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Home My WebLink About15102-zTOWH OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERJ~IT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL PULL COMPLETION OF THE WORK AUTHORIZED) N°. 15102 Z Permission is hereby granted to: .~ ............... ~,~¼ ............. ~ . ~..~....~I~ ....... ~.~.~.: ........ .: ........ at premises Ioceted at .....'7..~........~...~1~......~ ........ ~.,&'~... , .........~' .... County Tax Map No. 1000 Section ........ I.(..']. ......... Block ....... L.~.. ........Lot No ....... ...~:.....0. .......... to application doted ......... ~'~ n._~.~..l...~' .............. ;...., ]0..~..~.,~°' pursuant /- Building Inspector. and approved by the Rev. 6/30/80 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Approved....~. [.?.., 19~..~. · Permit No. )..~.~'.].0..~..~. Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT Received ........... ,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 inspectom on premises and in building for necessa~ insp~qtions, t .......~~...~.~v.~....~. ~. ........ (Signature of applican[, or name, if a corporation) (Mailing address of applicant) L~ ~ State whether applicant is_owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. .................................. .~ev~ ...................................................... Name of owner of premises ....... (as ~n the tax roll Ytq'atest deed) ~s ~uc~r:.~° faduly auth°rized °fficer' ...... (~q~~'o~' ~r) , Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... Location of land on which proposed work will be done .................................................. ...... .w..~ ......................... %~.~:,.~. ~ .x~e:.x. . .m~.. ~.~.~...&..k, ............. House 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 ..................................................................... b. Intended use and occupancy ...................................... ~,: ..~.,,~:-.~:c¢ · ~;* · ~' ........ 3. Nature of work (check which applicable): New Building .. ' Addition .......... Alteration Repair .............. Removal ............. Demolition .............. Other Work ............... (Description) 4. Estimated Cost .................................... Fee ..................... ................. : " (to be paid on filing this application) 5. lfdwelling, number of dweilinglunits ............... Number of 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 structur¢s, if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ........................................................ Dimensions'of same structure with alterations or additions: Front ................. Rear ....... Depth i Height Number of Stories Dimensions of entire new construction: Front . Rear Depth Height ............... Number of Stories ........................................................ 9. Size of lot: Fr~t .......... ~ ........... Rear ...................... Depth ...................... 10 D fP has ~ Nam of Form Owner · ate o urc e .......... ~ .................. e er ........................ 11. Zone or use district in which pr~mises are situated ..................................................... 12. Does proposed construction vio!ate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ......... , .............. Will excess fill be removed from premises: Yes No ]4. Name of Owner of premises ...i. ·............' .... ... Address .Phone No. Name of Architect .......... : ................. Address ................... Phone No ................ Name bf Contractor ......... ! ................. Address .... : .............. Phone No ................ 15. Is this property located !within 300 feet of a tidal wetland? *Yes ..... No ..... · If yes, Southold Town Trustees Permit maybe required. PLOT DIAGRAM .. Locate clearly and distinctly all: buildings, whether existing or proposed, and~ indicate all set-back dimensions from property lines. Give street and block ~umber or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, S.S COUNrFY OF ................. .......... (Na~ 'o'f'i~i'vidual sig- ' ' - '~i~o~;a'c'ti .......... being duly sworn, deposes and says that he is the applicant above named. He is the ...................... ~ ....................................................... (Contractor, agent, corporate officer, etc.) of said owner or owners, and is dul~ 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 his knowledge and belief; and that the work will be performed in the manne~ set forth in the application filed therewith. Sworn to before me this co .................... UN~ J. fl~)(~ll Term iExpires December 31, ,19,~.~..~