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Home My WebLink About16175-z ~vO~ NO. ~ TOWN OF SOUTHOLD 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. 16175 z Permission is hereby granted to: ....~....~...%...~...~..I..~ .............. ...~.-~.?...~ ................................................ ~~?~..~.:~.,..~.!~.~.'. .......... ~. _~~..~.~.~..~...~...~ ............... ~ ............... ,~ ...................... ~'t premises located at .....L~...~ ....... .(,~....~...l~.~....~...~...'?~...-~.).....~St~..~ ~ .... .a..~ .......... County Tax Mop No. ~000 Section ..... ..~.,~...,~. ..... Block ...... ~ .............. Lot No. Buildin~ Inspector. - Fee $.~,~} ................. Building Inspector Rev. 6/30/80 · ~,~,:~i~ 7:~)~ o; th~ N~ York TOWN HALL SOUTHOLD, N,Y, 11971 TEL.: 765-1802 BOARD OF HEALTH ...... 3 SETS OF PLANS ....... 'FORMNO, 1 SURVEY ......... , TOWN OF SOUTHOLD CHECK .......... BUILDING DEPARTMENT SEPTIC FORM ............. NOTIFY CALL ................ MAIL TO: Approved .~..., 19~..7. Permit No.). ~..1.7.~:~... Disapproved a/c ..................................... ................................ _ ~_ ?.~ N_?,~F..§p.U.7?_2 ?~ __~ (Building Inspector) APPLICATION FOR BUILDING PERMIT Date ................... 19... 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 6r 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 tkis 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, anjJ~er applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for regfoval )~r demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building c~d_e, tNfusirtg code, and regulations, and ~o admit authorized inspectors on premises and in building for necessary inspecti~/f,~ ~_.--7/'~//- /'~ ~ . ~ · State whether applicant is owuer, lessee, agent, arcliitect, engineer, general contractor, electrician, plumber or builder. ........ xili .............. Name of owner of premises ............................ (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) , ALL CONTRACTOR'S MUST BE SUFFOLK COUNTY LICENSED Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... ~ I. Location of land on which proposed work will be do[n~7. · . · .~..~..~- ·'~.. .... · .~.- · .~.'~ ..... .Q .A?.~. .......... House Number Street Hamlet County Tax Map No. 1000 Section ...~...D. ........... Block ..... .~..~. ......... Lot...~..~. ........... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy .................................................................... b. Intended use and occupancy ................................................................... 3. Nature of work (check which applicable): New Building ..... ' ..... Addition .......... AlteYatioh -. ...... Repair ~.~ ..... . ....... Rem?a1 .... :i .......... Demohtion I .............. Other Work ............... 4. Estimated Cost ....................... ~ 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 busines's, q6~ial,q~ m~ix~d~ o~ccUpancy, specify nature and extent of each type'of use ..... ' 7. Dimensions6f~Xistingstructures, ffany: Front ........... ~:.. Rear .............. Depth' i'iiiii'iiiiii... Height .... i J ........ Number of Stories ...................................... ~...: .............. Dimensions of same ~r~va~alterations or additions: Front ................. Rear .................. Depth ...................... 'Height ...................... Number of Stories ...................... 8. Dimensions of entire new construction: Front .......... ..... Rear ............... Depth ............... Height ............... Number of Stories ........................................................ 9. Sizeoflot: Front ...................... Rear .. .......... : ....... ~.. Depth ...................... 10. Date 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. Nanm of Owner of premises .................... Address ................... Phone No ................ Name of Architect ........................... Address ................... Phone No ................ Name of Contractor ........................... Address .... : .............. Phone No ................ 15. Is this property located within 300 feet of a tidal wetland? *Yes ..... No ..... *If yes, Southold Town Trustees Permit maybe required. PLOT DIAGRAM Locate clearly and distinctly a/1 buildings, whether existing or proposed, and. indicate all set-back dimensions from property ilnes. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. M 5 STATE OF NEW~Y~,xX S S ~OUNTy OF...'%¢,.k'k~O] .k.,. ..... ., ~bove named. ~Ie is the ............................. ...., ............................ (Contractor, agent, corporate officer, ~f said owner or owners, and is duly ~uthorized to perform or have performed the said work and to make and file this ~pplication; that all statements containgd in this application are true to the best of his knowledge and belief; and that the ~/ork will be performed in the manner set forth filed therewith. in the application ~worn to before me this ' qotaryeublic, .~...~'..~)~.?~/...~...... ... County . ~~. NOTN~t ~U~LIC, ~t~ of ~,~o~ I~, 4707878, ~;uf~ol[ County. s' Te~rd bpire~ M~f(:h ~0~