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Home My WebLink About22009-zFO~M TOWN OF SOUTHOLD BUILDING DEPARTMENI' TOWN HALL $OUTHOLD, N.Y. NO 22009 Z BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permission Is hereby granted to: ..,,'~,~......~:.....~.~......~ ~ ............ ....... ~....../~..,<:. ......... ~ .................................... ..~.~ ....... ~ .......... ~ ....... ,o...~.....~ ......... ~z......~ ........... ~ ........ ~ ........ ~ ................ ..~......~ ........... ~.....~......~~ ........ ~ ....... ~.~ ~ ......... ~..~ ........ ~ .................................................................................................... ........... ~~ ........... ~..,.,~;...~~ ...................................................... Coun~Tax Map No. 1000 Section ...,~ ......... Block ......... ~, ......... Lot No ...... ~ ............... the Building Inspector. F~ ~.,,..~ ...... ...................... Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 APPLICATION FOR BUILDING PERMIT BOARD OF' HEALTH ......... CALL . .' .......... INSTRUCTIONS , a. Tkis application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 sgts 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 des~cribed. 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.~rd~..x~. .~.. ~'~'.~ ...... -- (Signature of applicant, or na,me, if a corporation) (Mailing address of applicant) //~.~ D (Name and title of corporate officer) Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ../~.,..~~...d2/Y/Y..~ :...~.. (as on the tax roll or latest If applicant isa corporation, signature of duly authorized officer. FEEler' HOT,FY BO,LO,.G DEPA.TME.T AT 765-1802 9 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C,O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N.Y. STATE CONSTRUCTION & ENERGY CODES. NOT RESPONSIBLE FOR l. Location of land on which proposed work will be done ..................... OEStGN. OR.~ CONSTRUCTION ERROla~ .... ...................... .................. Ilouse Nmnber St r~'et Hamlet 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 ....~.~ .... ~ ....... . ............................ use and occupancy ....J/~.~ ................... ... ~ .............................. b. Intended Repair .............. Removal .............. Demolition o.n. ...... ........... Other W~rk ............... i -,. ~criptio ) 4 Estimated Cost ..... , Fee ~ i (to be paid on filin.~s~3[qltion) 5. If dwelling, number of dwellingiunits ............... Number of dwelling units on each fl~'6'~....?~..'. ....... If garage, number of c~s .... 6. If business, commercial or mixe~ occupancy, specify nature and extent of each type &use ..................... 7. Dimensions of existing st~etures, if any' Front ...... Rear .............. Depth .... Height ............... Number of Stories ...................... ~ ............................... · D~ensions of same st~cture with alterations or additions: Front ... ~ ........... Rear .... ~ ........ D ~ · epth ......... ~ .......... Height ... ~ ............... Number of Stories ..................... 8. Dimensions of entire new const~ction. Front , ~ ' ~*~- ~ ~ ~,~*h ~ ' Height ..... .~ ;~ ...... ~ ...... ........ Number of Stories ........................................ ~ .... - .......... 9. Size of lot: Front ~ ( J Rear ~ ' no~h 10. rote ofeu nas . ....... . ......... of 11. Zone or use district in which pr~mises are situated ........................................... ~ ......... 12. Does proposed construction vio~ate any zoning law, ordinance or regulation: .......................... ...... 13. Will lot be regraded ......... : ................... Will excess fill be removed from premises: Yes No 14. Nme of Owner of premises ...:. Address PhoneNo Nme of Architect .......... ~ ................. Address .. Phone No. Nme of Contractor ......... , ................. Address ................... Phone No ................ 15. Is this property within 300 feet of a tidal wetland? *Yes ........ No ......... · If yes, Southold Sown Trustees Permit may be required. PLOT DIAG~ Locate clearly and distinctly ~l[ bulldogs, whether existing or proposed, ~d, indicate ~l set-back d~ensions from prope~y 5nes. Give street and block number or description accord~g to deed, and show street n~es and ~dicate whether interior or comer lot. COUNTY OF ........ ~J~.~.. S.S ......... ~.~.~ .,s., .-/~?.~ ~.t~. ,~ ~. ................. being duly sworn, deposes and says that he is the applicant (Name of individual signifl~g contract) above named. .~'He is the i (Contractor, agent, corporate officer, etc.) of said owner or owners, and is dulyi 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 'set forth in the application filed therewith. Sworn to b~fore me this ................. Notary Pubhc, ... ' :LL' ,,,~fin · ROBERT I. SCOII, JR, / ? ~ .~.,~./. NOTARY PUBLICI StBte of NY;". .............................. No. 4725089, SOffolk Couffi ,, (Signature of applicant) TeEm Expire May 31,19