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Home My WebLink About22742-zFORM NO.3 TOWN OF $OUTHOLD BUILDING DEPARTMENT ToWN HALL $OUTHOLD, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Date .....~ ............................................ 19~...~ 22742 Z Permission Is hereby g~~~...~,~. .............................. ~ ~t, .... ~-~ ........... CounlyTox Mop No. lO00 Section.,..,/~.....~..,.., Block ............. o o. pursuant to application dated ............................................ 1 ......... IBulldlng Inspecto~ Fee ~ .~..~ and approved by the Rev. 6/30/80 · ~' ' FORM NO. 1 ~ TOWN OF SOUTHOLD ~ BUILDING DEPARTMENT ~ TOWN HALL SOUTHOLD, N.Y. 11971 /.. TEL.: 765-1802 ......... ,l~q.~pZ.C ~,o.~.&7¢' ':~' Examined ....C~./ ........ , 19__ermit ...... Approved / Disapproved. a/c ...................................... . · gBuil~)fig Inspector) APPLICATION FOR BUILDING' PERM IT 'ETS 3 $ OF PLAN.q ...... . .... SUR¥£¥ ClII~CK . . ..... . ..... CALL . . . HAIL TO: 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 sfi'eets 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 prenfises 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 Certificatd 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 Southbld, 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 authorized inspectors on premises and in building for necessa~ ln~~ . .... - (Signature of appli~, or name, if a corporation) ...4-/. ~z~z)~ ~...s-.zz4~.. c..~. ......... State whether applicant is owner, lessee, 'agent, architect, engineer, general contractor, electrician, plumber or builder. ........................ ... .... / ....... ..: ............... , ....... of owne; ofprem,ses .....· 9. ......... · (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authoriied officer.' (Name and title of corporate officer) Builder's License No .......................... Plumber's License No ......................... Electncmn s Lmense No ....................... Other Trade's License No ...................... Location of land on which proposed work will b.q'do~ne...~...C).~..~..C7. ?..~.-7. ............................. Itouse Number Street Hamlet Cotmty Tax Map No. 1'000 Section ....~..~.'.ff. ~ ........ Block ...,~. ......... ' Lot...' ............ Subdivision..; ..... . ............. ..... ............ '. Filed Map No ............... Lot ............... (Name) , ' State existing use and ~ccup~ncy ~f premises and intended use and ~cupancy ~f pr~p~sed c~nstructi~ni a. Existing use and occupancy ................... j~fj..lr?(~5~.~f.t~,~Of/ ............................ .. b. Intended use nd occupancy ' ~ ' . ~m~¢;~ ~ c~2 ,{~,6~ X~ ......... · 3. Nature of work (check which aPphcable): New Building . ~...' .... ~ .~dditio~ .......... Alteration .... · ........ Removal .............. . Demolition ....... Repair ...... . .... :~... Other Work ......... 4. Estimated Cost ,I (to be paid on filing this application) 5. If dwelling, number of dwellin~ units ' Number Of dwelling units on each floor If garage number of cars ~ ' ' 6 ' If busin.e'ss ......................................................................... · , co.mm, ercial or mi.x~d occupancy, specify nature and extent of,each type of use 7. Dimenmons el exmting structures, if any: Front ......, Height Number of Stories Dimensions of shme structure with alterations or additions: Front Rear _Depth ' i Hight ..... N' ............................. ' '. ................... ' mber of Sro ies ' 8 Dimenmons ofentir traction: Front Rear · e new cons ............. : ............... Depth ...... Height Number of Stories ........ 9 Size ofl0t: Front I ' Rear ' Depth 10 Date of Purchase ' ' ' Name of Former Owner 11 Zone or use ' ' ' ' ........ dmtnct m which pr~mises are situated ' ' 12. Does proposed construction violate any zoning law, ordina ce or regulation: ............. 13. Will ldt be regraded ....... 14. Name of Owner of premises .. Name of Architect ......... Name of Contractor ........ 15.' I,s this property within *If yes, Southold Locate clearly and distinctly all property tines. Give street and block interior or corner lot. ................... Will excess fill be removed from premises: Yes No Address ' Phone No ................ Address ................... Phone No ................. ................ Address ............. ' ...... Phone No ................ 300 feet of a tidal wetland? *Yes ........ No ......... ~own Trustees Permit may be required. PLOT DIAGRAM buildings, whether existing or proposed, and. indicate all set-back dimensions from number or description according to deed, and show street names and indicate whether STATE OF NEW O_[JNTY OF ........... ,~..... ',' ' ~~...~.~ ~ .... ' ......... being duly sworn, deposes and says that he is the applicant (Name of individual signi0g contract ' above named. H i e s the ., .............. (Co'nt~t0r}';~ en~, ...... co ~ orate ...... o fii cer, ...... etc.~ ............. "" ............ of said owner or owners, ~d is duly authorized to perfom or have performed the said work and to m~e and file this application; that all statements contai aed ~ this'application are irue to the best of his ~owledge and belief; and that the work will be perfomed ~n the nner~set forth tn the a ' ' te~l . ' pplication filed therewith ' Sworn to beforeme this ~ ) ~ . ......... ..... Nota~ Public, . .~~. ~..~.. Coun(;~ . . ........ ............. (S~gnature of apphcant) ' . N~A~C, St~ofN.Y. , . . ~ ' (Signatu~ . ' ~4725~. S~o~ Cou~ Te(m E~r. M~ 31.19~ - MINOI~ ,.SUBDIVI,.SION '' / / COUNTY