HomeMy WebLinkAbout22012-zFORM NO.$
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HN.L
SOUTHOLD, N.Y.
N-° 22012 Z
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
Date ..................................................... 19..
Permission Is hereby granted to:
...........................................................
___ ..~..~.)......~......././...¢..z./. ......................
to ~ ...... ~.. ......... ~~.,/.........~ ...... ~ .......... ~.-¢..-,..~.....~..~..
at premises located at ......................... .~....; ............. ~ .............................. ' .............................................
.¢..../.. m ~
CounlyTaxMapNo. 1000 Section..../~...~.. .......... Block .................... LotNo .............................
pursuant fo application dated ...... /~....~..../~'... ~ ........ ~ ................... 19.....,..~....~.., and approved by the
Building Inspector.
Fee $....~..~....~..'....¢~.. .......
Building Inspector
Rev. 6/30/80
FORM NO. t
TOWN OF SQUTHOLO
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD. N.Y. 11971
TEL.: 7G5- 1802
19 Permit ¢7.
BOARD OF HEALTH ...........
3 SETS OF PLANS ............
SURVEY .....................
CNECK ......................
SEPTIC FORM
NOTIFY
CALL .....................
HAIL TO:
Disapproved a/c .....................................
Ifil ~ w u, u ~ =. '.. (Buj3fl~/fg Inspector)
· ~ · INSTRUCTIONS
a. Tiffs 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 tiffs 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 throulA~out the work.
e. No building shall be occupied or used in whole or in part for apy 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, housin~ code, and regulations, and to
admit authorized hlspeetors on premises and in buildLng for necessary inspections.
~,-~3 ~ (Signature oL:i_pplicant, or nameA if a corporanon)
- . ........ ~,..,a .4.. ~,..~ ~;r. · .f. ~-I. ·
(Mailing address of applicant)
(Name and title of corporate officer)
Builder's License No .... I..~..~. ~.?. 1.. )-7t...-~[. .....
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
State whethor applicant is owuer, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
'ameofownerofpremises . ~'~'~ ,c-.~:,~,.-¢..,..r-.,..c,..,.~ .... .'~...q.c.',:kc_v'~ ~4.~. e_~.: .................... (as on the tax roll or latest deed)
APPROVED AS NOTED
applicant is a corporation, signature of duly authorized officer. I)AT~ ~[LR # oL,20/,2-~
NOTIFI¢ BUILDING' Di~PARTMENT AT
765-1802 9 AM 10 4 PM FOR
FOLLOWING INSPECTIONS:
1. FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE
4. Fh".iAL cf ':' ~ K'~'~': :;';...1'
.'gE (;O~.,';¢LE] [: F':'£ C 0
ALL COf,:'..';!"RUCT~(3r~ .c,~q,,'XLL ,%4cFI
Location of land on which proposed work will be done ........ ' laF RFOUfR.r:At~E~J?% OF '~'}~fS ~; Y
............................... . .........................
louse Number Street k~ i2~l~"O~;*t~O'l-,f ER~O~-
ount>, ra× 000 S,ct on ...,t .%..q. .... mock ...... I ........... Lot ...................
ubdivision ..................................... Filed Map No. . ............. Lot ...............
(Namel
ate existing use and OCCupancy of premises and intended usc and odCupancy o~proposed
Existing
occupancy~.~'}' '~ ..... ....... :.~,,a~.~ r..~ .... ~...
and
Intended
3. Nature of work (check :.vhic~ applicable): New Building ..... ' ..... Addition .......... Alteration ....
Repair .............. R:~movat .............. Demohtion .............. Other Work .~.e~rx ¢, e,_.; ....
4. Estimated Cost ~ ~ O ~ ,, O O (OescHptio~)
(to be paid on filing this application)
$. If dwelling, number of dwelling units ............... Number of dwelling units on each floor ........ ~ ......
If garage, number of cars .....
6. If business, cmmnercial ....................... · ........
or mixed occupancy, specify nature and extent of each type of use ............
7. Dimensions of existing structures if any: Front ........... Rear ....
Height ............... Number of Stories : ............ jjj... ....... Depth .......
Dimensions of same structure with alterations or additions: Front ...................... ~ .... ~ '
i~ ............... .. Rear ......
Depth ................ He t ...................... Number of Stories ..........
' 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ..............
9. Sizeoflot: Front ...................... Rear ...................... Depth ~,..?z.~[jff~5~t.. '.
12. Does proposed Construction violate any zoning law, ordinance or re~ulati~ ' ' ~'~' '~'~' '~ ......
13 Wilier be regraded ~ ~ : -- J ........ ' ' ' '
' ' '. ........................ Will excess fill be r~moved fro ' ~ .... : ........
14. N~eofOwnerofpremmes . ~o~ ' *~ ~ ~ ,~~Yes ~ N~
· If ~es ~ .~ .~ .-- w~th~n~O0 .feet of a tidal wetland? *YES .... 'NO ....
~ , ooutno~a ~own Trustees Permzt may be required.
... PLOT DIAG~M
Locate cle~ly ~d distNctly ~I bu~dNgs, whether existing or proposed, ~d, indicate ~1 set-back d~ensions fro~
prope~y Hnes. Give street ~d bl6ck number or description accordNg to deed, ~d show street nines and Ndicate whethe:
interior or comer lot.
· "'~~' ~/" '~'. -~'~. [-!! 4 being duly sworn, deposes and says that he is the applicant
(Namg of indMdual signing contract) ' ' '
above named.
lie is the ......................... ~.%._~.. ~ ..................................
k...~(Contract~agent, corporateofficer, etc.) ..............
of said owner or owners, and is duly authonze~-d-~pe~rform 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 set fortli in the application filed therewith.
SWorn to before~ ~h~ A . . ' ~
....... /'5~ ....... a~.~ ...... 19~¢
...