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Home My WebLink About15604-z FO~M 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- 15604,z Permms~on ~s hereby granted to: , ~..~....~..~.~. ~..: ........... .....~.~,~..~..~. ........................................ · ~.~-~..-."..,.~.,...~ :~ ~'-~.. .... ~...~ .. at premise, located at io..~.~...~.~...?..?....~.. ....... .~..~.?..~.. ........ ..~..~¢.~ ........... County Tax Map No '1000 Sect,o~ . . o....~....~r . Block ..... ..~..~ ........ Lot No ..... .~..). ........ pursuant to application dated~.~.....~:~''~. .'~..~ ........ , 19 ~..~.., and approved by the Budding Inspector. Rev. 6/30/80 FORM NO. 1" TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL COUTHOLD, N.Y. 11971 TEL.: 765-1802 E×a,nmed .~'"~.~...~., 19 Al' prov~~ .~q~.., 19~.~.. Permit No ./..4.(5..o.'-/. ~ Disapproved a/c ................................... (Building Inspector) APPLICATION FOR BUILDING PERNIIT Received ........... ,19 Date ................... 19 INSTRUCTIONS a Tiffs application must be completely filled m by typewriter or in ink and submitted to the Building Inspector, wi sets of plaus, 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 sir or areas, and giving a detailed description of layout of property must be drawn on the diagram wMch is part of this a! 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 pc, shall be kept on the premises available for inspection throughout tile work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupa 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 Building Zone Ordinance of the Town ,of Southold, Suffolk County, New York, and other applicable Laws, Ordinance Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein descril Tile applicant agrees to comply with all apphcable laws, ordinances, building code, housing code, and regulations, an, admit authorized inspectors on premises and in building for necessary inspections. ................... Cd . .cZ .... o. ......... (Signature of applicant, or name, if a corporation) ............................... i' ..... (raa±l±ng address of appic ) State whether apphcant is owner, lessee, agent, architect, engmeer, general contractor, electrician, plumber or brai, I ,.:.. Name of owner of premises ~,/.~ ,- /q,~s (as on the tax roll or latest deed) If applicant is a corporation, signalure o£duly authorized officer. (Name and title of corporate officer) Builder's License No ..... .~...O~. ............. Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No Location of land on which proposed work will be done [louse Numbe~ Street Hamlet County Tax Map No. 1000 Sectmn ...... .~ .~. ...... Block .......... { ....... Lot .... ~. ] ......... Subdtwston ............................... Filed Map No .............. Lot ............. (Name) State ex,sting use and occupancy ol ,,renuses and intended use and occupancy of proposed construction: a. Ex,sting use and occupancy ~ ~¢/( .,~ a b lnteuded use and occupancy .... / ..................... (( ................. "3. 'Nfih:re~o/'work (check which applicable): New Building .......... Addition .......... Alteratwn Repmr Removal Demoht~on ..... Other Work 4. Estimated Cost .......................... Fee ............................ ~l~ (to be paid on filing this application) 5. If dwelling, num of dwelling units ............... Number of dwelling units on each floor ............ Ifgarage number of cars I .......... 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ........... .~ .... 7. Dimonstons of exxsting strUctures, if any: Front ............... Rear .............. Depth,. ......... lleight Number of Stones . ........... Dimensions of same structure with alterations or additions: Front .. Rear · · Depth...................... Height ..................... . Number of Stories ............... · · 8. Dimensions of entire new construction: Front ............... Rear ............... ' Depth .......... lteight ............... Number of Stones ................................................... 9 Size of lot' Front 7 ' Rear " Depth 10 Date of Purchase Name of Former Owner .... 1 I. Zone or use d~strict :n which premises are mtuated ............................................ . . .. 12. Does proposed construction violate any zoning law, ordinance or regulation: ............................ 13. Will lot be regraded ............................ Will excess fill be removed from premises: Yes ....... Address ¢ .......... ~ ...... Phone No. 7~ ...... 14. Name of Owner ofpremises4:k?."~..~f. ~.~..,:n. ~./t/~ ~d '%~.~hl/ Name of Architect ........................... Address'. ..... ~.~ic01. .-..~'~' ~ .. Phone No. :. ............ Nmne of Contractor-&.~.~ . .~.tA. f~..c¢: ......... Address C.q ./b..q~. . ,.~ 15. Is this property located withinIo0 feet of a tidal wetland'/ * · If yes, Southold Town Trustees Permit may be required, PLOT DIAGRAM ' Locate clearly and dmtinctly all buildings, whether existing or proposed, and, indicate all set-back dimensions property lines. Give street and block number or description according to deed, and show street names and indicate whorl intoner or corner lot. --., ,, ,. (Signature of apphca~ work will be performed in the manner set forth in tile application filed therewith. Sworn to before me flus ................. ; ....dayof ..... .......... -~/^ .~ Notary Pubhc ...... '~...'~.:..~..t..~..,~(.,. ...... County STATE OF NEW YORK, S.S COUNTY OF ................ f ,,/o~ ~, /~f~c,.~,,~,,? ......... ................. 4-, ............. being duly sworn, deposes and says that he is the apphca (Name of mdiwdual signing contract) .. above illllned. lie is the ........... ;?..~7 .~.~...~-. ...... , .............. , .............................................. .(Contractor, agent, corporate officer, etc.) of said owner or owners, and ia duly authorized to perform or have performed the said work and to make and file ti application; that all statements contained in thru application are true to the best of Ms knowledge and belief; and that t