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Home My WebLink About16737-Z l~OB,~ NO. · TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT ('FHIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) NO- 16737 Z ...... ...... ......................................... ~..~...~.,..~:./..~. ................................................................. County TOx Map No. 1000 Section .... ./.../.~ ......... Block .......~..~.. ......... Lot No ......./.'.....~.... ...... pursuant to application dated ....... /./~....~. ............................... , 19....~.ff., and approved by the Building Inspector. Rev. 6/30/80 TOWN OF '~OUT¥1OLD FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined ....~.// ......... 19..~.2~' Approved.. -'~-,./'././ ........ , 19~.~. Permit No./~/'.~..~. ?. ~ Disapproved a/c ..................................... (Buildin~fispector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS BOARD OF HEALTH ...... 3 SETS OF PLANS ....... SURVEY .......... CHECK .......... SEPTIC FORM ............. NOTIFY CALL ................ MAlL TO: 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 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 shail 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, )~using code, and regulations, and to admit authorized inspectors on premises and in building for necesT~7, i~t:~~.)...~ .... (Signature ° f applicant ' °r ,~e'ff~c~?ti°~) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner otpremises ... ~... ! .r'5. g ....... .~. · .~*~. .... ~.[..q,~ .............. (as on the tax roll or latest deedS' I If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) ALL CONTRACTOR'S RUST BE SUFFOLK COUNTY LICENSED Builder's License No. ~ Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... ~ 7 o° 5- Location of land on which proposed work will be done ..... ~J.0..,~'dS. ............. ~r ......... ~ ....... House Nmn ber Street Hamlet County Tax Map No. 1000 Section .... {.{..~. ......... Block .... .O..l ........... Lot ..... Itl..~...I ....... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises ~and intended use and occupancy of proposed construction: use and occupancy ....... ~'~' '~' '~' ' . I/ ................................... Existing 3. Nature ofxvork (check which applicable): New Building .......... Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .. ~ ...... OtherWork ............... ~. ~<~. ~ ~ ~[ij, escriplion)m 4. Estimated Cost ................................. Fee ' (to be paid on filing this application) 5. If dwelling, number of dwelling units ............... Number of dwelling units on each floor ...... .......... If garage,~ber of cars ........................................................................ 6. If business, co'~erciat or mixed occupancy, specify nature and extent of each type of use ..................... 7. Height ......... ..~un}ber of Stories ........................................................ Dimensions of exis~tructures, if any: Front ............... Rear .............. Depth ............... Dimensions of same stmctur~h alterations or additions: Front ................. Rear .................. Depth ..... , ... ...... .... _ ...":-~gh~t ...................... Number of Stories ...................... 8. Dim ensi~U, ction,~t ............... Rear ............... Depth ............... Height · ~. Number of StoriL~-,&._.._.. ..................................................... 9. Size of lo~:~ ............. R~a~. ..................... Depth ...................... 10. Date of Purcha~ ...j · ... ~ . . . .~'N~e of Former Owner ............................. 11. Zoneor~~t.ed.....;. '''~<,i ......................................... 12. Does pro~w, ordinance or"~,~g~lation: ................................ 13. Will lot be ~e~ U .Will excess fi'lM~emoved from premises: Yes No 14. Name of Owner of premises ~ress .... ~ ...... Phone No ................ Name of Architect ~ ........... . .'2~... Phone No ................ Name of Contractor ~ ..... . .">E,h_one No ................ 15. Is this property located within 300 feet of a tidal wetland? *Yes ..... o ..... · If yes, Southold Town Trustees Permit maybe required. PLOT DIAGRAM Locate clearly and distinctly ~1 buildings, whether existing or proposed, and~ indicate M1 set-back dhnensions from proper~y Hnes. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, S.S COUNTY OF ................. ................................................. being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. tte is the ......................................................................................... (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his 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 ......... ~-cq~......~: . ~.t'..~...~... County Un[N K. ~ ~t No. 4707878, Term Expires kb~ch (Signature of applicant)