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HomeMy WebLinkAbout15132-z FoB~r ~0. 0 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWI~ HALL SOUTHOLD, N. Y. BUILDING PERJv~IT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N©. 15132 Z I) County Tax Map No. I000 Section ...... L~...-/. .......... Block ...... ~/..~ .......... Lot No ....... L...~'.. ........... Building Inspector. Rev. 6/30/80 ~ ,o'c' AS A~ TO A pM THE URIED coNCRE'fE FRAMING ~ pLUMBING C.;ONs'TRUCTION MUST FoR C.O. MEET N.Y FOR ~1 ERRORS, Examined .~..~.~. · Approved.. '~1' ' '1~ ' 'FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL,: 765-1803 ., ., 19 ~.(* Permit No. ]..~./..~..~..~. Disapproved a/c ..................................... :e±¥ed ........... , 9... (Building Inspector) APPLICATION FOR BUILDING PERMIT 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 t:e~ulati, ckns,,~nd to admit autlmrized inspectors on premises and in building for necessary inspecti~ (Signa~a'fe of applicant, or name, if a cor~atj~r~ (Mai lng a State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ...... ....................... _ -.-e.., ............................... .... ......................... If applicant is a corporation, signature of duly authorized officer. Builder's License No.. ~... .............. Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed,~rk will be done ....................... ,,-~,....,,~h.,,n. · - .,~3 .......... --,-,7 - ....... · . .~ ,,.~ ............................ ~ .............. ~-./, ...... /1.~/. v--, ,,,.-~... House Number Street ? Hamletl/ff County Tax Map No. 1000 Section//Z~. ............ Block../.~... ........... Lot.....~.~ ......... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises aai~,~ ~-,J' n n~ed us~~/,~ and occupancy of proposed construction: a. Existing use and occupancy ....... ~'.-.~-~-..-~ .............................................. b. Intended use and occupancy .... ./(:~,t..~r~'~.~ ....................... 3. Nature of work (check which applicable): New Building ..... ' ..... . . I , ~ Ad&t~on .j ......... Alterat~o]l,~. ......... Repair .............. Removal .............. Demolition .......... i .... Other Work ~ .... 4. Estimated Cost ................................. ~...- . Fee .... a~..ff'.:~...t~. ...................... ' (to b~ paid on filing this application) 5. If dwelling, number of dwelling units ............... Number of dwelling ufiits on each floor ................ If garage, number of cars ........................................... l ............................. 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ..................... 7. Dimensions of existing stractures, if any: Front ............... Rear ...... ~ ........ Depth ............... Height ............... Number of Stories ........................... ~ ............................. Dimensions of same structure with alterations or additions: Front ........... : ...... Rear .................. Depth ...................... Height ...................... Number of Stories ...................... -'.8. Dimensions of entire new construction: Front .......... ' ..... Rear ....... i ........ Depth ............... Height ............... Number of Stories ........................... i ................... 2 ......... 9 Size of lot: Front Rear Depth 10 Date of Purchase Name of Former Owner ~ 11. Zone or use district in which premises are situated ........................ ! ............................. 12. Does proposed construction violate any zoning law, ordinance or regulation: ...i ............................. 13. Will lot be regraded ............................ Will excess fill be removed from premises: Yes No 14. Name of Owner of premises .................... Address .............. i .....Phone No ................ Name of Architect ........................... Address .............. ! .....Phone No ................ Name of Contractor .......................... Address .... : ......... i .....Phone No ................ 15. Is this property located within 300 feet of a tidal wetland? ~¥es ..... 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 dknensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, S,S COUNTY OF ................. ................................................. being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) : above named. I He is the ............................................................ [ ............................. (Contractor, agent, corporate officer, et~.) of said owner or owners, and is duly authorized to perform or have performed the! said work and to make and file this knowledge and belief; hnd that the application; that 'all statements co~ntained in this applicgtiotk are true to the best of his work will be perfom3ed in the manner set forth in the application filed therewith. Sworn to before mi'this ........... · ~..~. ......... day of... ~,x.~r~ ........ , 19 . .~.~ Notary Public ..... ~2~'' 'Z' ~ i '~" ~"" i~l~'t~~ Count~ ....~ (Signature Of apphcant)