law, ordinance or regulahon ......................... 13. Wall lot be regraded ............... Will excess fill be removed from premises. Yes No 14. Name of Owner of premises ............ Address ................ Phone No ............... Name of Architect .............. Address .............. Phone No ............ Name of Contractor ................... Address ............... Phone No ............ 15. Is this property located wzthin 300 feet of a tidal wetland? *Yes ..... No ..... · If yes, Southold Town Trustees Permit maybe required. PLOT DIAGRAM Locate clearly and dlstmctly nlI buildings, whether exlstmg or proposed, and, indicate [dl set-back dnnenslons from ~roperty hnes. G~ve street and block number or descnphon accordmg to deed, and show street names and indicate whether ntenor or comer lot 3TATE OF NEW,YORK, 7OUNTY(_DOF. ~..?ff¢.~.~.. ~S S .. lCv~eY~..].' '~ ~2_~.].~ ....... being duly sworn, deposes ~d says that he ~sthe apphcant (Name of ~ndlwdual mgnmg contract) tbove named. tem the .... ~~~ ................. (Contractor, agent, co,orate officer, etc.) >f smd owner or owne~, ~d is duly authomed to perfo~ or have performed the smd work and to m~e ~d file ~s ~pphcat~on; that all statements cont~ed ~ th~s apphcation ~e tree to the best of ~s ~owledge and behef; and that the york wflI be perfomed m the m~ner set forth m the apphcatmn filed therewith ~wom to before me th~s .... ~.~ ........ day of. ~%~- ......... , 19 U OA J. CO0 ' Notary Public, State of NewYo~, ~/ No 4822563, Suffolk County~ Term Expires December 31, 19 '(% ' "" ~k~lgnature of applicant) ............