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HomeMy WebLinkAbout22552-zFORM NO,3 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 22552 Z BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) ~lldlng Inspectoh ......... and approved by the Rev. 6/30/80 i ~ j.~-V---~ BOARD OF HEALTH .... ~ .... · - FO,M,o., ~ ~ SETS O~ .~L..,~S ~ ........ /-~ TOWN OF SOOYMOLD ~ SURVEY .............. /BW~LD~N~ D~PAMY~ENY ~ CHECK .................... ~ TOWN HALL ~ SEPZlC FORH .............. ~ SOUTHOLD, N.Y. 11971 / , ~ TEL.:765-1803 ~ hOTZF~ ~ .~~,~ ~, / // % ~ ;. - . ,~,~, ..... / ......... ,~,... ..~ ~.:~'~;~;~ ~..~ _ _ ~ ~..~~... .................... : [:2 7 ................. . ........ ..... . APPLICATION FOR BUILDING PERMIT Date..~:.~.~"..., 195.~ INSTRUCTIONS · a. This application must be completely filled in by Wpewriter 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 buildh~gs on premises, relationship to adjoining premises or public streets '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 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 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 Southold, 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 ali applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. - '" o': r .... .... ~. ~. 5. :.....~./... ~.,.~ ~,..~., ............ . (Mailing'address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. /n ~ r APFROVED AS NOTED .... ~ ~ ~. ...................................................... ~. ~~p.~. ~,.~a""~ ..~ Name of owner of premises . .v~... ,, ........... ~.) ..................... ~" ..... :"'- ..... "':"~t" '; (as on the tax roll or lates~ ~UI~IN~ Oev~M~m~ ~ ~$~-180~,~ ~ TO 4 PM FOR ~ If applicant is a corporation, signature of duly authorized officer. FOL[O~NO INSPE~ONS: (Name and title of corporate officer) Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE: 2. ROUGH - FRAMING~ ~,P[UMffiNG, :3, INSULATION 4. FINAL - .CONSTRUCTION MUST BE COMPLET~E FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N.Y. STATE CONSTRUCTION & ENERGY CODES. NOT RESPONSIBEE FOR DESIGN OR CONSTRUCTION ERRORS 1. Location of land on which proposed work will be done .................................................. .3. o.~' ................. d'ne..:.,...~...~..¢..i ~¢.. .... ~./).-::.~.r~.¢/? .................. House Nmnber Street Hamlet County Tax Map No. 1000 Section .~..V.3~.~..I.O.g.'~'.?~Block .................. Lot.. /. ~?..~ ............ Subdivision ..................................... Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premises and intended use and occupancy, of proposed construction: a. Existing use and occupancy .......... Fh ........................ ,...,-., .,-, .......................... b. Intended use and occupancy ................... ~,: ...... ....~ .~..,,~,,.~,~ .................... 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration ...,, ..'.. Repair .............. RemOval .............. Demolition .............. O~er ,W~,k .~. ~.{)j,~.~Dff~- .... 4. Estimated Cost ............................ Fee ...................................... ] (to be paid on filing this application) 5 If dwelling number of dwelling Cnits Number of dwelling units on each floor If garage number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ..................... 7. Dimensions of existing structure~, if any: Front ............... .R. ear .............. Depth .... i:i: ....... Height ............ '... Number of Stories ................................................. Dimensions of same structure wi~h alterations or additions: Front ' Rear Depth ............. ~ ...... I.. Height ...................... Number of Stories ............... ~ ....... 8. Dimensions of entire~ ~onstrhction: Front ............ Rear ............... Depth ............ Height Number of Stories · 9. Size of lot: Front ........... ! ........... Rear ...................... Depth ., .................... 10 Date of Purchase i ' Name of Former Owner 11. Zone or use district in which premises are situated ..................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ......... j ................... Will excess fill be removed from premises: Yes No 14. Name of Owner of premises ... 1 ................. Address ................... Phone No ................ Name of Architect .......... [ ................. Address ................... Phone No ................ Name of Contractor ~ Address Phone No I5. Is this property within 3100 feet of a tidal wetland? *Yes ........ No ......... · If yes, Southold ~own Trustees Permit may be required. PLOT DIAGRAM Locate clearly and distinctly all ibuildings, whether existing or proposed, and. indicate ail set-back dimensions trom property lines. Give street and block ~ mmber or description according to deed, and show street names and indicate whether STATE OF NEW YO~,' '~ - ~ .. ~ ~.¢;1; .~., ..... : .~B.~ ${ B~ ............. being duly sworn, deposes and says that he is the applicant . ~ (Name of individual signigg contract) above named. He is the ........................ . ontractor, agent, corporate officer, etc.) of said owner or owners, and is duly!authorized to perform or have performed the said work and to make and file this application; that all statements contaihed in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner~j&t forth in the application filed therewith. Sworn to before me this ..................... · .... Lot /93 © '-U 0 0 .... ~.lflOS :]0 N~AOJ. ~*~ ~t 1~