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Home My WebLink About14739-zTOWN 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) Permission is hereb/granted to: ~-.;.4 ........ .~~ ......................... ~.~..~,..~..;,¥.:....?./..~.~ ...... , ...... .......... County Tax Map No. I000 Section ..... ,.~,.,..'~......~.. ..... Block ..... 0....,~:... ..... Lot No. ,.,.,~.,..?.......~ ...... pursuant to c~ppJication dated .......................... (~~. ~ ...................... , 19.~..~.., ond opproved by the Building Inspector. Building Inspector Rev. 6/30/80 Examined/~l.-.. .... , Approved .,7~y~..c,~?_.( ~,'0 .~.. ., 19 .~.b. Permit No.. ).~?..~.~..~.. Disapproved a/c ..................................... FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 (Building Inspector) APPLICATION FOR BUILDING PERMIT Received .......... ,19... 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 buildfl~gs 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 regu~atiops, and to admit authorized inspectors on premises and in building for necessary inspec~on~4.. --. ~ ........ ~. :.~.*. ! .~..~..f:?,..~. A.,,?/. c'Yb. ....... (Signature of applicant, or name, if a corporation) ......~¢~___.._... ....... +?. .... .o:,,. ............ (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, en~neer, general contractor, electrician, plumber or builder. .............. .................................................. Name of owner of premises ..~..7..~'~q..m..d~.?. ~..~..~...~.)?./...~..~....~.....~.('.~..~. ......................... (as on the tax roll or latest deed) If applica/~is a corporation, sijg,.~atur~ o,7~ly 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 ...................... ........ 1. Location of land on which proposed work will be done. . a..3.... ,.,a v'/o~ ..... House Number Street Hamlet ~ Coun~Ta×Map~o. 1000Section .... C)~C 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 .... · : '':x,',':z'~: ................................... b. Intended use and occupancy (~...~ { 3. Nature of work (check which abplicable): New Building .......... Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work.../~.~.rl .c..~... d/ Z-,,'] -~ (Description) 4. Estimated Cost .......... F~, ~ ~.~.~ ............ Fee ...................................... ~ (to be paid on filing this application) 5. If dwelling, number of dwelhng~umts ............... Number of dwelling units on each floor ................ If garage number of c~s ' 6. If business, commercial or m~xeB occupancy, specify nature and extent of each type of use ......... ~ ............ 7. Dimensions of existing structures, if any: Front ......... ~ ...... Rear .............. Depth ............... ight ' ' tte ............... Number of Stones ........................................................ - l)~e With It dditi Re nsions of same structure aerations or a ons: Front ......... ar .................. Depth ................... ;.. HeiSt ...................... Number of Stories ...................... 8. Dimensions of entire new construction Front Rear Depth tteighi ............... Number of Stories ....................................................... 9 Size of lot: Front ' Rear Depth 10 Date of Purchase ~ Name of Fo~er Owner 11. Zone or use district in which premises are situated .................................................... 12. Does proposed construction vioiate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ........................... Will excess fill be removed from premises: Yes No 14. Nme of Owner of premises .................... Address ................... Phone No ................ Nme of Architect .......................... Address ................... Phone No ................ Nme of Contractor ......................... Address ................... Phone No ................ PLOT DIAG~M Locate cle~ly ~d distinctly ~! bufld~gs, whether existing or proposed, ~d indicate ~1 set-back d~ensions from property ~ne~. Give street ~d block~number or description according to deed, ~d show street nines and indicate whether interior or corner lot. STATE OF NE~R~, . ~ __.._T~_ (~ ~ ........ being duly sworn, deposes and says that he is the applicant (Name of individUal s~gr ~g contract) above named. He is the r agent, co porate offic r, e~.)' ' of said owner or owners, ~d is duly author~perform or have perfomed the said work and to m~e and file this application; that all statements conthined ~ this application are true to the best of his ~owledge and belief; and that the work will be perfomed in the m~ne r set forth in the application flied therewith. Sworn to before me this ..... ~~ ..... day of~ ..... ~~ ..... 19 Nota~ Public ........... ~...~. County ; W ~ ~o. ~ 2~0, Su~o~k ~ (Signature of applicant) -., ~ Term Expires O~o~r 3!, 1~ _