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Home My WebLink About22028-zFORM NO.3 TOWN OF SOUTHOLO BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. N-° 22028 Z BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Date ................... ~. .................................... Permission Is hereby granted to: ............ ~ .......................... : ........... ~ .......................... ............. ~.~ ........ .~ ............ ~ .................................. to....~..~.;.~.....~ ......... ~ ......... ~....'-../../Z.?.........~..-~,...,.~. CounlyJax Map No. 1000 Section ..,./~.. ,~.. ......... Blook'......~.../.. ........... Lot No ...... ~...~..... ........... p~rs~onttoo~p,,co~,o~dated ..... ~ ......... .../..~. ................ ~...2~'.. andopp~e~edb~the Building Inspector, ~:~, Fee $ .................... // ' Building Inspector Rev. 6/30/80 ~~,: ,,, FORM NO. 1 TOWN OF 'SOUTHOLD .. ' BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 ~. TEL.: 765-1803 ....... V,' ..... _ Disapproved a/c ..................................... (~J Inspector) APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH 3 SETS OF PLANS .......... SURVEY ................... CIIECK ......... MAIL TO: Date ................... 1 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 heroin described. The applicant agrees to comply with ail 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) State whether applicant is owner, lesseeS" n~ (Mailing address of applicant) architect, engineer, general contractor, electrician, plumber or builder. .......................... ;,'/ ........ 7" 37 ............................. APPROVED:AS NOI ) ....... Name of owner of premises.../4f..Q~.t~/~).. ~.. ~.~./.~-./~.~ .................. DAT~:. ~B.P.# (as on the tax roll or lates~?d)~,~ If applicant is a corporation, signature of duly authorized officer. NOTIFY BUILDING DEPARTMENT AT 765-1802 9 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: (Name and title of corporate officer) 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE Builder's License No .......................... 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST Plumber's License No ......................... SE COMPLETE?OR C.O. ALL CONSTRUCTION SHALL MEET Electrician's License No ....................... THE REQUIREMENTS OF THE N.Y. . STATE CONSTRUCTION Other Trade's License No ...................... ~-/1 tr/L'~'~ ~)ES~NQODE~'~'oRNOTcoNS~'RUCTION,ERRQ. BE~---'RESPONSIBLE FOR I. Location ofland on which proposed work will be done .......... *''O~'"(~""(r-'''O~''6~'~~'~'''/'~'Y'/'/?'~"" Ilouse Number Street Hamlet County Tax Map No, lO00Section .....,~., ...... Block ..... ~. ............ ot ................... Subdivision ..................................... Filed Map No ............... . Lot ............... (Name) State existing use and occupancy of premises,~.,~, and//,intended use and occupancy of proposed construction:,3 :~',~ a. Existing use and occupancy ...... A.c.-/.~.:¢.' ~(.I.~..'t~ ...................... ;-.:,. '.i;., ]?~ .~.'.!", ~'(~:,(,...,~ ..'. .... b. Intended use and occupancy ......................................... i '': : .... . .... ' ' '. ;" "*" ' 3. Nature of work (check which apl~licable): New Building .......... Addition ..~..~}.~ .. t n ....... Repair ........ · g/... Remoral ............ Demolition ......... · .... · ' 4. Emmated Cost .... ~... ~ ........................ Fee ............. ~*~ 2 ~ . : ' (to be paid on 5. If dwelling number of dwellin~ ~nits . x,.--~. ~ ~ ...... it garage number of c~s ~ .......... 6. ~t OUSlness commercial or mixed ' ' . ~ ,occupancy, specify nature and extent of each type of use .................. 7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............. Height Num 6er o f Sto~es D~ensions of same structure wi~h alterations or additions: Front ................. Rear ................ Depth "Height' Number of Sto~es 8. Dimensions of entire new const~ction: Front ............... Rear .............. Depth ..... Height ............... Number of Stories ............................................ 2. .......... 9. Size of lot: Front ...........2 .......... Rear ............ Depth 10. Date of Purchase ' ................................ ........... ~ ........ ' ......... Name of Fomer Owner 11. Zone or use district in which premises are situated ............................. 12. Does proposed construction violate any zoning law, ordinance or regulation: .......................... ' ...... 13. Will lot be regraded ........................... Will excess fill be removed from premises: Yes ~o 14. Nme of Owner of premises .................... Address ................... Phone No ............... Nme of Architect .......................... Address ................... Phone No ................ Nme of Contractor ......................... Address ................... Phone No ................ 15. Is th~s property wtth~n 300 f~et of a tidal wetland? ~Yas ........ No ......... ~If yes, Southold T~wn Trustees Permit may be required. ... ~ PLOT DIAG~ Locate clearly ~d distinctly ~1 bulldogs, whether existing or proposed, ~d. indicate ~1 set-back d~ensions from~ propegy ~nes. Give street ~d block ~ amber or description accord~g to deed, and show street nines and ~dicate whether interior or comer lot. STATr OF Nr~-vou~_,~ //~. ~ ~ .... ~:~ ~. S.. ~,. '~ r~.~ ........ being duly sworn, deposes ~d says that he is the applicant (Name of individual signing contract) above named. 'of said owner or owners, ~d is dulyiautho~zed to pert'o~r have perfo~ed the said work and to m~e md file this application; that all statements contaihed ~ this application are true to the best of his knowledge and belief; and that the work will be perfomed in the m~ner ~et forth in the application filed therewith. Sworn to b~fore me thist i · , ......... · .... ' - Oualifled In Surfak Cou~ ~ ~ ~ / (Signature of applic~t) _..~mmi,sion E~ire, D~em~,~,.l,~ f