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Home My WebLink About21535-zFORM NO.3 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. N_O BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Date...'~././..~...... .......................................... 21535 Z at premises located at...,?~....~..~~:....,~......, .............................................................. Courtly Tax Map No. 1000 Section ....... ~.~, ',~.. ......... Block ........ ~ .......... Lot No ...... .~.~, ................ Building Inspector, Fee S,,,~,,~.~ Rev. 6/80/80 and approved by the E×amined .7//? ........... Disapproved a/c ..................................... APPLICATION FOR BUILDING PERMIT FORM NO. 1 TOWN OF SOUTHOLD · BUILDING DEPARTMENT TOWN HALL SOUTHOLD. N.Y. 11971 TEL.: 765-1803 BOARD OF HEALTH ......... S 3 SETS OF PLANS . SURVEY ......... CALL ................... HAIL TO: 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 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 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 Btfilding 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, buil~hg code, housing co~..~te,~nd-_ta2g;dlations, and to admit authorized inspectors on premises and in building for necessary insl~ctions .; .~.~-"./~: .., / - /('Signature of applicant, or name, if a corporation) ./// :/. .-' ~/ ,., ..... ~. . . / 1:,5 :~ r ~' ~* ,~',-,.,-'~,'.- /%,~ _//.Tf..~.. ,' '; ......... '/ ......... (' ,./ (Mailing adaress of appl~ant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ........... ........................................................................... Name of owner of premises .... ~],~,0/-,?'/ ,,.o.f:y.._....~...,{.,.*:~.?.?.(q~.,: ................................... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be' done .................................................. ..... ido>%:'- c/ House Number Street Hamlet County Tax Map No. 1000 Section . ~.S.g ......... Block ... ~.~ .......... Lot .... ~..~1 ........... Subdivision ................................. Filed Map No ............... Lot ............... . (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a Ex sting use and occupancy ~oe~,~.A ~':.o,/3~,:'' '3. Nature of w (check whtch apphcable): New Building ........... Addition .......... Alteratinn ..... ' ..... Repair ........... Remioval .............. ' Demolition .... .'...; ..... Other Work i .~.~..0.~ ..... ~ '" c i,~L(~escription) 4. Estimated Cost oz>o-~ ............ ~ ....................... Fee i (to be paid on filing this application) 5. If dwelling, number of dwellinglunits .............. Number of dwelling units on each floor .......... : ..... If garage number of cars 6 ' If butane'ss .... * .................................................................. · commermai or m]xecl occupancy specify nature and extent of each type of use 7' Dimension's ofexistingstruct~rCs ' ' ................... · if any: Front .... ....... Rear Depth Height Nmriger of Stories .... ' ................... Dimen ions ofsfim tm t re with alt tio dditio F s es cu era ns ora ns ront . .. Rear Depth ' H 'ght .................... ' .......... 8 D si s of entire new co ' ' F .................... '..' .....er o,,~,ones ........ tructi ont R Depth ............. · lmen on ns on: r ............... .. ear ............... Height Nun}ber of Stories ': .......... 9 S~ze of lot: Front ......... '.. Rea ............ 10' Dar fP ............ : r ...................... Depth ................... chas N off rmer Owner ' ' ' · e o ur e ........... i ..... ' .... ame o ..... . ...... 11 Zone disticti hih gm'is"' it 'd .... ' ...... ' " · or use r n w c pr esare s uate . ' ........ 12 D d ti ' llat oni glaw ....... ' ............................................. · oes propose construc on wo e any z n , ordinance or regulation: ................................ 13. Will lot be regraded ......... l ................... Will excess fill be removed from premises: Yes No 14 Name of Owner of premises Address · ' ' 'i .................................... Phone No ................ Name of Architdct .......... ~ ................. Address ~ ................... Phone No ............ . Name of Contractor ' ......... 1 ................. Address ................... Phone No... .............. 15. ' Is this property within 300 feet of a tidal wetland? *Yes ........ No ......... ·If yes, Southold ~own Trustees Permit may be required. PLOT DIAGRAM Locate clearly and distinctly all Ibuildings, whether- existing, or proposed, and. indicate ail Jet-back dimensions from property lines. Give street and block mmber or description according to deed, and show street names and indicate whether interior or corner lot. . AP P O EO AS OTED' .,, -- NOTIFY BU1L:~NG DEPARTMC"'I'{TVAT 765-I'802 9 AM TO 4 PM FOR TH, E , FOLLOWING ~NSPECTIONS: 1, FOUNOATtoN' - 'l~tVO REQUIRED FOR POURED CONCRETE 2, ROUGH - FRAMING & PLUMIIING 3. INSLILATION 4, FINAL CONSTRUCTION MUST BE COMPLETE FOR C,O, ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N.Y. STATE CONSTRUCTION& ENERGY CODES. NO~ RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS 3TATE OF NEW ¥0P/I~7 ~ / 2OUNTY OF.. & q .ffq ?/.t& .... ,~.? . ~ .:': ~. , .......... (Name o~ i~/dividuai signin~ contract) being duly sworn, deposes and says that he is the applicant ' ~bovenamed. . {e is the .., .... ~.' .z~..~. ~'.~. I ~ (Contractor, agent, corporate officer, etc ) .f said owner or owners, and is duly Cuthorized to perform or have performed the said work and to make and file this pplication; that all statements containled in thi~ application are true to the best of his knowledge and belief; and that the ~ork will be performed in the manner s~t forth in the application filed therewith· worn to before me t /s 3s0 ~, gnature ofapphcant) '~y Corem ss~on Expires-~lltrch-30, 19 ¥!i., ~