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Home My WebLink About23113-zFO~M NO.3 TOWN OF $OUTHOLD BUILDING DEPARTMENI' TOWN HALL $OUTHOLD, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 2 31 13 Z Dote ...... ,/.~ ........................................ Rev. 6/30/80 sUFFOLK COUNTY HEALTH DEPAFFFMENT SINGLE FAMILY OWE~.LING ONLY H.D. REF. NO. . THE SEWAGE DisPOSAL AND WATER SUP?,.Y FACILITIES FOR THIS LOCATION HAVE SEEN INSPE[,IEt~ SY THIS OEPARTMENT AND Ohief of Wastewater Management Section 7//' TOWN OF souT}.K)t.rl ' FORM NO. I TOWN OF SOUTHOLD BUILDING DEPARTMENT: TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 APPLICATION FOR BUILDINGPERMIT Examined ........ , 19 .. Approved ................. I . Pen?it No. -~' ''~ Dlsapprov ~, ~ ' ',(;?,. ~ ,~r)2 9 ¢~f~¢i 70 4 P~.,, RJR '~3.~E . Cuilct~ Ins¢ctor) INSTRUCTIONS BOARD OF IIEALTIt 3 SETS OF PLANS SURVEY ............ ~ ...... CIIECK lq^IL TO: Date ................... 19... 3, ~(~,~}l~I~o~fl~ ~&t bo ~o~.~letely nllcd m by ~pewnter or m ink and sub rotted to the Bmldmg Inspector, with: sc~s 'Of Rl~s. &~0~¢..~lo~ Dla~,to ~i~. Fee according to schedule ~/b>~.,-Yfgg~f~,~fiP~mg %c~o,o~;lot and of buildings on premises, relationship to adjo rang prem,ses or pubic street, ~e~.a ~)~ n~t&~[¢~4 ~}s6~.Bon of layout of property must be drawn on the dmgram whmh ~s part of t tis apph c; the w6rk ~bve?ed by this application may not be commenced before issuance of Building Pemdt. . d. Upon approval of this application, the Building Inspector will issued a Building Pe~it to the app~cant. Such permil sh~l be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in p~t for any purpose whatever until a Certificate' of Occupanc5 shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the BuildNg Dep~tment for the issuance of a B~iding Pemdt pursuant to Building Zone Ordinance of the Town of South01d, Suffolk County, New York, ~d other app~cable Laws, Ordin~ces Regulations, for the construction of bu~d~gs, additions'or alterations, or for removal or demolition, as hereN described The app~cant agrees to cmnply with all applicable laws, ordinances, buildblg code, housing code, and regulations, and tc admit authorized inspectdm on premises and N buildNg for necessa~ ~eet~s. ~ ,, . . - - (Signatur~f applicant, ~r name, if a corporation} .~..~n%. ~r ,~.~ ................... (Mailing address of applicau0 i t15~lumbm ~ r builder. State whether applicant ~s owner, lessee, agent, architect, engineer, general contractor, electrician, p e or . .¢~.,~b ...................... .' ..................... . .............. . ........................... Name of o,v,,e, of premises ......,.__.~r.[.. ~ ...... ........................... (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 ...................... l. Location of land on which proposed work will be done ............. ................ o.~.~ .... .~...~.\¥..~. ........... ... N~w,'ro ~K ..... . .... . ..... .... S,o~¢ ... R ........ House Number Street Ha County Tax Map No. f000Section .../../iP.¢. ...... Block ' .g. ' Lot..t~.fl ............. S~,bd~v~io,,..~.k..or¢...O.c.<O. ..................... '. l',ed mp No. ,~l ........... Lot..K ........... (Nalne) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy . . .~3.~.~}~.~ . . ~ b. Intended use and occupancy ............................................. ~ .................... '3. Nature of work (check which pplicable): New Buildi g .......... Addition ........ Alteration .......... Repair RemoVal .............. Demolition Other Wolk r~ene~ .)p' ............... ' : ............... 4. Estimated Cost~,.O!D.,.~.(~. ........................ Fee ...................... (Description) (to be paid on filing this application) ' ' ' 5. If dwelling, number of dwelling units ............... Nmnber of dwelling units on each floor.. · If garage, number of cars ..... !... ' ............. 6. If business, commercial or m~.xed,occupancy, specify nature and extent of.each type of use ............ 7. Dimensions of existing structures:,lfany: Front Rear .............. De ~ ......... He ~t ............... Num er of Stories ................... ' ..... Dimensions of shme structure wit:h alterations or additions: Front ................................ D pth ' ! Hight .................. Rear ................ e ....................... e .......... N b f St its ' ' ' 8 Dim i ofentir ction:Fr ........ "' um ere or .................. · ens ons c new constru' ont ' ' H 'ght 'Num~ fSt ties .............. '~ Rear ............... Depth ... 9 Si fl F i Rear .... · zee ct: rent ............... ; . ' ........................... ..... Deptt 10 ...................... ~ ...................... Date of Purchase . : .......... i ................. Na.m.e of Former Own'er .............. 11. Zone or use district in which premises are situated 12. D°es pr°p°sed construction violaie any zoning law, ordinance or regulation: 13. Will ldt be regraded ....... ; · · l ................ Will excess fill be removed from premises: Yes No 14. Name of Owner of premises .... ' ....... ; ...... ' ' · . ~ddress ................... Phone No ........... :.. N~me of Architect ....................... '... Address ................... Phone No. Nmne of Contractor ... · ........... ................ Address ................... Phone No ............ 15.' Is this property within 3010 feet of a tidal 'wetland? *Yes ....... No ......... · If yes, Southold To~n Trustees Permit may be required. .. ' I PLOT DIAGRAM Locate clearly and distinctly all buddings, whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. ;TATE OF NEg, z-~ORIC: f"', ........ s ............ (Name of individual signi~ontract) ' being duly sworn, depose~ and says that he is the applicant bore named. ~e is the ...... ........... ~)~ ....... . .......... . .............................. . ~ (Contractor, agent, corporate officer, etc.) f said owner or owners, ~d is duly authorized to perform or have perfo~ed the said work and to m~e and file this )plication; that all statements contained~ in tl~is application are t'rne t~ the best of his knowledge and belief; and that the ork will be perfo~:med in the mmmer set ~fort x in the application filed therewith. woru to before me this °ta~ eu~' ' '~~ C°unty ~ ~ota~ ~ublio, State of ~ow York , ' ~ .................... No. 407960fi ~ ~ r ' ' / / f applicant) ~ommission E~ires Oecem~