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Home My WebLink About14505-z FOEM NO. ~ TO~N OF SOfT'OLD BtilLDING DE?AR'rMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERA~IT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) .............. ~.~ ........ ~~/....~.,....~ ...... .,. .................................... County Tax Map No. lO00 Section ......... ~ ......... Block ......... ~ ....... Lot No..,.~.......~ ....... pursuont to application dated ............ j~......-rs~. ............. .~. ............ , 19.~...,_~and approved by the Building Inspector. Building Inspector Rev. 6/30/80 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL ,~OUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined ~,~tld~q../. 3.., 19~.C Approved C~'~' '/' '3'' ', 19g~ Permit No../..~..~.~. ~7~-~ Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date . &(~?./.~ ........... 19aP~ a. Tkis 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 uthorized ins ectors on premises and in building for necessary inspections. / / ~ / / / ........ ......... (Signature of applica ~, 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 . .. .... J .............. (as on the tax roll or latest d~d)/ If applicant is a corporation, signature of duly 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 ...................... i. location of ]a~d o~ which p~oposed wo~ w~] bc do~c...~'.~ .......... ~ .............................. .................... House Number Street Hamlet - County Tax Map No. 1000 Section Block Lot.. Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy 0f proposed construction: a. Existing use and occupancy ..~..~.~.~.)/~<~) '~ '' ~' '~' ~ ''' b. Intended use and occupancy .. 3. Nature of work (check which a~plicable): pw Building ..... ' .....Ad~,tion ......... Alteration . Repair .............. RemOval ... ~ ......... Demolition .~ ....... Other Work ....... ~ . ] (De ription 4. Estimated Cost ..................... Fee ...... i .................. ; '" (to be paid on filing this application) ' /. Number of dwelling units on ea h floor 5. If dwelling, number of dwellingiunits ............. c ................ If garage number of cars .. 6. If business, commercial or mixe'd occupancy, specify nature and extent of each type of use .-.-.w-.. i; Z ........... 7. Dimensions of existing structures, 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 Depth /, Heaght Number of Stories 9. alze of lot: Front . .~.._..~ .~n.~ ....... Rear ...................... De~tlb ! ...... ~,'7~ .... */' ...... 10. Date of Purchase ~.i~/. ........... Nam of o er Owner ..jql~l~.~*..Z~' ~]~q ..... la. Zone or use district in which' -'' pr~misesaresituated...~i~.rr~ ........................ ~ .......... 12. Does proposed construc,tion violate any zoning law, ordinance or regulation: . .$~-?. ........................... 13. Will lot be regraded . .~-~. ............ .~.,. %~..~.. Will exceeds filJ~e removed from premises) ~ Yes 14. Name of Owner of premises ~4 .~.2;..~ ,~.~.h~.|!~ddress ~'.~,O~ .~.~ .~. l~;~ I. r~. Phone N~,).~...~.~ Name of Architect ...~I~QI&~,~.. .............. Address )~,~' ~,.~-~..2Z~-/.-'~. Phone No.'~...~'. ........... Name of Contractor . .~,/,..O~.~.W. ............. ? Address ...f~.~.... ~:~)~'(_~. Phone No 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 corner lot. STATE OF NEW YO~I~t~ .. ....... ~7~ *... M(...~if[~ . being duly sworn, deposes =d says that he is the applicant (Name of individual sighing contract) above named. (Contractor, agent, corporate officer, etc.) of said owner or owners, ~d is duly authorized to perform or have peffomed the said work and to m~e and file this application;that all statements contained ~ this application are true to the best of his knowledge and belief; and that the work will be perfomed in the m~n~r set forth in the application filed therewith. Sworn to before me this ....................· · ..dayof. .................... . 19 ~A~Y B. PANKIEWICZ ~ .... ,. / (Signature of applic~t) vl ~2.~61950 - SUFFOLK ~OO~'~V