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Home My WebLink About22556-zFORM NO.$ 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) ._/~ / ~ ~ r'~ Date .............................................................. 19 ........... N_ 22,556 Z ............................................... ~.:~.:/.... ........ .x...~...~,. .......................................... CountyTaxMapNo. 1000 Section ~ t" Block ..,,~'.., . LotNo. '~/ pursuant to application dated ........... '.'.'.'.'.'.'.'.'.'.'.'.'.'~,.... :~: .~: i ~ ............... and approved bythe ,.,,d,%n~ Fee $.~ ....... ~ ..... Rev. 6~30~80 Approved .... ' ~. ~.~.~L- , Disapproved a/c ..................... ~i ..... ' - ' ' ' ~J~ICATION FOR BUILDING'PERMIT FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N,Y, 11971 TEL,: 765-1802 ' BOARD OF HEALTH ......... 3 SETS OF PLA~S .......... SURVEY .................. CHECK ..... 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 r~ets 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 st?eets _ or areas, and giving a detailed description of layout ~f property mu~t be drawn on the diagram which is part of this appli- t. 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 Southbld, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or denmlition, 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 necessary inspectioas. -- (Signature of applicant, or nam~ ifa corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, generai 'contractor, electrician, plumber or builder. Name of owner of premises ........................................................................ (as on the tax roll or latest deed) If applicant is a corporation, $ign.ature of duly authorized officer. (Name and title of corporate officer) Builder's License No .......................... Plumber s L~cense No ............... . .......... Electrician's License No. Other Trade's License No ...................... Location of land on which proposed work will be done· "~,C_.tf_ c:l ~ N~ ........ '.'.;..:.. ...................... : ........ i...'.: .... . IJou e Nu,n ,er Streetr ........ .............. County Tax Map No. 1000 Section .... '.. [~. [ ......... 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 b Intended use and occupancy ' · 3. Nature of work (check which ~pPlicable): New Building . ~ ........ A. ddition .......... Alteration .......... Repair .............. Removal .............. Demolition . . . Other Work .-fT. CN C~. . . es 4. Estima ~ F: : 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 busine'ss commercial ' ' ' + .................................................................... · , or mi.xled occupancy, specify nature and extent of each type of use ..................... 7. Dimensions of existing structures if any: Front Rear Height Nurn~er of Stories ............................. Depth j .............. Dimensions of shine structure ' ' · with alterations or additions: Front ................. Rear ................. Depth ~ !~ ~,,h+ ' · .... o .'. · · Number of Stories .......... '. ~ 8 Dimensions of entire new construction: Front ......... ' ; Rear Depth Height Number of Stories ........................................... Size of lot: Front ' ........ ......... ,~ ............ Rear Depth Date of Purchase i ....................................... ............................. Name of Former Owner ...................... Zone or use district in which piemises are situated ............. ' ..... Does proposed construction vi?late any zoning law ...................................... , ordinance or regulation: .............................. Will lot be regraded ....... ;i .................... Will excess fill be removed from premises: Yes No Name of Owner. of premises .. i .................. Address ......... .......... Phone No ............ :... Name of Architect . ......... ' Address Phone No Name of Contractor ........ i .................. Address ................... Phone No ................ 15.' I.s this property within i300 feet of a tidal wetland? eyes ........ No ......... ~ · If yes, Southold iTown Trustees Permit may be required. ..: PLOT DIAGRAM : Lodate clearly and distinctly ali buildings, 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. 10. 11. 12. 13. .14. ~ t,LOWIh G INSPECTIONS: 'I F()I. JMDA'i'tO~ .. ~'WO I~[~OIj ~' fqNAL~ ~' o ' " CONoT~UCTIO~ MUS'r Al,,[ CONSTRuCT~O~ SHAEL ME~T THE REQUIREMENTS OF THE N.E ~TATE CONSTRUCTION & ENERGY COO~, NO~ RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS STATE OF NEW YQRK- ................... , ......... ' ......... being duly sworn, deposes ~d says that he is the applicant (Name of individual signiqg contract) above named. ~ (Contractor agent corporate officer etc ) ' of said owner or owners, ~d is duly [authorized to perfom or have perfo~ed the said work and to m~e and file this application; that all statements contaifled ~ this application are true to the best of his knowledge and belief; and that the work will be perfo~ed in the manner get forth in the application filed therewith. Sworn to before me this ~ I Note Public . 0 ~ , . . N~ARY PUB~ ~Lof N~ .~ ...... · ......... - ~ ~mgnamre olappuc~t)