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Home My WebLink About22159-zFORM NO.$ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 22159 Z Permission Is hereby granted to: ....... ~.~./...~.....~.~....~,~/ ... ~~....~..~..,...~~.....,~, ........... .~..~..~~./...~f.....L~,.. ,o ......... ~..~.x ........... ~....~.~.~ ........ ~....~.~~..~ ........ Count,/Tax Map No. 1000 Section ~' 7 .... Block / Lot No. /. ,,~f. ~ pursuant to application dated ..........~.......~'/,...~.......~.. ........... ./...~.. ....... 19..?....~......, and approved bythe Bulldlng Inspecfo. r, ,Rev. 6130/80 JUN 17 1994 I Tow OF Approved ..... ~.~... Disapproved a/e ..................................... 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 ................... CIIECK ....... ; ............ SEPTIC FORH ............ ,. A~ff~ATION FOR BUILDING PERMIT Location of land on which proposed work will be done.:~ ........ :l> .................... · ltouse Nmn her Street County Tax Map No. 1000 Section .. .... ~.7 ......... 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 usc and occupancy .. ~OOR .*.. ~.~C~ ...... b. Intended use and occupancy . ~0 .... ~.~d~'~...~ (Name and title of corporate officer) · Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... FOLLOWING INSPECTIONS; I. ~:OUNOATIO~" rv~O FOR PC:JRE,~ "~ 5 2. aO:~(5:~ - FR: .... 3. ~NS ~i. INSTRUCTIONS a. Tlds application must be completely filled in by ty'pewriter orin 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 buildings 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 all applicable laws, ordinances, building code, housing gode, and regulations, and to ;o e ; acorporatio ) ...... ; .................... (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder· ........ ./h. ................................................, .............................. testl~J[~i0~B.R # If applicant is a corporation, signature o f dul authorized officer. ' /~./.O~. ~.'~. ....... E' /~'~G'/~,e-/"[At/t] ¢- . .~../~. ,/~.....LS'S! ir AJ~'-/~ NOTIFY BUILDING DEP.A'ffI'MENT At 765-1802 9 AM TO 4 ~M FOR THE 3. Nature of work (check which !applicable): New Building .................... ~lteratmn ......... R ' ~ - Addition epa~r ........ ~/ .... Removal .............. Demolition .............. Other Work ;N~..~2~...CC7 ...... 4. Estimated Cost .... i .................... Fee ............... 'i ....... ~' ~. ....... 5. ng, nu,mber~o f Cwelhqg units . .~ ........ Number °f dwelling units oh each '~eo~ '.~ ~'i!. .-uatugc, num oer oI cars ... ...... .W/iq: ............................................ 6. Ir business, commercial or mixed occupancy, specify nature and extent or each type or use 7.Dimensions of existing strnctu!res, if any: Front ............... Rear .............. Depth ............... Height Nt~mb of Stori Dime i sofsa t eWthalt ti additio .............................. ' .......... D pt~s on me strnc ur i era ons or ns: Front ...... ': ...... Rear ............... 8 D~m ..................... Height ...................... Number of Stories .... ; ......... io f ntire conslt etlon Front · ' H ens nso e new ru : ............... Rear ............... Depth ....... eight ............... Number of Stories ................. ' ....... 9 Size of lot: Front · . ..................... Rear .... Depth 10. Date of Purchase ' ................................... ............. Name of Former Owner ..... 1 1. Zone or use district in which p~ernises are situated.. ~.~5 J .~. eb.~ -r ¢ ~r 9. ....... 12. Does proposed construction violate any zoning law, ordinance or regulation ..... ' .. 13. Will lot be re,faded ~0 , ,, : ' ' ....................... 14. nr ..... ~ ~ ' ' '."' ;o' 'i ' ' 'fl ' ' ' ~' ....... wall excess fill be removed from premises: Yes .No ~un~ ot ~Jwner ot prem~ses~.O.~T¢-P.c~.~t~e/C.v, tS-f~.4C. TAddress .~.:Q: (3.~..¢.~..~( .... Phone No..~./.6,.~7.~2 .. Name of Architect ......... : .......... Address .................... Phone No. Name of Contractor,~q~/g,~.t ~ · .............. Is this property within 1300 feet of a ~tidal wetland? *Yes.,~ ..... No... · If yes, SoutholdlTown Trustees ~ermit may be required. ' ..... PLOT DIAG RA~ ocate clearly and distinctly alI buildings, whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and block; n,./mber or description according to deed, and show street names and indicate whether interior or corner lot. ......... ~a'"~ . being duly sworn, deposes and says that he is the applicant ( me ofindividual signi~l~' ' ' ' above natned. lie is the ...................... ' tJ (Con~ractor agent c~rporate officer i ........................... of sa~d owner or owners and is dutyi'at thorzefl to perform or have performed the'said work and to make and file this application; that all statements contained in this application are true to the best of his 'knowledge and belief; and that the work will be performed in the manner iet forth in the application filed therewith. Sworn to before me, tt~ !. /) . . HELENE [1 'IORNE Notary Public, St aofNewYerk ...... . ....... No. 49! 364 t [~gnature of applicant) Qualified in S~ ~olk County . Commission Exp.!res May 22, 19 I