HomeMy WebLinkAbout14852-z ]gO~ NO. ~
TOWN Oi= $OUTHOt. D
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD, N. Y.
BUILDING PER~IT
(THIS PEP. MIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
14852 Z
......................................................................................................... ......
County Tax Map No. 1000 Section ..../(.C~.c~ ....... Block ..~..(~ ........... Lot No...O..~ .......
pursuant ,o application dated ..~..~ ....... ZZ ................., lpg., ond approv~ by the
Building Inspector.
Building Inspector
Rev, 6/30/80
FIELD INSPECTION COMMENTS
FOUNDATION (1st)
FOUNDATION (2nd)
ROUGH FRAME &
PLUMBING
INSULATION PER N.
STATE ENERGY
FINAL
ADDITIONAL COMMENTS:
7/;
Examined .~'~/~.~... Z...
Approved · .~.~'~....7 .... ,
'FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1803
1 .&.. Pe it No../..¢. ......
Received ........... ,19...
Disapproved a/c ..-~. ........... 7. ......... . .~..../ ....
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
a. This applicafion 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 promises, 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 applieatlon 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 nece~ . . ..~...~
_ (Signaturi of applicant,~.oq name, if fi'corporation) /
(Mailing address of apl~Icant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
............................................
Name of owner of premises~...'~7.~../e)~....~...~..'..~..~../~...e..~..0.~. ,/.k:..~.Bf.. ~../-'?..~.~7 ........................ (as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No ..........................
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ...................... c~ ~ t7 (J . .~..~..77.ff./....~...~./. ~Z. (~. j/~,.~_
1. Location of land on which proposed work will be done. ff).~Q../..ff....~..O..,f)~.. / .................
House Number Street Hamlet
County Tax Map No. 1000 Section ...... ~.. ('~.. · .~ ...... Block ...... 6 ......... Lot ..... ~.~./~ .........
Subdivision ..................................... Filed Map No ............... Lot ...............
(Name)
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy....~.~. ~../~.....~...2~..77.'?../~.~.~...~.../~../~../.~..~7 ...........................
b. Intended use and occupancy ................. ~ ...........................
3. Nature of work (check winch .....apphcable): New Building ........ . ........ Addition..i. Alterat~ .to?' ......,i ....
Repair .............. Removal .............. Demolition . ' .. Other Work..5{-~ ....
~ y ~,~ ~ (Description)
4. Estimated Cost .......... O ~9 Fee
(to be ~pmd on filing this application)
5. If dweliing, number of dwelling units ............... Number o f 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 ....... i ....... Depth .............
Height Number of Stories '
Dimensions of same structure with alterations or additions: Front ............ : ..... Rear ................
Depth ...................... Height ...................... Number of Stories ....................
8. Dimensions of entire new construction: Front ............... Rear ........ ....... Depth .............
Height ............... Number of Stories ............................ ! ..........................
9. Size of lot: Front ...................... Rear ...................... iDepth ....................
10. Date of Purchase ............................. Name of Former Owner . ..........................
11. Zone or use district in which premises are situated
12. Does proposed construction vinlate any zoning law, ordinance or regulation: .... i ............................
13. Will lot be regraded ............................ Will excess fill be remove~ from premises Yes No
14 Name of Owner of premises ................ Address ............. ~ Phone No .....
Name of Architect Address Phone No
Name of Contractor .......................... Address ............... i ....Phone No ................
15. Is this property located within 1.00 feet of a tidal wetland? * ;Yes ..... No .....
· If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and, indicate all sot-back dimensions from
property lines. Give street and block number or description according to deed, and sho'
interior or corner lot.
v street names and indicate whether
STATE OF NEW YORK, S S
~OUNTY OF... ............... '
being duly sworn, deposes and says th the applicant
(Name of individual signing contract)
above named.
He is the ............................................................. 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 hfi 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
............ ...........
Notary Public, ............. .~/'...../v).~. .~..~'~-~.. .... County
. ~, 4707878, Sutlots counryc~ ,.~
lerm Expires March 30,
-~ ..... ~. re of applicant)