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Home My WebLink About15552-z ll'OJ~,~ NO. e~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TO~N HALL $OUTHOLD, N. ¥. BUILDING PER~IT CI'HIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 15552, Z County Tax Map No. 1000 Section ..... .C~..~'....~. ....... Block ..... .?...~.. ......... Lot No.....~...:..,~....' ........ pursuant to opplicotion doted~.~ ................... 19.~..J~., and approved by the Building Inspector. Building Inspector Rev. 6/30(80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Exanlined .~P~..~ .... 19 Approved~ '~ 19~j' PermltN I~,~Z ~ Received ........... ,19... Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT Date .................. ,19... INSTRUCTIONS a. Tiffs 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 InspedforWill 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 ~ 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 inspections. (Signature of applicant, or name, if a corporation) (mailing address of ~pplicant)bUider--'l-''. State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or Nameofownerofpremises ~./°a'Y. 4 /F~TE ~','~' ,¢~'~lk /'~1~ BP (as on the tax roll,,~:~~ ~~ atest e d) If applicant is a corporation, sig~ture of duly authorized officer. ~OTIFY BO~LDING DEPA~r~[NT AT ~~ ff.~ , ~ 765..1802 9 A~ 'TO-~ PM POR THE (Name and title of co,orate officer) F~NDAT~ON ~O ~EQU~RED FOR Pt)OREO CONCreTE Builder's License No ...... ~ .~ .............. ' ROOG~ 3, INSU~YIOPl Plumber's License No ......................... i, Pt IAi Electrician's License No, ALL CO~f~t'aOCTiON Other Trade's License No .................... "· '* C~' NOT 1. Location o¢land on which proposed work will be done ............................................ ltouse Number Street Hamlet County Tax Map No. 1000 Section ...... ~.~ ........ Block .... ~ ........... 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 ~5 (~ b. Intended nsc and occupancy ..... (Tq~ ......... q ...... . ~(( ..................... '"3. Nature of work (check which ~pplicable): New Building .......... Addition ........ '~Alter~tion ..... Repair ............. Removal .............. Demolition .............. Other Work/T¢~.,-.-e' ........ 4 Estimated Cost D'~3"t ~ ~ (Description) (to be paid on filing this application) 5. If dwelling, number of dwelling units ............... Number of dwelling units on each floor ................ If garage ntimber of cars ' 6 If busme'ss .... ~ .................................................................... . , commercial or mixed occupancy, specify nature and extent of each type of use ..................... 7. Dimensions of existing struc,tures if any' Front Rear Height Num[~er of Stories ............... ~... Depth ,. ............. Dimensions of same structure with alterations or additions Front ..................... Depth i Height ................. Rear ................. ............................................ Number of Stories 8. Dimensions of entire new construction: Front Rear ..................... ii Depth Hight Number of Stoies ........................................ 9 S' eof lot Front '7.. . Rear i · Depth 10 Dst of Purch .................. ' ....................... 1 1 ' e ase .......... ~ ................... Name of Fenner Owner ........................ · Zone or use district in which premises are situated .......... ' ' ' ' 12 Do p ed t tie i01 i la ' ' di ......................................... · es ropes cons rue nv ate anyzon ng w, or nance or regulation: ............................ 13. Will lot be regraded ........ i ...... /~ ............. Will excess fill be removed from premises: Yes No Name of Architect ......... i .................. Address ...... ' ............. Phone No. '.~...~.~[.~.? ? ? .... 15. Is this property locatedl 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 al1 buildings, whether existing or proposed, and. indicate all set-back dimensions from property lines· Give street and block number or descnphon according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, COUNTY OF ................. S.S ......... ~('b~ ....'f'i ...........: .................... being duly sworn, deposes and says that he is the applicant . ame o ndividualsigniBgcontract) bev d a e tla'nle . [ -* He 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 this application; that all statements contained in .this applicatian are true to the best of his knowledge and belief; and that the ~work will be performed in tile inannerl set forth in tile application filed therewith· Sworn to before me this ........... '~ .......... day cfi ................ , 19~.. NotaryPublic..~.~.:..!~..~...~..~.. N01~ HEL£M K. O[ ¥0E )qt¥ PggtlO, State of gew ¥0tl~ (Signature of applicant ) . No. 470TOTS, Suffolk County ~erm £xp,ire~ March 30 ~a ,~!