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Home My WebLink About16072-z l~O~ NO. ~ TOWN 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) No_ 16072 z I.~.. 19.~..7.. .. Dote / Permission is hereby granted to: /~ ^ // __ County Tax Map No. 1000 Section .../...~.. .............. Block ...................... Lot No. pursuant to application dated ......... .~.~..~....~. ............. , Building Inspector. and approved by the Building Inspe~tor Rev. 6/30/80 'FORM NO, 1 TOWN OF SOUTHOLD gUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL,: 765-1802 Examined...~. ~-~.'.'.'.'.'.'.'~./..~. ·., 19 '~.7 .~'~,~,,~../.ff.., 19g.7. Permit No..l .G. 9.7.~..~. Approved Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS BOARD OF HEALTH ...... 3 SETS OF PLANS ....... SURVEY ~EPTIC FORM ............. : ~OT~FY MAIL . ~te .~ .&¢ ...... ~9 a. This application must be completely filled in by typewriter or in ink and submitteg 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. 4 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 with all applicable laws, ordinances, building code, housing code, and regulations, and to in building for necessary inspections. ~ .~ ~ admit authorized inked ~.~x.) ~/,~1[ '~qs~...~~. ~. ~i ...... ~ (Signature of albplicant, or na e, if p t'on) ....... (Mailing address of applicant) State whether applicant is owner, lesse_%e agent, architect, engineer, general contractor, electrician, plumber or builder. .~.h. '¥..~.. .... .,.~.. , ........ : .......................... Name of owner of premises ...V~e[~ ~%.7. - ~m%h~..~d F~ .~qt ........ , ................... (as on [he tax roll or lathed) If applicant isa corporation, signature of duly3uthorized officer. ............. 7~6-1~2 ~ .~ rD ~ p~ t~R THE (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 ....................... 8~ COMIc[iT[ ~O~ C O 1. Location of land on which proposed work will be done .... ' ............... .... (p.o ............... ............... .......... ...... '. House Number Street Hamlet ~o~.~ *a~ ~, ~o. ,000 ~c~,on ..... t.~9 ......... ,,o~... ~ .......... ~o~..0.3.7 .......... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: d ' a. Existing use and occupancy .... ..5'.C-../kb.O.. .a :...~M.l.~.~. .O ....., .......................... b. Intended use and occupancy . ,..~.~ ..~-...~. ~[~.C.~...~CO.ttl/~.d...~..Cw..~, .010.1. i .~.~1. ?..~. 0.'~.. 6{qK~.C~.~. ..... ' : c ~,,.l~"e''4-'' '', 3. Nature ofwork (check which applicable): New Building .....' ..... Addition .......... Alteration .......... Repair .............. RemOval .............. Demolition ............ Other Work ~,~. ~o~(l [..'~I~.C~ t. ' [Description) 4. Estimated Cost.~JI .~ .0.~ ..... ~ ......................... 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 .... i ................................................................... 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use;.., i ................ 7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............... tteight ..... ~.¢ . . . 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 ...................... Depth ...................... 10. !)ate of Purchase .......... i ................. .Lame of Former Owner ............................. 11. Zone or use district in which pr~mises are situated... FI ................... ~ ~) ........................... 12. 13oes proposed construction violate any zoning law, ordinance or regulation: ../~. ............................ 13. Will lot be regraded ... ~,/.~., i ..... . ............... Will excess fill be removed from premises: Yes No 14. Name of Owner of premises .k]t~ta,'~;.C~m,C-.~'~.Address ................... PhoneNo ............... ' Name of Architect ......... ; ......... , .... Address .,~: ........... ~ ...... Phone No ....... . ...... t .... Nmne of Contractor. ~'61~.{~ !l~,~ff..e~P'g.J~l~,. Address ~;~'~.~. t.~[~.(.d._ Phone No 5'~..~.~.~~ . 15. ls this property locatediwithin 300 feet of a tidal wetland? *Yes ..... No .~,~. · If yes, Southold Town Trustees Permit maybe required. PLOT DIAGRAM Locate clearly and distinctly al! buildings, whether existing or proposed, and, indicate all set-back dimensions f~om property lines. Give street and blockl number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, S.S cOUNTY OF ................. (Name of individual signing contract) above named. ..... being duly sworn, deposes and says that he is the applicant He is the ..................... , .................................................................... , (Contractor, agent, corporate officer, etc.) of said owner or owners, and is d~ty 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 his knowledge and belief; and that the work will be performed in the mannbr set forth in the application filed therewith. Sworn to before me this ............ .~. ~...~.~ .; ~dT~ of~/''~"~,/] ~'~a,~ ........... 19 Notary Public ....... /.,r~q.-r,-.q-,~...'~x..,../~'.,If -?...t~... County ~"t ~ltlJg ~ ~ ~ y~ (Signature of applicant) . No. 4707878, Suffolk Counly~o IMm Expires March 30, 1~_.~~r