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Home My WebLink About13867-z FORM NO. ft TOWN 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) Date ~''/f' ... 13867 Z .................. "./;. .................................. I9..~~ Permission is hereby granted to: ~2(/_J / ]~] C]~ ' to .................................................................. ~ ....................................................... ~. ......... County Tax Map No. 1000 Section ~?c~> Block ~ Lot No. '~ / ................ . pursuant to application dated ....................................... 19... nd 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.: 765-1I]02 Examined"'¢ 'F ...... , /s rT¢ Approved ................ ]9... erufit No ............ Disapproved a/c ..................................... ~ i 5 1985 ~,, ~ BLDG. DEPT. · ~ ~' TOWN OF .$QU. THOL'D Received ........... ,19... (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 st'ieets 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 authorizedinspectorsonpremisesandinbuildingforneeessa,,~~ .~..~.~~7 (Signature of applicant, or name, if a corporation) ...... (Mailing address of applicant) State whether applicant is owner, lessee, age.nt, architect, engineer, general contractor, electrician, plumber or builder. ....... ©..~. ~.~.~. ................. '. ........................................................ Name of owner of premises ....... t.:..~...../~.. /Y~C~&~_/~ (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... .................... 1. Location of land on which proposed work will be done .................................................. .. :? ~ ......... ~a~ ~a~,~'~ ~ House Num bet .... ~eet Hamlet County Tax Map No. 1000 Section iD r~- Block ...9.~ ...... ~ ...... Lot O~'~. Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occfipancy ... : .................... ~.,n,ande~ ~e.nd oco~.ancy ... ~:.a/~ ~ ~ .... d~ ~.... ~(.~ 5 ~¢. ~. ....................... 3. Nature of work (check which apphcable): New Building .......... Addition .......... AlteratioN .~ ......... Repair .............. Removal .............. Demolition .............. Other Work,/.-7 .~..r~..c..z~.... 4. Estnnated Cost ................................. Fee ...................................... * ~' (to be paid on filing this application) 5. If~welling, number of dwellin~ units ...... ~.. ...... Number of dwelling units on each floor .... ~;. ......... If garage, number of cars ........................................................................ 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ..................... 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 ............... Height Number of Stories 9 Size of lot: Front ' Rear Depth 10. Date of Purchase .......... i ................... Name of Fonuer Owner ............................. 1 1. Zone or use district in which premises are situated ...................... 12. Does proposed construction w01ate any zoning law, ordinance or regulation: .... ,$Jf..O. ....................... 13. W/ll lot be regraded ..... 14. Name of Owner of nremises' . ,.., ................. Address t~ ~.~'../(7..f-..t~..J.~ b... Phone No.. 7.(~ ~./.~'( .~. .... Name of Architect ......... : ................. Address ................... Phone No ................ Name of Contractor .' Address Phone No PLOT DIAGRAM Locate' clearly and distinctly al'l buildings, whether existing or proposed, and, indicate all set-back dimensions f[om property lines. Give street and bloc]: number or description according to deed, and show street names and indicate whether interior or corner lot. '~-~oc~::~c,~ STATE OF NEW YORK_ o C ' COUNTY OF...-~..(-(..f:.~ ..... · ..~'.~.~.~b.'7. . ~'.......t....................c [~g'C ' being duly sworn, deposes and says that he is the applicant (Name of individual sigfiing contract) above named. He is the ......................................................................................... (Contractor, agent, corporate officer, etc.) of said owner or owne~, ~d is duly authorized to perform or have perfo~ed the said work and to m~e and file this application that all statements contained m th~s apphcation are true to the best of his knowledge and belief; and that the work will be perfomed in the m~ner set forth ~ the application filed therewith. Sworn to before me this : ................ day of '" HEI 5'I I( Df: ¥OE NOI~RY PO31iC, Sta*e o~ tqe,;~ ; NO ~Z07878, SLiff?k (Signature of applicant)