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Home My WebLink About21976-zFORM TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNtiL FULL COMPLEtiON OF THE WORK AUTHORIZED) CountyTax Map No. 1000 Section ...... ~..:.~ ........... Block ........ ~'.~, ........ LotNo ......,.,d?..~... ............. Building Inspector. Fee $ ......................... and approved by the Rev, 6/30/80 Approved ........ %/ FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 Disapproved a/c ..................................... BOARD OF HEALTH .......... 3 SETS OF PLANS .......... SURVEY ................... CHECK .................... SEPTIC FORH .............. CALL ................... MAIL TO: Afl · (guildin~, Inspector) APPLICATION FOR BUILDING PERMIT Date ................ 19... INSTRUCTIONS a. This application must be completely filled in by typewriter 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 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 aH applicable laws, ordinances, building code, ho~jng cod. g, .arid regulations, and to admit authorized inspectors on premises and m bmldmg for necessary lnspectmns. ~.:-"'5/...-/~' ~ · .. ;2....~-~; .---. · .: ~:.zM,.. ~--~: ..... .... .~.~-...~ 5. ..... .,: · *. .... -- t~gnature ot appncanr, or name, ~r a corporauon) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ......... ....... ........ : ....................................................... Narneofownerofpremises :d'~'d c/'' f~,,,o~,-- />/~-o/~ /ti. .(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. 1. Location of land on which proposed work will be done .................................................. .......... .s:.:. ?::, ............ /:. ?, /. d .................... ........................ House Number Street Hamlet County Tax Map No. 1000 Section ....... (?. ........ Block ....... .~. ......... Lot / Subdivision ..................................... Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premi_ses gad intended use and occupancy of proposed construction: g P Y ....................... /~,: ......................................... a. Existin use and occu anc ' - Nature of work (check which applicable): New Building ......... Addition .......... Al. teratior~: .:.....x.~.. Repair ...: .......... Removal .............. Demolition .............. Other~Wci~k ~^~c l^ be~l~ c"'~,g-¥~g. (Description) 4. Estimated Cost ?. ,~ ................................ Fee ...................................... (to be paid on filing' this application) of dwelling :units 5. If dwelling, number ' ' ' Number of dwelling units on each floor If garage number of cars j 6. If business, commercial or mixe~l occupancy, specify naturo¥,and extent of each type of use ..................... 7 ...... if any: Front Rear Depth D~menslons of exlstlng structures Height ............... Number of Stories ........................................................ Dimensions of same structure with alterations or additions: Front ................. Rear .................. Depth .................... !.. Height .. Number of Stories 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height ............... Number of Stories ............................................. -;'. ......... 9 Size of lot: Front Rear Depth I0. Date of Purchase ........... . ....... . ......... Name of Former Owner ............................. 11. Zone or use district in which pr{raises are situated n violate lng law ..................... ~/..~ .............................. 12. Does proposed constructio any zen , ordinance or regulation: ............................ .. 13. Will lot be regraded . ..W~ ..... i ..... #t ............ Will excess fill be removed from premises: ~/,~ Yes Nc' 14. Name of Owner ofpremises. ~..,;",J. .... {~..m~ ............................ Address ~f~.~. /'&~ ?d ~'~-4k/2 P-hone No. ?.t(~/./.2/. ... .." Name of Architect ........ ~.i ................. Address ii i})~(]~i~)' .. Phone No. Name of Contractor ..~.h.. v.~.~. .............. Address ~:~'~(L~/ PhoneNo. 15. Is th±s property within 300 feet of a t±dal wetland? eyes ........ No ......... ~If yes, $outhold ~own Trustees Perm±t may be requ±red. PLOT DIAGRAM Locate clearly and distinctly all ibuildings, whe~er existing or proposed, and, indicate all set-back dimensions from property lines. Give street anti block pumber or description according to deed, and show street names and indicate whether interior or corner lot. : C~9~ STATE OF NEW~.~:ORK./7/ (Name of individual signing contract) above named. He is the ...................... ~ ....................................................... . (Contractor, agent, corporate officer, etc.) of said owner or owners, ~d is duly ~authorized to perform or have perfomed the said work and to m~e and file this application; that all statements contai~ed ~ this application are true to the best of his ~owledge and belief; and that the work w~l be perfomed in the mmner Set forth in the application filed therewith. Sworn to before me this ~ ~bl~, St~ ~ N~ Y~ (Signature of applicant) No. 487950~ Qualified In Suffolk Coun~ ~ml~lon Expires De~m~r