Loading...
HomeMy WebLinkAbout15569-zTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTNOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 15569, Z Permission is hereby granted to: tp ....... a remlses ~ote at .......... ., ............. County Tax Map No. 1000 Section .... ..~..-')....~)., ....... Block ....... l....~m'... ...... Lot No....~...~..t..~ .......... pursuant to application dated~--9'...~...~.....~. .................. , 19.~..~., and approved by the Building Inspector. Fee $.....~....:..~ .... Building Inspector Rev, 6/30/80 FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL £OUTHOLD, N,Y. 11971 TEL,: 765-1803 Examined .'~4~ J, % .... 19~.~. Approve~ .~..~. ·., 19~. Permit No. ? .kTg.~.~..~.. Disapproved a/c ..................................... (Building Inspector) ~ ~ APPLICATION FOR BUILDING PERMIT .................. 1,. INSTRUCTIONS a. Tins 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 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- ~,ation. 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 cod'61 and regulations, and to admit authorized inspectors on premises and in building for necessary inspection{l (x) ' ............,, .c- .kaC>d ............ (Signature ![_ay.p.liyTnt, or.::m. 7,.i:.~ :trporation' licant ~s owner lessee aent arch~ ect, engciiJi, iiini}ii~' ~a~iiiii~SuiiJiiJ iiiliii' State whether app' ' , , g , ~-~ ' ' ' · ....................... .......... .0. , , Nameofownerofpremises '~'~ ~'' ~'~';'~tic~''~''''~)~'~''~'~/i~ .............................. t '~::'~ .............. e' "'('a; ~)~'icer ~t~e' t'a'x' Jo'li ~; i~t~;t' J~d') ......................... } If applicant is a corporation, signature of duly authoriz d offi . (Name and title of corporate officer) Builder's License No ........................... Plumber's License No ......... .k~O..~¢,.....~.O. Electrician's License No ........................ Other Trade's License No ....................... Location of land on whiclt proposed work will be done ......................... - .............' ........... > .p.× ...................... House Nmnber Street t~amte~ County Tax Map No. 1000 Section ............ ,, ......Blqck ..... ~..u/. ........ Lot ................... (Name~ State existing use and occupancy qf premises and intended use and occupancy of proposed construction: a. Existing use and occupancy .. . ~$ ..................... b. Intended use and occupancy..5. ~.~.P~ .~.~..~ ~..~.....~...~....~". ~J~.~..~.~. .... ~ ~..~..~. ~J'~-..' .... 3. Natur~ of work (check which applicable): New Building ..... '. ....'Addition .......... Alteration .......... Repair ...... r~. · ~.. ,~ Rem~vah ......... ~/.. Demolition ..... ~_. ....... Other Work ............... ~['~t~ c~ ~.l/,, ?E ~_.~3.~ ~f..\~X, ~c~ (/~tT--~C.~__. (Description) 4. Lstimated Cost . .~.7¢., ..... i ......................... Fee .,,l 2. ....; ............................. (to be paid on. filing this application) 5. If dwelling, number of dwelling iunits ..... Number of dwelling units on each floor .... If garage number of ears 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ..................... 7. Dimensions ofexmt~ng structures, ffany: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ........................................................ Dimensions of same structure w~th alterations or additions: Front ................. Rear .................. Depth ................... :.. Height ...................... Number of Stories ...................... 8. Dimensions of entire new consffuction: Front ............... Rear ............... Depth ............... Height ............... Nur0ber of Stories ........................................................ 9 Size of lot: Front ' Rear Depth 10. Date of Purchase .......... ! ................... Name of Former Owner ............................. 11. Zone Or use district in which pri~mises are situated ..................................................... 12. Does proposed construction wolate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ............................ Will excess fill be removed from premises; Yes No 14. Name of Owner of premises . : ...... Address ...... Phone No. Name of Architect , Address Phone No Name of Contractor ........ ~ .................. Address ................... Phone No ................ 'withlnl:00 feet of a tidal wetland? * Yes No .... 15. Is this property located! · If yes, Southold Town Trustees Permitmay be required. ' PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions fl~om property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. ~ ~'~©V~ ~$ NOTED 'm -~q~z~sr~ENT AT' ~IGN O~ CC,~ST~.C'~70N ERRORS, STATE OF NEW YORK, t~ o e ' COUNTY or .It. ........... .~.), ~' ~ , ........... t~3b'TO~. · ~ .~..' .~ ................ being duly sworn, deposes and says that he is the applica;t . (N~me of individual signing clontract). ' above named. Heisthe ..... t .......... ............................................................. (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 cohtained in this application are true to the best of his knowledge and belief; and that the work will ibe performed ~n the manner set forth in the application filed therewith. Sworn to before me this ~ ........................ day Of ...................... 19... Notary Public, . .......... , ................. County