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Home My WebLink About13964-zTOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDIHG PERJ~AIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N9 13964 Z Date Permission is hereby granted to: ....... ~.L.:-!...~.~ .............................................. ,, .r,_~.....~..~...,......~.~....~.~. ............... ~ at premises located at ............... ~ ............................................. County Tax Map No. 1000 Section ....... ..~...L~ ....... Block ....... ..~....~ ....... Lot No ........ ..'~..~.. ........... pursuant to application dated ............. ...~...~. ...................., 19.~..~.~.., end approved by the Building Inspector. Fee $..~....~. ........... Building Inspector Rev. 6/30/80 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL ~OUTHOLD, N.Y. 11971 TEL.: 765-1802 kpproved )isapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT Received ....... .... ,1~.. ~ INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 =ts 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 ,r areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appll- ation. 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 hall 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 ~t Certificate of Occupancy hall have been granted by the Building Ir~spector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the inilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or [egulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. ?he applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to dmit authorized inspectors on premises and in building for necessary insp .~ ' (Signature of applicant, or name, if a corporation) ..... (¢.: .~..,..~.e~....'?..'z .q... ~ c:'.~.¢../. (?.~.7. (Mailing address of applicant) ~tate .whether applicant is owner,(l(l(l(~, agent, architect, en~neer, general contractor, electrician, plumber or builder. ....... O.y~ ~.~. ~. ~o.4... A4-. ~..~.cy ...................................................... ,ame of owner of premises ..... .f~...t3/7..~-...?.M;r..~. ' (as on the tax roll or latest deed) 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 ...................... Location of land on which proposed work will be done .................................................. ..... ~a, ~.... ~ o..~i ........ '~o..~.*. ~. ~ ................. ..~. c.,.~. ~..4'. .................... House Nnmber Street Hamlet County Tax Map No. 1000 Section ..... [.~. .......... Block ...... (9. .......... 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 .... AC...~q..: ............. . .~.-i' ....... : ....... .~ .................... b. Intended use and occupancy ..... .r'~ q .... ~ ............... o Nature of work (check which apphcable): New Building Repair .............. Removal Estimated Cost .... ~/~-~'. · .i... If dwelling, number of dwelling units .......... 'Addition .......... Alteration .......... ............. Demolition .............. Other Work. ~E~t.~ ~ .... .~..~...~...~ ~ (Description) (to be paid on filing this application) ............... Number of dwelling units on each floor ................ If garage number of cars ' 6. If business, ' ' ~ ' commercial or m~xed occupancy, specify nature and extent of each type of use .................... 7. Dimensions of existing structures, if any: Front ............... Rear ......... i .... Depth .............. Height ............... Number of Stories ................................................. . Dimensions of same structure with alterations or additions: Front ................. Rear ................. Depth ................... I... Height ...................... Number of Stories ..................... 8 Dimensions of entire new construction: Front Rear Depth Height ...... ......... Nutnber of Stones ........................................................ 9. Size of lot: Front .......... : ............ Rear ...................... Depth ...................... 10. Date of Purchase .......... i ................... Name of Former Owner ............................. 1 1. Zone or use district in which p[emises are situated ..................................................... 12. Does.proposed construction vi01ate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ........ 1 .................... Will excess fill be removed from premises: Yes No 14. Name of Owner of premises . .! .................. Address ................... Phone No ................ Name of Architect ......... 1 Address Phone No. Name of Contractor ... ~ .................. Address ................... 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/Y0gK , S ~ COUt_,,~, --~NlfY OF~ ..... :, ' ~ ... '~J~. ·; .~..~.-"'.~'~. · ..~.~ ................. being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. He is the ............................................................................. (Contractor, agent, corporate officer, etc.) of said owner or owners, and is du, ly authorized to perform or have performed the said work and to make and file this application; that all statements coi~tained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manger set forth in the application filed therewith. Sworn to before me this .......................... 19d .... .~.....~ ....... .... County ...... Notary Public t~_~ NOI'AR¥ ~U8[1¢, $}?. of bl.w York (Signature of applicant)