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Home My WebLink About21526-z;ORM TOWN OF $OUTHOLD BUILD)NG DEPARTMENT TOWN HAU. SOUTHOLD, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZEDI Date ............................................................Z...~..~.,~'~ 19....~...~.,. No 21526 Z Permission Is hereby granted to: ' ....................................... ~-..-' ~:,/,,: . /. ~,'Z. ./Z-. ./ z : . .~-~. . ................. '.:':,7'" ............................. to ......... . . .~. .~. ~.~. . ....... ~ .......... .~. . ~ r,~. ~ ~.~. . . . . . . . .z~.~. .-,~. ~,~: .......... .~. . . ./. .~'. ~. . . . ................. · Ncc..~.~.z:........./..~ ...... .~.~........~....~.~.,r,,J....~.....~ ........ ~.~....~.....~,c__, at premises located at.......~'..,~......~...O~... .................................... ........................................... ~..~_~~ ........ ~: ........ /../..~ ............................. CounlyTax Map No. 1000 Section ....../../.~ ........ Block ....... ../...'-~... ............ Lot No. ,...,~..~........,~.. ........... pursuant to application dated ................ .~./,,~...~.. .............. ' ............. 1 9..,,~...~.., ..... and approved bythe Building Inspector. Fee ~.,,.~.~..'N., ...... Rev. 6/30/80 2pp oved ..i ............. Disapproved a/c ..................................... FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL,: 765-1803 . (B~difig Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS BOARD OF HEALTH ......... ~ SETS OF PLANS ......... ~suRv£Y .................. ~CllCC~ ................... SEPTIC FORH ............. a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 ~ets 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 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 i~sued 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 all applicable laws, ordinances, building code, housing code~ and regulations, and to admit authorized inspectors on premises and in building for necessa~~~,lffa~ -- - me, if a corporation) a. 0~Iailin~address of applicant) , . State whether applicant is owner, lessee, agent, architect, engineer, general donlracto/, electrician, t~lumber or builder. (as on the tax roll or latest deed)~~ If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) · FOU.OWING INSPECTIONS: Builder's License No ............... ~r ......... I. FOUNDATION - 'ltNO REQUIRED / FOR POURED CONCRETE Plumber's License No .......... '/' "q~ ....... 2. ROUGH - FRAMING & PLUMBING Electrician's License No ......... 4. FINAL CON,qTRU~WION MUST BE COMPLEIt: FOR ~.O. Ortner Trade's License No ...................... Atl. CONST~IJ~ON 8}~tI.L MEET THE REQUlREMENI8 {~ '~lg N.~. 1. Location of land on which proposed work will be done ................... OT~,T~. 0ONSIi~Ig'IION .8,. ~¥.. Itouse Num bet Street Hamlet County Tax Map No. 1000 Section .,,/~ .~. ............ Block . ./.~. ' Lot..,'/./...~../. ? ........ A//.~. Filed Map No. Lot ...... : ........ Subdivision (Name) . State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ..... ~. ....................................... . .., ..:; .,.. ~.. .............. b/Intended use ~nd occupancy ~--,~)Lp./~ . . · 3. Nature of work (check which applicable): New Building ........... Addition .......... Alteratiofl~SLe~.,... ~.. Repair Removal .......... Demolition .... :... Other Work 4~..~,.~.-.~ · .. (Description) 4. Estimated Cost '.~,~.c.~..~.. ' 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 .../~ .................................................... ,.a .............. 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use . /~/./(ff~. .............. 7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ..... ~ . o~...~..~....' ................................ Dimensions of same structure, with alterations or additions: Front . O/~{,- .......... Rear .................. Depth .... ' ................... Height ........... ' ........... ~umber of Stories ........... ~ .......... 8. Dimensions of entire new construction: Front ... (v*,/~. ...... Rear ............... Depth ............... Height ............... Number of Stories ........................................................ 9. Size oflut: Front . .,,XJ~..~q.~...~...i .. Rear ...................... D~epth ...................... 10. Date of Purchase . ~ t/.~.?.~_~ .......... · ......... Name of Former Owner . '.~..O.'~. 09'/~?..'r.~. / ...... ~ ....... 11. Zone or use district in which premises are situated... I..?-~.. ~. ~)..~.. U.~: · .';~. ................................ 12. Does proposed construction violate any zoning law, ordinance or regulation: .~.0 ............................ 13. Will lot be regraded ...~.r~.. ..................... Will excess fill be remove~[ from premises: Yes N~ 14. Name of Owner of premises~.?~. ~.~.~ .~.~. ,.,6..~.1~... Address/.3. J'..~.I~ 1.~...i~.. Phone No. ~.~..?.qT~.(~';... Name of Architect .. ~./~. .................... Address ................... Phone No ............ ...:. Name of Contractor . .~d./.fft> ................... Address ................... Phone No ................ 1.5, 15 ch£s property within 300 feet of a t±dal wetland? ~,Yes ........ No..7~ .... · If yes, Southold Town Trustees Permit may be required. PLOT DIAGRAM Locate dearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. sTATE OF NEcla/-~OR~_~x I l// S S ...... -~---'~. _[. t~k._...~.~..~ ........ being duly sworn, deposes md says that he is the applicant ' fNa~e of individual signing contract) tbbv~named. . . . (Contractor, agent, corporate officer, etc.) f said 6Wfler~'or :~ners, ~ is duly authohzed to perfo~ or have perfo~ed the said work and to m~e and file this pplication; that all statements containcd ~ this application are true to the best of his knowledge and belief; and that the 'ork will be perfo~ed in the manner set forth in the application filed therewith. worn to before me this C ty ~~ ...................... (Signature of applic~t)