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Home My WebLink About15869-z ~OEM NO. ~ TO~N OF $OUT~OL~ B~II. DIHG DEPART/~EHT TOWN HALL SOUTHOLD, N. Y. No_ BUILDING PERMIT (THIS pERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Z Date ................................. Permission is hereby granted4~: ~ ~ . .;...~j.~.....~ ................................................. ...C~...~~..~.:.~.:.....L!...~..~.~..: ......... ,o ................................ at remlses located at ...~.....~../..~.~...~.;:%~...~..~ .~..~1 ~ .~....~......~........~~ County Tax Map No. 1000 Section ../...~.....~Z. ...... Block ...... ...C~.....~:.. ...... Lot No .....L.I ................ pursuant to application dated ,,,,.,(~4~ ........ ~ .................... , 19.,~.2.,, and approved by the Building Inspector. Building Inspector Rev. 6/30/80 BLDG. DEPT. TOWN OF SOU~ ....... BOARD OF HEALTH ...... 3 SETS OF PLANS ....... No. SURVEY::: :4':'g: ' ' TOWN OF SOUTHOLD CHECK · BUILDING DEPARTMENT SEFTIC FORM - TOWN HALL NOTIFY $OUTHOLD, N.Y. 11971 TEL,: 765-1802 CALL ....... ~ ........ MAIL TO: ~ ...Q~....q. ..... 197.'/. Permit No./. bT.~..~.9..~.. Approved Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT 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 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, N...~.awX/ork, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterat~, o~for removal or dcm_ olitigaor7~ herein described. The applicant agrees to comply with all applicable laws, ordina~4~s,.b/d'.m.g c~.~, housin/~ode(anyregulations, and to admit authorized inspectors on premises and in building for nece~i~~_~~..~.~ ' ..................................... (Signature of applicant, or name, if a corporation), State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises . .gE ,t44-:n4~.[ ....................................................... frl ~ (as on the tax roll or [gt~,~deed~].~. L~.P If applicant is a corporation, signature of duly author~ed officer. P:t: .~.._~ :.~ .......... BY' .............................................. :? v t~02 ~0 ~a:~ ~'1~ (Name and title of co¢orate officer) - ~ O~.' Ow~.~(4 ALL CONTRACTOR'S MUST BE SUFFOLK COUNTY LICENSED FO~,;,~jF~,~ r~p~ .:~,~t~'} Builder's License No ...... ~ ........... ~:{~¢ ?oU~:4,, r ?C?~) 400 .,, * ~','~' ' ~L Plumber's License No .......................... ~ ~N?~'~o~c~ ~ Other Trade's License No ...................... ~,.}F ~;¢:~.~ ,(" ~ ~: .: 1. Location of land on which proposed work will be doAc .......... / ..... ~t~,~s'~ ,-~,' ~r' ~,,,e~,,.~> ~, ,-~' /.0.P .......... ................................. House Number Street Hamlet County Tax Map No. i000 Section .. Z~.~ .......... 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 ......... ~.. ' ~ ' .............. b. Intended use and occupancy ....... ~. ~~~ ~ ..................... 3. Nature of work (check which applicable): New Building ..... ' ..... Addition .......... Alteratig)n .......... Repair .............. Removal .............. Demolition .......... ~ ....Other Work. j~....~-'c~'~ ...... ' (Description) 4 Estimated Cost ' Fee ~ (to b~, 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 ...... i ........ Depth ............... Height ............... Number of Stories ......................................................... Dimensions'of same structure with alterations or additions: Front ........... . ...... Rear .................. Depth ....... .: ............... Height ................. , .... Number Of Stories ...................... Dimensions of entire new construction: Front Rear ' Depth Height Number of Stories Size of lot: Front ...................... Rear ...................... i 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: "'i ............................. 13. Will lot be regraded ............................ Will excess fill be removed from premises: Yes No 14. Name of Owner of premises .................... Address .............. i .....Phone No ................ Name of Architect ........................... Address .............. ..... Phone No ................ Name of Contractor .......................... Address .... : ......... I .....Phone No ................ 15. Is 'this property located within 300 feet off a tidal wetland? *Yes ..... No ..... *If yes, Southold Town Trustees Permi ed. : Locate clearly and distinctly all buildings, whether existing or proposed, and. ilndicate all set-back dimensions from property lines. Give street and block number or description according to deed, and shbw street names and indicate whether interior or ( STATE OF NEW YORK, S.S COUNTY OF ................. ................................................. being duly sworn, deposes . (Name of individual signing contract) : above named. : ,% and says that he is the applicant lie is the ........................................................................................ (Contractor, agent, corporate officer, etd.) of said owner or owners, and is duly authorized to perform or have performed thel 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 : ........ , ...... day of ..... ........ 19, ././- / , Notary Public,.....~_-_,~...~.,. ~.,L.. ~/&~-.''' ...County H~.OI ~.I)EVOE ( ture of applicant) Ne, 47078'18, Suffolk ~,~l~ My~ o Tena Expires M&fch $0,1~.,.-~/