HomeMy WebLinkAbout14764-z FOu'M' NO. 0
TOWN OF SOUT~OLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N.o 14764 Z
Permission is hereby granted to:
zz .........
at premises located at ............................................................................................................................
County Tax Map No. 1000 Section ...... ..Q).J,O....'~'J~..,,.. Block .... ..~..,...~. ....... Lot No ..... I...~. ..............
pursuant to application dated .... .~ ......... .~.l ................... , 19..~.¢., and approv~ by the
Building Inspector.
Building Inspector
Rev. 6/30/80
'FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1803
. ! k..., 19
Examined '~ ~ ~ , 197.~. lq.~ ~,q :~
Approved .......... Permit No ..........
Disapproved a/c .....................................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
BLDG. DEPT,
TOWN O~F SOUTHOLD
ReceJ_ved .......... ,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 scl~edule.
b. Plot plan showing location of lot and of buildings m~ 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, SuTfolk 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 co~ housing code, and regulations, and to
admit auth°rized inspect°rs °n premises and in building f°r necesi~7'iYY~ti~(Signature ~o~ corporatinn) ................. ~ ....
(MhJli~dre~s of applicant)
State whether applicant is~, lessee, agent, architect, engineer, general contractor, electrician,~lu.r~h~or builder.
....................................... ......
............................. D~TE: B',P ~ )
Name of owner ofpremises . .~...~.~..D.O. ~. ~--~, ktJOg~'a~o~? ...... "~.C....~. .... ~..V.,.
(as on the tax roll orm~[~JLO!NG gl~[ ~,~RTMENT AT
If applicant is a corporation, signature of duly authorized officer. 766-1802 9 AM TO ¢ ~M FOR THE
~ FOLLOWING ,~JSPECT ONS:
1 FOUN~ATIO~ Tka*~O [~EQUIRED
(Name and title of corporate officer) FO~ POU~[:~
2 flOUGt~ ~,,~AM~.,.~ &
Builder's License No .......................... 3, INSOLA
4, FINAt. C(I~ISTRUC'I~'3N MUST
Pinmbe~'s ~icans¢ No ......................... ALL COA~}~ ~;~C"F~ON SN~,LL
Electrician's License No ....................... STAT~ CONST~UC'~ON ~
CODES, NOT R~gPONg{~LE
Other Trade's License No ...................... ~'~ES~GN OR
............ .............................................................
House Number Street Hamlet
County Tax Map No. 1000 Section .~.a, .,.~. Block .... ~ ........... Lot..~...[. ) .......
Subdivision ..................................... Filed Map No ............... Lot ...............
(Name)
State existing use and occupancy of premises and intended use and ~ccupancy of proposed construction:
a. Existing use and occupan, cy ......... !~.O..t~-..~,~-../.-...~...'~..~.~?/? ...... .--mw....&.~...o~...~..
b. Intended use and occupancy .....~. I[ .-. ~..~ .~..~. O..~...._.,....~. ) !! .~.~_..~..~.~..~. ............
3. Nature of work (check which applicable): New Building ..... ' ..... Addition . .i ........ Alteration ..........
Repair .............. Removal ......... ~,-,, ~, Demolition ........... ... Other Work...~,.e_~_~ ....
~/ ~Y~ ~?~'~'~'~)tgff '~' ~"~-%.~ o-e i[.~-/e~ "(DesCription)
4. EstimatedCost..ao.a,o. ............ . .bi ............................
(to be ~aid on filing this application)
5. If dwelling, number of dwelling units .............. Number of dwelling units on each floor ...... *.,. ........
If garage, number of cars ~ . .... ' .
6. If business, commercial or mixed occupancy, specify natur, q grig extent of each tYPe,,0f use ........... ,., ~ ..... ~...
7. Dimensions of existing structure~, if any Front ~.~.(2~/ Rear . ...trl:. ?. ~[.'~. .... Depth . ! .~..¢:.'~ ........
Height ~ )~ ~t~ Number of Stories ....... ./ .................... i ............................
Dimensions of same structure with alterations or additions: Front ............ i ..... Rear .......... .......
Depth ...................... Height ...................... Number of Stories .....................
8. Dimensions of entire new construction: Front Rear I Depth
Height Number of Stories
9. Size of lot: Front ...................... Rear ...................... !De~th ............... . ......
10. Date of Purchase ..... ~..~.r'/{ .................. Name of Former Owner .i. ~wl.t~ £,4,.¢4~...~, .~rc~.lt..
11. Zone or use district in which premises are situated ......................... : ............................
12. Does proposed construction violate any zoning law, ordinance or regUlatinn: ...~. ..........................
13. Will lot be regraded .................. Will excess fill,be removed from premises: yes No
14. Name of Owner of premises .~..ff.&~.9{g.. ~\-)~o~., Address .~.. 3 .~t.~ ,~e~e .~2~ ~. Phone No. ~ .G.~ .--.~ .~.'7.~...
Name of Architect ..... ',~ 7. ..... '.'.~ .......... Address ........ ........ I ....Phone No ................
Name of Contractor ............ , .............. Address .... ~. .....7. ....... Phone No ...............
15. Is this property located within 1,00 feet of a tidal wetland? *iYes ..... No ~'.~.~. '
· If yes, Southold Town Trustees Permit may be required, l 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 number or description according to deed, and show street names and indicate whether
interior or con er lot.
STATE OF NEW Y_.ORK~ "S
(Name of individual signing contract)
above named.
says that he is the applicant
He is the
(Contractor, agent, corporate officer, etc.}
of said owner or owners, and is duly authorized to perform or have performed the shid work and to make and file this
application;that all statements contained in this application are. true to the best of hk, 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
........................ day of .... ~ ............. ,19.. ~" .....
Notary Public, . ..... (...j ............... ;, ...... County
c/*la~¥ l~ta~ ~0s~£~ ........
~OTARY PUBLIC, Sta e of Now Yorl~ / /
No. 52.4~55242, Suffolk Co[Irlly