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Home My WebLink About21466-zFODM NO.3 TOWN OF SOUTHOLD BUILDING DEPAI~TMENT TOWN HALL SOU[HOLD, N.Y. No_ 21466 Z BUILDING PEI~MIT [THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permission is hereby granted to: ..................... po, ~ ;~',~ , ...................... ....... ted a d~_~. ,~ ~, , at premises Iaea t .......................... .~. ...................................................................... Count/lax Map No. 1000 Section ...... /...0...~.. ........ Block .......... ;, ~ .......... lot No ........ .~...,~...~..~.. ....... pursuant1° application dated ......... .~ ................................... 19...~...~.. ..... and approved bythe Building Inspector. tee ~,.~.~... Rev. 6/30/80 9 ~g~l I 76~-1802 9 AM TO 4 PM FOR THE FOLLOWING iNSPECTIONS: I, FouNDATION TWO REQUIRED FOR PouRED cONCRETE 2. ROUGH - FRA~,~ING ~ PLUMBING 3. iNSULATION 4. FINAL - CONSTRUCTION MuST ~E cOMPLETE FOR C,O. ALL cONSTRUCTION SHA~ ME~ THE REQUIREMENTS OF THE N.Y. STATE cONSTRUCTION & ENERGY cODES. N~ RESPONSIBLE FOR DESIGN OR ~Ns~UCTION ERRORS '¢ C..M ' ~/-/" STATE OF NEWyOI~.I~, ,, 2 75993 19... ......... ?f Disapproved a/c ' APPLICATION FOR BUILDING PERMIT FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 INSTRUCTIONS B~n or HE^LTH ......... SETS OF PLANS .,~'~SURVEY ................... .~CIIECK CALL ................... vv f.} Date .................. 19. 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 sti'eets or areas, and giving a detailed description of layout of property must be drawn on the diagram which is p~rt of this appli- cation. c. The work covered by tiffs application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issued a BuildingPermit 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 South61d, 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 code, and regulations, and to admit authorized inspectors on premises and in building for necessary ~ns. pection, s. / . -- ~Signature of applicant, or name, if a corporation) .¢..?.'. ..... (Mailing address'6f applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. N~ne ofowner ofpremises...'~....~......L-.~.. ~ .~f..~ ~ ."~..../., .~...~ ............ (as on the tax roll or latest d~eed 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 whichfi~oposed work will be done ..... : .... : ._.._. ............ ~ ....... ; ................. Itouse Number . Street Hamlet¢' County Tax Map No. 1000 Section .. I IQ..~ ............ Block Z~ ' 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 .... , .................... b. Intended use and occupancy . .. F ..... . .............. '3. Nature of work (check whic pPlicable): New Build g . ~ ........ Addition .......... Alter~ion ...... '.. . Repair ............... . Removal .............. Demolition ........'.... .... Other Work'~,~//~. ~ ~ ~ : ..... ' ' ~, ~.~2.. (Descripti'~n) 4. Estimated Cost .......................... Fee .................................. , · (to be paid on filing this application) 5. If dwelling, number of dwelling units./~/~ .......... Number of dwelling units on each floor ................ ·If garage, number of cars .... 1./q~t3 ............... ' .............................. , .................. 6. If business, commercial or mixed, occupancy, specify nature and extent of.each type of use . i f i ~ if ~/~ R D ''"''"'''"''' 7. Dimens OhS o ex stingstructur s, any: Front ........... ear .............. epth ....... Hight 0b fSt ' "' ' e ............... Nu er o eries .......................... ' ' ' with It ti dditi F .............................. Dimensions of shine structure. .a era ohs or a OhS: rent ............ · .... Rear ... ............... ~D.epth ..... ~ k ........(.12,~. ~bX~. Height ....... ': 7'," ........ , Number of Stories ....... '.; ..... 8. ~J~menmonsolentire nc~V'c~Oflstrttction. Front . tqt D ~¢/ ~. 'j ' ~,t ' ' · · , .- t ~/ t -- · · ..,- ......... ~,ear...:~.. . ~,eptn ..t/g ....... ne~gnt .. La..t~, ......... Number of Stories .... .'7.. . . ' ...... ' ' ' ' 9. Sizeoflot Front q~/ . v~, ,~'~zt ........ ~ ....~. ....... ',4 ',-; ~',~ ............. ....................... ,*-.~. n ............... l~.epth .. ~..l. T ........ 10. Date of Purchase ~ ',1~.. ' ~',~, ..... -~2f.,, ,/ ~ '/, ....... ..... · ................ .x f~ame o~ y. ornler uwner ./~rrj. tq,,M. F. 4 2/.':..~. ...... 11. Zone or use district in which pr~mises are si!bated../.d~£~ ............................. ~ ....... '13.12. WillD°eSlotPr°p°sedbe re radedc°nstructi°n violate.?jb any zoning law, ordinance,, or regulation'. . ........ .~. .................... , g ...... '~ · · ' ~' · 'c ...... r~ ....Wall cxc~ess nil be renloved from premises: Yes No · 14. ~ameofOw.ner ofpre,.mises No.-7. g fi_ 7Zq, p~ame of Architect /~./,q- ..( . Addres~ '" ~ ' ~ "~ ,. ~.-., ...... tt-; ... .................. ~ .............. · .... VD. one 1NO ............... Name of Contractor ......... ~ ................. Address ............ ; ...... Phone No ......... ' ' 15.' I.s this property within ~00 feet of a tidal wetland? *Yes ..... No. ~ ....... · If yes, Southold Town Trustees Permit may be required. PLOT DIAGRAM Locate clearly and distinctly sill buildings, Whether existing or proposed, and~indicate all set-back dimensions from property lines. Give street and block humber or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YOI~I~, S ,S ' ' coumy ov .. ..... ..... ......... being duly sworu, deposes says that he is the applicant ! (Name of individual signin~ contract) 'above named. (Contractor, agent, cori~orate officer, etc.) of said owner or owners, and is duly Cuthorized to perform or have performed the said work and to make and file this application; that all statements containled in this' application are true to the best of his knowledge and belief; and that the work will be performed in the manner sbt forth in the application filed therewith. Sworn to before me this ~7.c& ' day of ........... ,19 ',/o'tary Public,.....~. ~.-~:.. ........... x ...... County/.- ' · Notary Public, State of New York ' (Signature'~ f applicant) , N~. 4822563, Suffolk County~L ' ' '~ .... , ',,.~,: Dee~mber 31.19