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HomeMy WebLinkAbout14897-zTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PEP,MIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Date Permission is herebt granted to: ........ ] . l~ ....... , .~~~, ~.~, I~ ...... ..................................... County Tax Map No. 1000 Section ...... ..(~.....c)...~. ...... Block ...... ..(~.....~. ....... Lot No ....... .~. ............... pursuant ,o opplicotion doted .......... '~..~/...~. ................ . ]9..~..~....---- ond approved by the Building Inspector. Fee $....~ ............ Building Inspector Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL COUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined.....~ ~.x.x.~.l..lt..., 19~o. Approved ......... 1.9.., 19~.~.. Permit No. Disapproved a/c ..................................... Receive . . ,19 (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 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 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 necessary iltspections. (Sjg~atur?,of~plican[,~_f_ ~ .. ~..4~..-ff~ .Dr name, i~fa corporation) .... ,, ,'" . .. · (mailing addre~ ~f ipplicant<J] State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ~~ .~... .;J~~~ · .~./~. .......... If applicant is a/corporation,,,~ignature 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 ...................... r~.j/~ ~.~ ~/.~ ~ ' . .3~.~' 1. Location of land on which proposed~work wilt be do. · . ....... House Number Street Hamlet County Tax Map No. 1000 Section .... .~.~..~. ....... Block ..... .~.{o. ........ Lot .... ~ ............ Subdivision ' Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of pj-exmises and intend..e..d.3tse and occupancy of proposed construction: a. Existing use and occupancy...:,~..~ .~.. ~ .c~.~. 7. ~-~. ................. b. Intended use and occupancy ....................... v..' ............... ~. .......................... 3. Nature ofwork (check which applicable): New Building .......... Addition..! ........ Alteration,/.?; ....... Repair .............. Removal .............. Demolition ........... ... Other Work ...-~".~f. (Des~qption) 4. Estimated Cost ........... 7 .... ' ..................... Fee4~ If dwelling, number of dwelling units ............... If garage, number of cars ............................. If business, commercial or mixed occupancy, specify nature 0 Dimensions of existing structures, if any: Front ........... 7. Height ............... Number of Stories Dimensions of same structure with alterations Depth ...................... Hei~at 8. Dimensions of entire new construction: Front... Height ............... Number of Stories 9. Sizeoflot: Fron~t ...................... ~ 10. Date of Purchase ....................... 1 1. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, 13. Will lot be regraded ............................ 14. Name of Owner of premises .................... Address Name of Architect ........................... Address .. Name of Contractor .......................... Address ...... 15. Is this property located withinli00 feet of a tidal wetl * If yes, Southold Town Trustees Permit may be required. PLOT DIAGRAM this application) floor ' premises: Yes No · ...!A..Phone No ................ ..... ! ....Phone No ................ * ..... STATE OF NEW YORK - ~ (Name of individual signing contract) above named. He is the gent, corporate officer, etc.)I of said owner or owners, and is duly authorized to perform or have performed the s~id work and to make and file this application; that all statements contained in this application are true to the best of his 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 ' 19.f. Notary Public, . ......... ~ .............. County NOTARY PUBLIC, State of New Yolk' -- ~ No, 4635190 Suffolk County It)~Tfl~/ [UBLTC Commission Expires October 30, 1988 (Signature of applicant) © ¥' Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and shoo street names and indicate whether interior or corner lot.