HomeMy WebLinkAbout16058-z FORM NO. 0
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOV/H HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N*_ 1~058 z
Permission is hereby granted to: , ,~ ;
.... ,g.~i~..,~...~...~,~ ............
. ..~~..~... .............. .~.~.~/,
County Tax Map No. 1000 Section ............ .~..~.. .... Block ........... ~ ...... Lot No ........ .~....0~... .......
pursuant to application dated ....... ..~.~.....~ ......................., 19.~..Z, and approved by the
Building Inspector.
Rev. 6/30/80
' om .o. SURVEY- ,-;-.-, ·
TOWN OF SOUTHOLD CHECK :~-' 'o.o.-M'-~ .
BUILDING DEPARTMENT S[PT[¢ ~01B. M ..
TOWN HALL ~ ~-~ O~'~/~']~ ' '':
8OUTHOLD, N.Y. 11971
TEL.: 765-1802 CALL
Disapproved a/c .....................................
(Bui~dSng Inspector)
APPLICATION FOR BUILDING PERMIT
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, 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,~ith all applicablle, laws, ordinances, buildinNg code, housing code, and regulations, and to
admit autlaorizea insp,.ctors on p.emises and in bui_ding for necessary insp~c~ . ff /~ r
(Signature of applicant, or name, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises C.- , / z~t4
(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 HUST BE SUFFOLK COUNTY LICENSED
Builder's License No .... ~ .............
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
1. Location of land on which proposed work will be done~ .................................................
House Number Street Hamlet
:7.
County "Fax Map No. ~000 Section ................. Block ............... Lot ...............
Subdivision ..................................... Filed Map No ............... Lot ...............
(Nmne)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
Existing use and occupanc
fl.
· Y ............... O' si'' . I ......... ..................
use and occupancy .......... /~t.w~ · ~ · ~ ................................
b.
Intended
3. Nature of work (check which applicable): New Building ..... ' ..... Addition .......... Alteratior~,':~._~_ ~ - , ......
P, epair .............. Rembval ............ Demolition .............. Other Work..
(Descriplion)~t,
4. Estimated Cost ... ~ ,~..O. O ........................ Fee ......................................
' (to be paid on filing this application)
5. If dwelling, number of dwellingiunits ............... Number of dwelling units on each floor ................
If garage, number of cars .... i ...................................................................
6. If business, commercial or mixeld 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 .................
Dimensions of entire new construction: Front . Rear Depth
Height ............... Number of Stories .......................................................
9. Size of lot: Front .......... : ............ Rear ...................... Depth .....................
10..D. ate 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 Address Phone No
Name of Architect ......... i .................. Address ................... Phone No ................
Name of Contractor ........ i .................. Address .... : .............. Phone Ne.x: y .............
15. Is this property located within 300 feet of a tidal wetland? *Yes ..... No .~.
*If yes, Southold Town Trcstees Permit maybe required.
' PLOT DIAGRAM
Locate clearly and distinctly ali 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
S.S
COUNTY OF .................
/-or*/9
............................ i': ................... being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named.
He is the ........................................................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is dull authorized to perform or have performed the said work and to make and file this
application; that all statements conl ained in this application are true to the best of his knowledge and belief; and that the
work will he performed in the manner set forth in the application filed therewith.
Sworn to b~fore me this
HI~LEN lC O£ VOE
NOTARY PUBLIC, ~e of New Yelk
No. 470787~, Suffolk Ce~nty~:~'
Term Expires Merch 30, t[,_.
(Signature of applicant)