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Home My WebLink About22748-zFORM NO.3 TOWN OF $OUTHOU) BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. N9 22748 Z BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permission Is hereby granted to: ....... ....................................................... to ..~~..~~....,~~. ......... ~.........~,.. ........ ~~ ............. ............................... pursuant to application dated .......................................................... '19 ................ and approved by the Building Inspector. Fee $.....~.....~..r..... ,~}~:y Rev. 6/30~80 · no'.~ or ~ormer~¥ ~nc'. North -For~, ~.ous'mg /~i~nce, NoCh For~- rea = 126607 s.f. 53.00' 0,00' w. .........103.'( o ~o ROAD N.86o43'0 o"w. ( N.Y S. RTE. 2'5 N'83°2 $'0($'W. N.87' ~ Ih ~ U W I~ FORM NO. 1 ,'~?_~ : ....... ; 3 SETS OF PLA~s ' 2~: · :: TOWN OF SOUTHOLD SURVEY ' ~ ~ ~ 0 ~95 ~UILmNG DEPARTMENT · o., ;;;;, .... ...... ;~ ...... ~ SOUThOLD, N.Y. 11971 · y:.: ......... . · ........... ........................ ~ APPLICATION FOR BUILDING INSTRUCTIONS ~. ~1~s a~Hc~fio~ must b~ completely fiU~d ~ by ~c~d~ o~ ~ inn ~'d submitted to t~ Build~8 I~s~c~o~, cafiom c. TN~ ~o~k coY~d by t~s ~ppHc~fion m~y ~o~ b~ comm~ccd'bcFo~ ~ssu~cc o~ Bu~d~$ ~iL d. U~o~ ~p~oval o~ t~is ~pUc~fio~, ~h~ BuHd~$ Ins~ccto~ ~H1 ~ssucd ~ BuNd~$ ~i~ to thc a~p~c~L Suc~ sb~l b~ k~p~ o~ ~h~ ~m~s~s ~v~bl~ ~o~ ~s~cQo~ th~oushou~ th~ ~o~k. R~$ula~o~s, ~ thc co~st~cfio~ oF bu~d~$, ~dd~fio~s o~ ~l~fio~s, o~ ~o~ ~mov~l o~ d~moHQo~, ~s b~ d~scdbcd. · b~ app~c~t a$~s to comply ~t~ all ~p~l~ca~lc l~s, o~d~c~s, bu~d~ cod~, house,S cod~, ~d ~eSulafio~s, ~d to admit authorized ~specto~ on premises and ~ build~g for necessaw i~pections.. (S~nature of applicant, or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, age,t, architect, engineer, genera~ contractor, electrician, plumber or builder. ~ i:;h .-.: ............... .... . . e of owner of premises ......... ~ .... /~ ~ ~f ~ · (as on the tax roll or latest deed) If applicant is a corporation, signature df 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 Location of land on which proposed work will be done .................................................. ltouse Number Street Hamlet ......... Connty Tax Map No. 1000 Section . . ./.q ~. .......... Block . . . ~.. ' Lot..--W'.~... :~...~.4 ...... Subdivision ........ . ............................. Filed Map No. (Name) .............. Lot ............... State existing use and occupancy of premises ..... .......... occupancy of proposed construction: a. Existing Use and occupancy ....... b. Intended use and occupancy .,4<'. ~'~_ .3. Nature of work (check whiqh applicable): New Building . ~ ........ ~ddition .......... Alteration ........ Repair .............. Removal .............. · Demolition ..... ; .......... Other Work .4/~,?,o.. 4. Estimated Cost ..... oo o . - ' ,, - · escnption) 5 If dwelling number of dwell!lng units (to be paid on filing this application) If garage number of cars I ............... Number of dwelling units on each floor 6 If business Commercial or mlxed (~ 2.' ',2' 2' 2'2'.,['"; ..... , ....................... 7 ' ' , . . . ~,--p,-,,y, ~p~cny nature aha extent of each type of use Dimensions ot existing structures if any: Front ' Height Num bet of Stories ' Depth ................ , Rear ............................. Dimensions of shine structur~ with alterations Jr' ............................................ Depth i Height a?,o. ns:Front ................. Rear ....... ' ......... ................. Number of Stories .......... 8 Dimensions of entire new co0struction: Front ' · Rear ..................... Height N~mber of Stories .............................. Depth .............. 'size of l;i: .............' ....................... , ................................ Front .~ ' Rear ' Date of Purchase ........ ~' ........................... Depth ........ ' ....... ' Name of Former Owner ................. Zone or use district in which premises are situated .................. ' .................... r ~ · .. ..... Does proposed construction vliolate any zoning law ordinaI~ce or reg~la~i'o'n: i ............................... Will 10t be regraded ' · ............................ '~"~ ':i':i .................. Will excess fill be rem0ved ~om premises: Yes No Name of Owner of pre ~s s ...... , ....... Address ..; ...... ...... Phone No ........... .. Nam~ of Architect I ..... ............................ Address Phone No ...... ' .... Name of Contractor ....... i .......... ' .................. ·.. '. Is this property ?~ ''':' '!'' ......... Address ... ~ ......... ~ ...... Pho o ....... 15.' within 300 feet of a tidal wetland? *Yes ........ · If yes, Southoldl Town Trustees Permit may be required. No..~ ..... PLOT DIAGRAM ' ' Locate clearly and distinctly all buildings, Whether existing proposed, and. indicate all set-back dimensions from property hnes. Give street and bloc~ number or or description according to deed, and show street names and indicate whether interior or corner lot. I 10. 11. .12. 13. .14. 7S5-.1802 ~YAM TO ~ PM FO~ THE : FC R P(~IJRED'CONCHET~ ,~,, :.Fg~AL COR~STRLICT~ON gF COMPL,EYE FOR WF~ffE ~CONSTRUCT~ON & ENERGY STATE __ ,-, C', , / ;'~FqmN OR' CONSTRUC'I'ff}N EaROIqS OF NE -~ ' ' , oF. , .... Fb.~.c.(_~...~.. ~cC~.,. ~ , . ' ~ ..... ',: :- ' ' ': ' ' 'i ......... ~J'" ........ oemg amy sworn, deposes and says u'~ame olmmvlaua~ s~gnm§ cqntracDy , that he is the applicant lbove named, i ~ , . - (..,..... leis the · ,. J (c '"&"i;~'i~ .................... ' ..... ~ ontractor, age , c o a e officer, etc.) .............. ,f ~aid owner or owners, ~d is duly ~authodzed to perfo~ or ~ave peffo~ed fi~e said work and to m~e ad ~1~ this pplicafion; that all statements contained ~ this'application are tru~ to the best of his knowledge and belie~; and that the ,'ork w~l be perfo~ed in t~e m~ner ~et forth ~ tile application filed therewith. ,worn to before me ~his [ .... ,... . , ~o. 48~B~0~ i '~- ' ..................... fl~ll~ i~ ~k ~. ~ ,, '~i" ~ .............. m~ge~mba 8,1~ ( gnature of a licit) ~ml~lon E~' ~ ' , PP