HomeMy WebLinkAbout24217-zFORM NO.3
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y.
24217 Z
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED]
Permission is hereby granted to:
....... L.I.~/~../~,.. ~GI~E.I.~8 ..............................................
....... ~O,,.C~L~I~K.,.~Q~, ................................................
....... SDU.T. HDLII.. ~.Y....ll..~?.l., .......................................
tO .... £R£C.T.../~.. E. ENCF-... RS...AP..BL [ ~'D...EDR ....................................................................................
at premises located at ........... .. ...... .4-.~0..... ~;L,~B.I~.. RD ............................................. ~C~U.7.1Tt. QL~ ............
CountyTax Map No......~Z~;.8.8.9. ...... Section ..i;~5. ............. Block ....g.0.Q2 ......... Lot No. O.qS. ................
pursuant to application dated ...¢.l,Jj¥.t~ ......... ,......t.q ......................... 19......5.7. ...... and approved bythe
Bulldlt'~cccg Inspector.
Fee $ ....... ,~, ~,,,Q,Q .....
................................. ................
Rev. 6/80/80
FORH biO. 1
TOIqN OF SOUTIIOI.II ·
BUILDING I)EP^RTHIr, biT
T()I./N llAI.L
SOUTIIOIA), N.Y. 11971
TEL: 765- 1802
I~;OAP, D OF IIEAI,TII ...............
SETS OF PLANS ...............
~/SURVEY ........................
//CIIECK ............. ~. ~,,. .........
SEP'FIC FORM ....... '},.
APPI.I CNI'I ON I"OR IHI I 1.1)1 NC PF, IIH I'F
] NSTRIJCTI OHS
a. 'ihls application ,rust be coapletely filled in l:,y typc4.~rltor or in ink a~xl ~bnitt~ to the hdldi~ Insl~ctor with
3 stats of plan% acmwate plot plan to scale. F~ according to sch~lule.
b. Plot plan shying l~ati~ of lot a~l of beildlngs ~ ~i~s, relationship to ~ljoinlsg prcan[ses or Ixt>lic
struts or areas, atxl giving a detail~l descripti~ of la~t of prolerty ~mt be dr~m ~ the dla~m ~dch is Imrt of
c. 'lhe ;~)rk c¢~r~l by this al~)licaLion Pny ~)t I~ c¢~mr, nc~l I~fore {~mmnce of Ikdh{ing l¥1mit.
d. UlXm al~)~al of Ods aH)licati~b the lk;ilding lnslector will is~m n ~dld{ng Pomit to thc a~lleant. Such
l~n,fit shall 1~ kept ~ I.l~ pr~ni~s ~ailable For ins~ctim tl,rne~,m*t the ~d~.
e. ~ I~}ldln~ simll I~ ~pi~l o~ used in ~]e or in ~: fo~ ~ I~r~se ~mt~er unLi] a C~tific~te oF
(Xxaqmm:y shall hme ]~n grmlC~l by the ~fildJng lns~ctor.
hlq%IfZ'l'l~ TS I]~{l~ }~ to tl~ lhdldiag ~lmrt~mlt for the issua~e of n lh/ilding Pemit la~rmmnt to the
Ikd/ding 7~ ~lbm~me of the 'l~m of ~mthold, ~ff[olk ~mty, ~ York, aml other al~llcgble l~s, O~in~es or
~flatlons, for tim c~stnmti~ of lmildi~Bs, aMitims ¢~ alreraei~s, or for r~al or doral {tion, as herein
(~scrilml. abe applicm~t a~s to c~[y with ali a~lJcable l~s, o~hmaces, I~{lding c~e, h~sing crMe, ara
re~latlnes, aml Lo m~it mJtl~rlz~l ins~tors ~ lmims m~ in ladlding for necesso~ {nsl~ct{~m.
(Sig~mture off al~llcnnt, ~ n~, if a coqx~ratimO
(~dling ~xldress o~ a~licank)
State whether apphc, nt ~s ¢mner, lessee, agent, architect, engineer, general ccmtractor, electr{clan, phmtber or lalilder.
~*re oaaxqr of pr~nises ...L ~ ~.%w......'.~. o~..CTj .........................
(as c~ the tax roll or latest deed)
]f applicant is a corporati¢m, si?4mature of duly authoriz~<l officer.
(Hare and title of corporate oEflcer)
4. FINAL - C,4:)~I~IJ4~'~IQli MU~'
BE ¢OMPU~tl FOR ¢.0.
ALL CONSTRUCTION Sl~d.L MEET
THE REQUIREMENTS
lk, ilders l,icen:m K~ ..........................
I'h~l~qrs l,{ceas¢~ No ..........................
Electricians Licee.qe No ......................
O[~ N.Y.
Other 'rr~h's Licen~ ~ ..................... , __ ~ST~TE CONSTRUCTION ~NERGY
DESIGN OR, ~NSTRU~I~ ~RORS
..... ................. ................................. ........................
lka~se ~r Strut
~,~y ',:~ ~. ~. m, ~,:~, ..... ~. ...... ,.,~k ..9.~ ........ ,~ .D~. .....' ....
~,lMivlsicm ...................................... Fil~l ~hp ~ ................ l~t ...............
(~)
Slale existing u~ ami ~a,~ off ~,daes a~ inte,xl~l use ar~l ~o,~a~x'y off ~1 c~stmctlu~:
~. ~i~ti,,,~ ,,~ ~,~, ~,,,~,,~a ..~a~.~..~o~ ...... ~ ..................................................
I'
I
Di
9.
II. 5xe or u~ diatrict in ~lt(:}t p~aaiaea a~e sitxmtc~l
15.
i-
PLOT I)/A(IRAH
((~)lll I nt~Lor, ;Igen(., Col ix)ral e OI[ J('LH', ('l (:,)
~)rn lo I~ft)~ Ihia
0O'
II
¥- O'
Z
~' ROFO
,/