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Home My WebLink About21718-zFORM NO,$ 'I'OWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. No BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED] Date...~.~ ..~./..~. .......................................... 21718 Z / ............................... atpremlsoslocatedat..._,.~....~.........~...~.~......_.~..~...:~~~' ~1 ' ....................................................... CountyTax Map No, 1000 Section ............ .~......-~.. · J ...... Block ........... ~. ........... Lot No ...... ..~.~..,.. I. ........... pursuant to application dated,, ........,/_,0./~ ............................... 19,..¢'...,~.,. ...... and approved by tho Building Inspector, Fee $,~,,,~,~.,, Rev, 6/30/80 ¢/ ~" Building Inspector FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL ~ SOUTHOLD, N.Y. 11971 '(J ~ TEL.: 765-1803 Approved..<%/. ~ ........ 19 ~.~ Permit No.~.../Z/~-~ Disapproved a/c ..................................... ............................... APPLICATION FOR BUILDING PERMIT BbARD OF HEALTH 3 SETS OF PLANS SURVEY CIIECK~. .................. SEPTIC FOR~I ............. }fAlL TO: Date /0 - S 195~'?' INSTRUCTIONS . '-i 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 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 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 Occupan'cy shall have been granted by the Building Inspector: APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permii 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 necessary_. ____inspections. ~, . .... ......... (Mailing address of applicant)~ State whether applicant is owner, lessee, agent, architect, engineer, generai contractor, electrician, plumber or builder. N~me of owner of premises . .~.'. ~ . . .............. ,r ........ ( s on the tax roll o'Z'latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Buil'der's License No. '...~)~..' ......... Plumber's License No ' Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work w'ill be'done ........................ ~. · ...... · ' ....... . .............. · House Number Street Hamlet cotmty Tax Map No. 1000 Section ...~.~..d3 .......... Block JO~ ' Lot..//'. .............. Subdivision ........ . ............................ '. Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premise~s and intended use and occupancy of proposed construction: a. Existing use and occupancy ............. .*~'!'~ ','". .... ., ..,~. ~ ~: .,.,~,.'~ .......... b. Intended use and occupancy. . .~ ......... · ............ ... ::,"' ',',"" ............... ,. ' , ,' ., ,,,. ............ · 3. Nature ofwTrk' (check which ~pplicable): New Building .: ........ Addition .......... Alterat. ign ....... :.. Repair .. ........... Removal ....... ~ .'. Demolition ..... : ......... Other Work ,/'/~,~fi ~. 7 .ffT,~...~.' ~~ ~'"" (D ipti ) 4. Estimated Cos . · .~ .................... Fee ............................... (to be paid on filing this application) 5. If dwelling, number of dwellin~ units ............. Number of dwelling units on each floor ................ . If garage, number of cars .... [ ................................................................ ~ .... 6. If business, commercial or mi~x~d occupancy, specify nature and extent oLeach type of use ................. · .... 7. Dimensions of existing st~ctu~es, if any: Front .... r .......... Rea~ .............. Depth ............... Height Nmhber of Stories ' Dimensions of shine structure ~ith alterations or additions: Front ................. Rear ................. . Depth ' HeiSt ' Number of Stories . D~mens~ons of entire new construction: Front Rear ............... : ............... Depth .............. Height ............... NuCber of Stories ......................................................... 9 Size of lot: Front ' Rear ' · ......... ~' Depth 10 Date of Purchase ~ Name of Foyer Owner ..................... 11. Zone or use district in which p~emises are situated .................................................... .12. Does proposed construction viqlate any zoninglaw, ordina~ce or regulation: ....... .... . ......... ...,. . 13. Will lot be regraded ....... ; ~ ................... Will excess fill be removed from premises: Yes No 14 N~e of Owner of premises ~ Address Phone No . · N~e of ~chitect . · ' Add ' ' 0n ....... ~ ................. ress ........... ...... Phone No ............. ... ~. N f C ~ Add ' ' ' ~ me o tractor ........ + ................. ress .......... : ..... Phone No .............. ' 300 ' ' ' 15. I~ thSs properey w~thSn feet of a tSdal weCland? eyes ........ No ......... " ~If yes~ Southold ~o~n Trustees Permit may be required. ~ PLOT DIAG~ Locate clearly ~d distinctly ~1~ build~gs, Whether existing or proposed, ~d. indicate ~1 set-back d~ensions from propegy hnes. Give street and block number or descdption accord~g to deed, and show street nines and indicate whether ~tefior or corner lot. AWf)N ALL CONSTRUi :HALL ,MEET S1;STE ~ ENERGY 120~,... NOT FOR STATE OF NE'~-4qgRK~ COUNTRY OF.. .... (Name of individual signing~ontract) above named. ..... being duly sworn, depose~ and says tha~ he is the applicant He is the . 4. · .. ............ ' gent, corl~orate officer, etc.) ' · of said owner or owners, and is duly !aU~form or have performed the said work and to make and file this application; that all statements contained tn this application are true to the best of his knowledge a~nd belief; and that the work will be performed in the manner set forth in thexapplication filed therewith. Sworn to before me thi~ I ~ i ~ ' at, allfled lo Suflom CoU°~ (O;'~t/ff . '' ' ~O~Signature of applicant) . Commission Expires December, 8, 19~,~ ·