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FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y. 1 I
O 1
BUILDING PERMIT r
(THIS PERMIT MUST BE KEPT ON THE PREMISES NTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
WM 21229 Z Date .....1.1 19.~f
Permission is hereby gran d to; /
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at pYemises located at . .0........ .
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County Tax Map No. 000 Section Block Lot No...... Z........
pursuant to applic ion dated . 19.9-5 and approved by the
Building Inspect
Fee ...X->e
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wild for
Rev. 6/30/80
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COUNDATION (2nd) _
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STATE ENERGY
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M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
REMARKS:
DATE J INSPECTOR
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ q --ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
REMARKS:
DATE -INSPECTOR
M-1802
BUILDING DEPT.
INSPECTION
[ ) FOUNDATION 1ST [ ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ) FINAL
REMARKS:
DATE INSPECTOR
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BOARD OF HEALTH
FORM NO.1 3 SETS OF PLANS
FEB - 919M TOWN OF SOUTHOLD SURVEY _ _ _ .
BUILDING DEPARTMENT CIMCR
- TOWN HALL SEPTIC FORM
SOUTHOLD, N.Y. 11971
TEL.: 765-1802 NOT, FY's
CALL -3ral•-•2NY0.
Examined , , , , , , , , 19 MAIL TO:
Approved 1:20. I95;1911 mit No.
Disapproved a/c
uildi &-sp-t
;e,or)
APPLICATION FOR BUILDING PERMIT
Date 19
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 herein described.
The applicant agrees to comply w-ifh all applid sble laws, ordinances, building code, housing code, and regulations, and to
admit authorized inspectors on premises and in building for necessa inspectio s.
(Signature of japp'Cant, or name 41Y. , if a c r ation)
J- V.
A03. 0. J
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
pc a ?c~2 .....1,f............ ............j.............................................
Name of owner of premises . . . . . .
Y(as on the tax roll or latest deed)
If a licant is a co oration; signature of duly authorized officer.
ame and title of corporate officer)
Builder's License No . .
Plumber's License No. r2
Electrician's License No. ..bi O G?'? L-'-
. Other Trade's License No .
1. Location of land on which proposed work will be done . .
House Number Street Hamlet
County Tax Map No. 1000 Section 1 -I,q.......... Block ..1.2 Lot ..:3t
Subdivision Filed Map No. Lot
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy nnc~~ v~
b. Intended use and occupancy.'.?.?
3 Nature of work check which applicable): New Building Addition • • Alte ation
Repair . p val Demolition ; Other
(Description
4. Estimated Cost /U goo, 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 .~5 h
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use . Y'Zk? 9. •Kf!G+
7. Dimensions of existing structures, if any: Front FQ......... Rear Depth . J.'z-."........ .
Height Number of Stories I..,........................................c......... .
Dimensions , , with alterations or additions: Front Rear
Depth . of same structure w. Height Number of Stories
8. Dimensions of entire new construction: Front Rear Depth
Height Number of Stories . .
9. Size of lot: Front %~(Jr`L~II........... .
Rear I 7 .5; yy......... Depth
10 • • • • Nafne ofFormer can .
1. Zone or used strict in which premises s are situated . . . . A. . Ha" i .
0ICJ i? v!''iG
12. Does proposed construction violate any zoning law, ordinance or regulation: .
13. Will lot be regraded r~ Will exces211,t retovve~r~m premises: Yes No°
14. Name of Owner of premises J~RNIJif ! 9.~~P 1.3RE5 Address ~mte5c. ~azC~ al,~l• Phone No. 3
Name of Architect Address Phone No............... .
Name of Contractor Address Phone No............... .
15. Is this property within 300 feet of a tidal wetland? *Yes........ No.........
*If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly 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.
AP RO D AS NOTED
DATE: ; B.R #
FEE: Z~a By..
NOTIFY BUILDING DEPARTM T AT
766-1802 9 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS:
1. FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING
9. INSULATION
4, FINAL - CONSTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET
THE REQUIREMENTS OF THE N.Y.
STATE CONSTRUCTION & ENERGY
CODES. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
STATE OF NFcW RK
COUNTY OF. F .~....S
• • • • ~I• • • ~ r kS • • • • • • • • • • • • • being duly sworn, deposes and says that he is the applicant
(Na e of individual signing contract)
above named. LL/~
He is the 2 E~ c~ Q J~ /7/~~ d J ~fi Ri s T~ c
2.
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly, authorized to perform or have performed the said work and to make and file this
application; that all statements contained in this application are true to the best of his knowledge and belief; and that the
work will be performed in the manner set forth in,the application filed therewith.
Sworn to before me his da o 19 . t--'
.
Notary Pu ic, County
CLAIRE L, GPublic, L
NoQuslified in 879501 Newyork (Signa r f a ica .
No.487960b (Signature of applicant)
Suffolk December 8 1
Commission Expires
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& WATER LINES NEED TESTING BEFOHE COVERING -K
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54DE LC d P8~d 9 0 = REQUIRED
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