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Home My WebLink About16091-z FOBM NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HAI.L SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) No- 16091 Z Do,e~ ......... /....~. ........... , *'.~...7 Permission is hereby ~ronte. ct ,o:. ~ ~// ~~ X ~~ ~.~~~.~ .......... .......... ~~~/~/~ / / ~o ......... ~~...~.~..~ ........ ~. ~ ~..~.~..~....~. r~ ........... ...... ......................... ~t pr~ml~*~ ~at~d ~t ............................................................................................................................ ............ ~.~.~ ...... ~.~....~..~ ..................................................... ................................... G.~..~...~...~. z~...~.~ ~x ~ ~/~ ......... ~' ...... '7 ........ Coun~ Tox Mop ~o. I000 Section ....... ~.~ ......... Bilk .......... ~.. ...... kot ~o ..... ~..~....~.. ..... Butld~no In*poctor. Rev. 6/30/80 765-1802 BUILDING DEPT. INSPECTION FOUNDATION 15T [ ] ROUGH PLBG. FOUNDATION 2ND [ ] INSULATION FRAMING [ ] FINAL REMARKS: BOARD OF HEALTH ...... 3 SETS OF PLANS ....... FORM NO. i SURVEY .......... TOWN OF SOUTHOLD CHECK .......... BUILDING DEPARTMENT SEFTIC FORM ............. TOWN HALL $OUTHOLD, N,Y. 11971 NOTIFY TEL.: 765-1802 CALL ................ MAIL TO: Approve ./f..., Disapproved a/c ..................................... (Building 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 with*all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. ... ~.'e,~ ~ ~.~. :~. ,,:/.. :/~. ~,.C! .~.-V.:~ .... (Signature of applicant, or name, if a corporation) ...~. ~.oo.-M~¢. yt.?~ ¢,?:. ............... (Mailing'~ddress of apl~licant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises .... ~~~..~"~...-- ,, , , ,, ............................ c~' (as on the tax roll or lat, e~t ~deed) . / /'3 If applicant is a~orporat, ion, signatu~orizedofficer. C/t~ /'~'~'4~ ~/"9/ ......... ....... (o¢. , - ('Name and title of corporate officer) - /2 ,~.~,,..~a/~¢'~.~ '¢~ ~J ALL CONTRACTOR'S 1,lUST ~ SUFFOLK COUNTY LICENSED / x -'~" --"'~-~' k~/ ~/r~ Builder's License No. ................ t/ eM Plumber's License No ......................... Electrician's License No ....................... Other Trade s License No ...................... Location of land on which proposed work will be done: tO :-~' ' ' ' · ' .................................. 7/- ................... ....... .............. County Tax Map No. 1000 Section .... .~./.~. ......... Block ..... ~ .......... Lot .... ?:~../. .......... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premises and.intended~use aCd occupancy of proposed construction: b, Intended use and occupancy .,,.~.~. ~..e,c/,'M~,s~/~': ....................... " (to be p~/id~b~n filing this application) 5. If dwelling, number o f dwelling iunits ............... Number of dwelling units on each floor ................ number of cars ~ If garage ......................................................................... 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 .............. Depth ............... Height ............... Number of Stories .... ~'. ....... ' ..................... ~ ? ................... Dimensions'of same structure wlith alterations or additions: Front ................. Rear .................. Depth ' Height Number of Stories Dimensions of entire new construction: Front Rear Depth Height ............... Number of Stones ....... : ................................................ 9. Sizeoflot: Front .......... i ........... Rear ........ ~ .... .......... Depth ...................... 10. Date of Purchase .......... ! .................. Name of Former Owner ............................. 11. Zone or use district in which premises are situated ..... C. .'~. ~ .~. ......................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ........ i i~i~i ................ 13. Will lot beregraded.. .. . ... , ... ... .. .. ..... .. ..~ 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 ........ i ................. Address .... : .............. Phone No ................ 15. Is this property located iwithin 300 feet of a tidal wetland? *Yes ..... No ..... ~If yes, Southold Town Trustees Permit maybe required. i 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 lot. STATE OF NEW YORK, COUNTY OF ................. (Name of individual sig~ing 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 dffly 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 mann6r set forth in the application filed therewith. Sworn to before me this · ' NOTA~t PUBL C, State of NOw Yed; ....' ........................... No. 4707878, Suffolk Cqunt~c:~:j, (Signature of applicant)