HomeMy WebLinkAbout15113-zTO~N OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
15113
Z
Permission is hereby granted to:
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at premises Iocoted at ..~...?...~.~.......~...~......~...~....-~- ....... ~')~ ...................
County Tax Map No. 1000 Section ..... ..~....-)...?. ........ Block (~ (~ Lot No. ~
Building Inspector,
Building Inspector
Rev. 6/30/80
FORM NO. 1
TOWN OF SOUTHOLD ,
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD, N.Y. 11971
TEL.: 765-1803
.,
., 19~.~. Permit No.]..~,~.1.1.~...:.~..
Disapproved a/c .....................................
.......... ~19...
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and st~bmitted 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~s 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 pre, mises 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 iru~l~ctions.
... ...............
(Signaturg 6f appJican_t, or name, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises .D~q '~/t'.~..~.....~,... ~.. ~.;.~....&..~O~~~ ........
(as on the tax roll or latest, de~}
If applicant is a corporation, signature of duly authorized officer.
.............................................. ~TI~ 6UILDtNC~ OEPART~T AT
~ (Name a~d rifle o[co~omto o[~cor) , 786-1802 9 .A~ TO 4 ~ ~ THE
~LOWING IN~PEC~ONS:
~uilder's"~[conso No .......................... 1 ~UNDAT~ON ~'WO R~UIRED
~R POUR~[~ CONCR~T~
Pinmb¢~'s LJcanse Ho ......................... 2 ROU~ FRA~tNG ~ PLUM~ING
3.
E~ectricJan's LJcan~c No ....................... ~, FINAL CONSTRUCTION ~UST
~ COMPLETE ~OR C.O
O~h~ T~dc s L]consc ~o ...................... A~ CONSTRUCT~N SH~[ ~EET
THE ~QUIREMENT5 .OF
.................................................. ~o~4 ~.~ . ~.~ ~ ......................
House Number Street / Hamlet
County Tax Map No. 1000 Section ........ ~ ...... Block ...... ~. ......... Lot ...... ~ ...........
Subdivision ..................................... Filed Map No.
(Name) "
State existing use and occupancy of premises and infended use and occupancg'0( proposed ¢onsF~jc.tion:
a. Existing use ann occupancy ............. 'x..'8~O~ 2... ~~..:=:.~ ...............
b. Intended use and occupancy " '" ~ '
3. Nat~re-ofwgrk (check which applicable): New Building ..... ' ..... Addition .......... Alteration .~., ........
Repair . .. 2.. i ....... Removal ....... I ...... Demolition ....... ,. ...... Other Work.."...,4'.~-~4~1~,...
Estimated d~>~tB .'.., ii; .~..O. ! er --'""'e
(to be paid on filing this application)
5. If dwelling, number of dwelling uflits ..... ./ ........ Number of dwelling units on each floor. ? ~.~.~..~..~.~...~..ffP~
If garage, number of cars ...... . ............................................................... ;..
6. If business, commerciai or mixed 6ccupancy, specify naturq and extent of each type of use ........... ~ .........
7. Dimensions of existing structures,iif any: Front. ~.*~.. d°.'~ .... Rear .............. Depth ...............
Height ............... Number of Stories .............. ~>,~f18 ......................................
Dimensions'of same structure with alterations or additions Front .~',~,~ Rear
Depth ..................... i Height ....... ~ ~.q ..,~,~.
--8. Dimensions of entire new construction: Front ............... Rear ............... P~-?th',~'~
Height .. .............. Number of Stories ................................ ~. .............
9 .......... Size of lot' Front ~.~. · , ......... Rear ..... ~. ~} .............. Depth ..................... ,~"~
10. Date of Purchase ./~$.. ~.4.4~.~..~ ............ Naj:0e of~For/n~ Ow~ller /1~,~$'.~.~. ;d,..~ t.~.~ ....
11. DZone or use district in wh. ich p. remises are situated ...... '~O~,.~:J~g~.. ~.,t~e., ,~w,r~.,'~..~. ................
12. ocs proposed construction, w,olate ~a~y~_zoning law, ordinance or regulation: .../~..~. ..................
13. Will lot be regraded ...~P'o~.. {~/..~1'~*~'_ ..... ,.. Will excess fill be removed from premises: ~ Yes t~'~)
14. Nmne of Owner o f premises .~:::~t~.,~..~...../OJw'~t.~dress ~ .~_?,~.,~}~q~..~.. Phone No45/~. ~.
Nmne of Architect ........... i ............... Address ~,~.F..,(/.~.~'.. ~. .... Phone No ................
Nmne of Contractor .......... 4 ............... Address ....,4J~J~,. ~/.z..~'..~'~.... Phone2~o..e..., ..........
15. Is this property located within 300 feet of a tidal we(land? *Yes ..... ~
· If yes, Southold Town Trustees Permit maybe required.
, PLOT DIAGRAM
Locate clearly and distinctly all bl~ildings, whether existing or proposed, and, indicate all set-back dimensions from
property lines. Give street and block number or description according to deed, and show street names and indicate whether
interior or corner lot.
~A. TE OF NEW YORK..
OUNVV Or .... '?
....... ~'t M.... ~.Z~Zl~/.l~'~d. ............. being duly sworn, deposes and says that he is the applicant
(Name of individual signin~ contract)
tbove named.
te is the
: (Contractor, agent, corporate officer, etc.)
)f said owner or owners, and is duly aUthorized to perform or have performed the said work and to make and file this
'~pplication; that all statements contained in this application are true to the best of his knowledge and belief; and that the
york will be performed in the manner s~t forth in the application filed therewith.
;worn to before me this
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