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Home My WebLink About16458-zTOV/N OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT O'HIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) .~'~a..~~.....~.:.y...,. ........................... at premises ,ocoted at [.~....~..........~.~ii...~ ................................ .... ..%. .... ~ ...... ~ ................... ;; .............................. .~; ...... . ......... ~o~ To× ~o~ No. ,00o ~,~,,o~ ..... ~ ....... ~,~ .......... .~ ....... ~o, No..~..'.~. ......... p, rsuant to opplJcotio, doted .... ~.~)~.~...1~.~..~.. Building Inspector. ..... , 19.~.~.., and approved by the Rev 6/30/80 ~./ O.~/'> ~,- "¢ BOARD OF HEALTH ...... 3 SETS OF PLANS ....... FORM NO, 1 SURVEY . . . TOWN OF SOUTHOLD CIIEC, K · [[4~,4~,,. [ BUILDING DEPARTMENT SEPTIC FORM /OWN HALL NOTIFY _~ SOUTHOLD, N.Y. 11971 CALL~~/.__~ TEL.: 765-180~ MAIL TO: (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be cmnpletely filled in by typewriter or in mk and sublmtted to the Building Inspector, v 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 s or areas, and giving a detmled description of layout of property must be drawn on tile diagram which is part of this 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 p shall be kept on the premises available for inspection throughout the work. e No building shall be occupied or used in whole or m part for any purpose whatever until a Certificate of Occu! *hall bare been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant, Budding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinan. Regulahons, for tile construction of braidings, additions or alterations, or for removal or demolition, as heroin desc I he applicant agrees to comply with all apphcable laws, ordinances, building code, housing code, and regulations, a adnut authorized inspectors on premises and in building for necessary inspections (Signature of applicant, or name, if a corporation (Mailing address of applicant) %late whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or bu · c.o.,u.z orc_ .......... , . ........... ~ ........ ~y,~.t~ ..... ; ..~.'s. (~ on ~ m ~oil o~ ~? p i/ ~. apphcant is a corporatton, signature of duly authorized officer F~: (Name and hdc of coq~orate of Qcer) ALL CONTRACTOR'S MUST BE SUFFOLK COUNTY LICENSED FO~ Buddcr's Lmcnse No. '~'~ ....... ~tOuG~ 3 Plumber's License No ................. 4 ¢i~A[ Llectr c an s License No .............. * · ~. ALL ' Zlt. Sl'~OC/ION r~ HEOU~E~MEN~S OF ~ N.Y Odmr Trado's L~cense No ........... ST~ CONSTR[JC~ b ENERGY ....... ............ ....... llouse Number Street Hamlet ,000s ¢.o. ..... ... ..... 3 ........ State ex~stmg use and occupancy of prenuses and intended use aud occupancy of proposed construction. Extstmg use and occupancy ....... ]~Q ..................... ~ Intendeauseandoccnpancy .~r .......... Nature o£ work (ct~eck which applicable)' New Building .......... Addition ..... Alteration .... Repair ....... Removal .............. Demolition .............. Other Work ............ ~ ~]~ (Descnplion) 4 Estimated Cost l .q .2.~.'. ................. Fee ........................ ' (to be paid on filing this apphcatJon) 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 ............. Depth. .. Height ....... Number of Stones ........................................ D~rnensions of same structure with alterations or additions' Front .............. Rear .............. Depth ................. Height .................... Number of Stones ................... 8. Dimensions of entire 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 district in which premises are situated .......................................... 1 2. Does proposed construction vxolate any zoning law, ordinance or regulation' . ...................... 13 Will lot be regraded ................... Will excess fill be removed from premises: Yes 14 Name of Owner of premises ................ Address ................. Phone No ............ Name of Architect ..................... Address ................ Phone No ........... Nmne of Contractor--/'-/,t~/.~. ~'6/11~./~."~.l~. Address~. t~. ~...t~l~Phone No., .a~Ot~.'-.~r. ~.2~. 15. Is this property located within 300 feet of a tidal wetland? *Yes ..... No~.. *If yes, Sou?hold Town Trustees Permit maybe required. PLOT DIAGRA~ Locate clearly and distinctly all buddings, whether existing or proposed, and. indicate all set-back dmaensions fr, property lines G~ve street and block number or description according to deed, and show street names and lndmate whetl interior or corner tot. STATE OF NEW YORK, S.S COUNTY OF ......... ...... being duly sworn, deposes and says that he is the apph, (Name of individual signing contract) above nanred tie is the ..... (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file apphcatmn; that all statements contained in this application are true to the best of his knowledge and belief; and that work will be performed in the manner set forth m the application filed therewith. Sworn to before me this ........ ~/[ ......... da~.f ~)~ ....... ,19 '/'7 801~ l~ ~~ (Signature of apph,~