HomeMy WebLinkAbout23240-zFORM NO.3
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD, N.Y.
BUILDING PERMIT
ITHIS PERMIT MUST BE KEPT ON THE PREMtSES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
23240 Z
//
Permission is hereby granted to:
~~ ...... .~.....~~ .......................
.... ,2',~£~..... ,..~,~..~.~.~..,..,~ ....
to...~,,~:~.= ........... .~ ......... ~.~-~ ............. ~....¢.....~(...~~ .............................
............ ~ ............ ~..,'~ ....... ~.: .....................................................................................
....................................................................... ~....~~ .............................................
Coun'h/ Tax Map No. 1000 Section ,...../../...~., ........... Block ...... ~ ............. Lot No ....... ~..,:.~.~ ............
pursuant to application dated ......../~../.~. ......... / ........................ ,9..~ ~.. ..... and approved by the
Building Inspector.
Fee$..~.C..~ .......
//Building Inspector
Rev, 6/30/80
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT;
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL,: 765.1802
Disapproved a/c ..........
B~RD'OF HE^LTtI
3 sETs OF PLANS
SURVEY
CIIECK ......... ~ ......
SEPTIC EORH
CALL ........
HAIL TO:
Date ...Z/~./. ........ ,
INSTRUCTIONS
a. Ttfis apl~lication must be completely filled in by typewriter or in ink and submitted to the Building Iuspector, ,~
sets of plans, accurate plot plan to scale. Fee according to sdmdule.
b. Plot plan showing location of lot and of buildhngs on premises, relationship to adjoining premises or public s~
or areas, and giving a detailed description of layout of property mu~t be drawn on the diagram which is part of this
cation.
c. The work covered by tltis applicatiou may not be commenced before issuance of Building Permit.
d. Upon approval or this application, the Building Inspector will issued a Building Permit to the applicant. Such p
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 Occui
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant !
Building Zone Ordinance of the Town of South01d, Suffolk County, New York, and other applicable Laws, Ordinan,
Regulations, for the constructkm of buildings, additions or alterations, or for removal or demolition, as herein desc
The applicant agrees to comply with all applicable laws, ordinances, building code, housiog code, and regulations, a
admit authorized inspectors on premises and .in building for necessary inspects..--~.~ .M~'.t:.r.t,~M'v .t'''l ~:~r'~'~ ) * '~ JS?-''-~l.rW.~'~m~....~.
-- (Signature of applicant, or name, if a corporation
(Mailing address of applicant')
State wheflmr applicant is owner, lessee, agent, architect, engineer, generai 'contractor, electrician, plumber or bu
.................................... .' .......... ...................
Name
of
owner of premises ............................................ :~ .......................
(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 .............................................
· ................... .......... ........
/louse Num her Street Hamlet
. '.t/
Cou'nty Tax Map No. 1000 Section ....... .*ff. ......... Block .............. :... Lot .... ~ /
Subdivision ' Filed Map No ............... Lot ........... (Name)
Stat4 existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy .
b. Intended use and occupancy ' '
0
'0
b..