HomeMy WebLinkAbout22465-zFORM NO.3
TOWN OF $OUTHOLD
BUll. DING DEPARTMENT
TOWN HALL
$OUTHOLD, N.Y.
Ne 22465 Z
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLE'IION OF THE WORK AUTHORIZED)
Permission Is hereby granted to:
..... ~L~:.....~/. ........................................
..~¥~ ~...... ~.~......./.../. z~ .......
to....~.~...~.~: ............... ,~.... ............ ~......;..,~ ...... ~.~.~ ............. ~...~,.. .......
.... ~.,/.~d .-~J'. ........ ~4~...4..~ ........... ~.: .............
........................................................................... ~~ ....... ~ ................................
Oounh/Tax Map No. 1000 Section .....,/~.,,~...'~,. ........... Block .......... ..~.....'~......~i'~o ........ ..(~..~ ...........
pursuant to application dared .............. ../..//...,..'~... ............................. 19...~.~.., and approved bythe
Building Inspector,
/~" Building Inspector
Rev, 6/30/80
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-180:3
.
Disapproved a/c ................................ '
0~u/alno Inspector)
APPLICATION FOR BUILDING' PERMIT
B~ARD OF HEALTH .........
3 SETS OF PLAHS ...... ....
SURVEY ..................
CI~ECK ......... ~ .........
SEPTIC FORN .............
CALL ~ . . , . .
HAIL TO:
Date . '."~. ............. 19
INSTRUCTIONS
~ a. This application must be completely filled in by typewriter or in ink and submitted to th, e ~uilding 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 ~remises or public sti'eets
or areas, and giving a detailed description of layout of property mu~t 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 DepartmBnt for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Tou(n of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of 15'uildings, 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 necessary inspections.
(Signature of applicant, or name, if a corporation)
(Mailing address of applicant)
State ~~is owner, lessee, 'agent, architect, engineer, generai 'contractor, electrician, plumber or builder.
Name of owner of premises .~.7.~. ~...'~....~~
. (as on the tax roll or latl~.ed~?r~.,
If applicant is a corporation, signature of duly authoriied officer.' FEE: ~'- ,
. (Name and title of corporate officer)
Builder's License No ..........................
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
1. Location of land on which proposed work will be ~lon~e~ .......... ~., ....... Dlffill~l Iffi¥ .QIIN$~.~...
...... . ....... . ....... ........
House Number ~teet Hamlet : .
Cou'nty ,Tax Map No. 1000 Section .1.~.'..~.~. .......... ~10yk ...~ ......... i... Lot .............
Subdivismn .................................... '. Filed Map No ............... l~6t ...............
(Name)
State existing use and occupancy of premises and intended use and occupancy of proposed construction}
NOTIFY BUILDING,DEPARTMENT AT
765-1802 9 AM TO 4 PM FOR THE
FOLLOWING
1. FOUNDATION - TWO REQUIRED
ROUGH - FRAMINg. & PLUMBING
$. INSUI~IlON
4. FINAL - CONSTnUCTION
ALL CONOTfluL~rIoN SNAJ.L MEET
THE flC-~UIAEMENT8 OF THE N.Y.
STATE SlRUCnO# & ENEReY
CODESF NOT RESPONmBLE FOR
Existing use and occupancy '
b. Intended use and occupancy ..................... ' ...............................................
'3. Nature of work (check which applicable): New Building . [ ....... ~ A. dditioln .......... Alterat_~on .... ;...~
Repair .............. Removal .............. Demolition . Other Work
.C{.0.0. ~ .... ' I. (D ipti )
4 dC ' '
Estimate est . escr on
· · ...... : .................... Fee ....... , ........................
(to be paid on filing this application)
5. If dwelling number of dwelling units .. i ......... Number of d~,ellinglunits on each floor... .............
If gara. ge, number of cars ........................ ' ........- ......... [ ...................... ...
6.' If bus~ness, commercial or mixed occupancy, specify nature and extent of,eac~ type of use ...................
7, Dimensions of existing structures, if any: Front ............... Rear ............... Depth .....
Height ............... Number of Stories ..... ~ .............. ' .... '.l ..............................
Dimensions of shine structure with alterations or additions: Front ......... i ......,:.. Rear ..... .~,.
Depth .... ~ .................. Height ....... '.., .. ..........., Numbe ?~%o~[~fi,~;~.'~ ~.!C;:,,.~.~?: 27.?)~.~.1~. ....
8. Dimensions of entire new construction. Front . . . ear < di' ~' ~;;t '
........... ; R ........... -;. · r~g~
....
.Height ...: ........... Number of Stories .......................... , ~, .
9, Size ofl0t: Front .................... ~.. Rear ....... ' :~?.~ ,BY:~Z(I~8i:~i:;' ~,:g '~i ' ~ ' ~'~ ....
2~' ........ ~) r ~;.p~..~?~..~,~...
10. Date of Purchase . ] ~. ~.. ~ .......... . ........ . Name o~ vetoer Owner ~, ~. }~ q r . .' .
1 I. Zone or use district in which premises are situated ......... . ~, ' .... ' ' '
............ ,...¥~.r .~. l~:~ ~l~l&~;,~c~ .~h;~ ....
.I 2. Does proposed construction violate any zoning law, ordinance or regulation: ;q
13. . ................
14. ~ ~?~ prem,ses ........... '"' t''" Address..; ...... ... } .}.:j .... ~
Nme of Contractor ............... ~ .... ~ -, :.-,~-~? .~ ,*,.~, ....
15. Is this property within 300 feet' ;f' i' tih'ff~g~fa;~'?'' ;~¢ ..... i ,:.?,,,,>. ~ng~. ~?~ {:,~> .~j4~ ....
. *If yes, Southold ~own Trustees Permit may be required ~,~'~") ~0,':~<~ ~}~}~,.zL~,~
PLOT DIAG~
Locate clearly ~d d~shnctly ~I bulldogs, whether existin~ or nronosaa ~.~i~,~ ~,, ~,
STAr OF'N W YO o
(N~m~ of individual signing oontraot)
abov~ named.
(Contractor, agent, cor'porate officer, etc.I
of said owner or owners, ~d is duly author~ed to perfom or have perfo~ed the
application; that all statements contained N this'application am frue to the best of hi
work wflI be perfo~ed in the m~ner set forth N the application filed therewith.
Sworn to before me this
Su~o~K
No, 4725~89
being duly sworn, deploses and says that
he is the applicant
aid work and to make and file this
; knowledge and belief; and that the
(Signature of applicant) ·