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Home My WebLink About16516-z FORM NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N°-16516 z Permission is hereby granted to: · . ~ .............. :5...~. ........................ .....'75'~. o..~. ~ ..~ ................................................ .g;~ .............. ~...: ...................... ~ ,~'--~ ~o.~ c~'~-o-~ I0'--,-, :i~--,,~ ...~ ...~g~'J ',J-,~ at premises located at .~.J...~....'~....~. ......................... :. ..:- .................. County Tax Map No, I000 Section ..... ,,(~.,~.,,O, ....... Block ..... ..C~.,...'~.. ...... Lot No ....... ..C~..~. ........ pursuant to application dated ..... ~..~..~.....~. ................... , 19.~..-]., and approved by the Building Inspector. Fee ....................... Building Inspector Rev. 6/30/80 Examined ...1~.. ~. [. !.., 195.~. Approved .O..~.~..\l..., 19'~ .-/. Permit No.}..~.~..I..~..~.. BOARD OF HEALTH ...... . 3 SETS O~__p~LANS ........ F NO., SURVEY. TOWN OF SOUTHOLD CHECK BUILDING DEPARTMENT gEPTIC FORM ............. : TOWN HALL $OUTHOLD, N.Y. 11971 NOTIFY ~.~S-~ //~_:.~ TEL.: 765-1802 CALL .............. MAIL TO: Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT Date ..... .}.o. 1. 7. ...... , 192~2 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 i~pections. ( applicant, ...... or~on) x .... .... (Mailing address of applicant) ] } ~ ~/! State whether applicant is_owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. .......... .o..w. ............................................................................ Name of owner of premises ...... .~. .k O. .~. TO. l't .... ?'..~...~.~. ~ .~. lO ..................................... (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 MUST BE SUFFOLK COUNTY LICENSED Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... umer lrade s License No ...... .~..~..~}.i ......... Location of land on which proposed work will be done .................................................. ..... .~.?. ~o. ................. .~. ~ .~ ~ ..... ~? .,,~ ........... .5..~.~ .~. ~.~.,~,~ .... ~'/... ! ./.'~ .~/. .... House Number Street Hamlet County Tax Map No. 1000 Section .. i....~. ~. ....... Block ....... .~.. ........ Lot ..... .~ ........... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occnpancy of proposed construction: a. Existing use and occupancy . .~. ~, .,~e ~bk- ,~! 5r, '*~-,:~ ......... .... '~ ,- ~ ' /; :. ,~ d." ' :': ~, ~i~i ,~b:¥~,;~, q'~ ......... b. Intended use and occupancy . .~. · .~. · ~,,,.-.,. ~,, :.~;~?,,::~;~i~.;. ................... 3. Nature of work (check which a~plicable): New Building ..... ' ..... Addition .......... Altera~.~ ?,~'1~; ....... Repair .............. Rem,oval .............. Demolition .............. Other Work .~..-~..e.&~ &. ..... ~,j ~ l~j (Descrip:tion) 4. Estimated Cost ~'Jc~o 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 .... ! .................................................................... 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 with alterations or additions: Front ................. Rear Dimensions of entire new cons[ruction: Front .......... . ..... Rear ............... Depth ............... Height ............... Number of Stories ........................................................ 10.9'DateSiZe of lOt:of PurchaseFr°nt ....................... ~'] J u Rear .................. ~o~e~r~w~er~ . .D.ed. ~.¥ ...................... .6:..t.~. 1 1. Zone or use district in which premises are situated ....... 12. Does proposed construction vidlate any zoning law, ordinance or regulation: .... O. ~ ........................ 13. Will lot be regraded .... .~.~.: .................... Will excess fill be removed from premises: Yes No' Nam of A hite Add Ph N e rc ct ' ress ................... one o ................ Name of Contractor ........................... Address .... : .............. Phone No ................ 15. Is this property locatedi within 300 feet of a tidal wetland? *Yes ..... No ..'~... *If yes, Southold Town Trustees Permit maybe required. .. j PLOT DIAGRAM Locate clearly and distinctly all 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. Itt o~o ~9~n STATE OF NEW~P,~/_ (Name of individual sigfliffg contract) above named. ..... being duly sworn, deposes and says that he is the applicant He is the ........... ~ .~. }']. l~.~i .......... ' ...................................................... (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 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 q