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Home My WebLink About21618-zFO~M NO.3 TOWN OF $OUTHO~D BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 21618 Z BUiLDiNG PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) CountyTax Map No. 1000 Section ....... .~.....~.. ......... BIo~k ......... ,,,~,,,%~,. ........ LotNo ........ ~ ........... c ti n dated ~ ./.~., , pursuant to appll a a ................. ~ .............................. 19...~.~... ..... and approved bythe Building Inspector. // ¢,,/ Building Inspecior Rev. 6~30/80 ':' FORM NO. 1 TOWN OF: SOUTNOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N,Y. 11971 EXa,nined'~. "' f~//~'~ t'"), TEL.: 765-~802 · · ....... No: ' Disapproved'a/c .., ....................[ .... ", INSTRUCTIONs b Plot ,,1.- _, tJ ,plan.to scale, Fee acco~-dm~ to sP~h ter orin ink nd submitted to the Build' g Ins cc · or areas, and giving a detailed description of layo~Jlamgs on premises, relationship to adjoinin- r ' ' · ~,~n ~aOWmg location of lot and of ~-- ,5°' edule., m P tot, with cation. , . of p{operty must be drawn g p emzses or public sti'eei , c. The work COVered by this application may n~t be COmmenced on the diagram which is part of this appl. d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such perm~ before issuance of Bui/ding Pea'nit. shall be kept on the premises available for inspection throughout the Work. . e. No building shall be occupied or Used in Whole or in shall have been granted bY the Building InSpector. . .. part for any purpose whatever until a Certificate of Occupanc, APPLICATION IS HEREBY MADE to the Build/ne Department for the i}suance of a Building Permit pursuant to Regulations, for the construction of but/dings, additions or alterations, or ' Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws - The applicant agrees to Comply with all applicable laws, ordinances, building code, d~-~,amon, as herein descr/bed admit for removal or ~,-,~:,. . Ordinances o authorized inSpectors on premises and in buildhng for necessary inspections, regulations, and tc housing code, and (Signature of applicant, or name ifa Corporation) ' ' (Mailing address of applicant') .... ' State whether applicant ssee, 'agent, architect, engineer, generM 'COntractor, electrician, plumber or builder. Nameofownerofp emises ..................... '- · . · . '. i~. :<~ ~,~,~,~ ~- /~.~ ... ~ ................ .. If applicant is a corporation, signature ofdul ...... (as o tak roll or latest dee'd) ..................... · . Y aumorlzed officer. ' ; (Name and title of co.~.'~r'; ' ' ;.'- .......... ,. · v ate Oltlcer) Builder's License No Plumber's License No.. Electrician's License No. : Other Trade's ............... ' ....... License No ...................... I. Locati}on of land on wllich proposed Work will be done. '" · ........ : . ........ ~trcet ' ......~-' ........ ,..~..~. r~. ,/, 4~. ~ Counly Tax Map No. 1000 Section .~ ~' B oc "~ Hamlet Subdsvis on . ' ........... k . . .q~. . . ' L ....... . .............. ' .......... o t . .~5 .~. . State existing Use an,' ~- (Nmnc) .' .... F~Jcd Map No ......... · ~, ' ..... · . u uccupancy oF premises and ip+.---, , . .... .uut ...... : ........ a' Ex'slmg "se and occupanc¥ .~. /~Z 'XJ'UeO usc and °ccupancy °f pr°p°sed :onstruct,o· b ........ z,~. z./. ~.c>~ · n. · Intended us ' '~ ...... e and occupancy ~ r3' '. "; '.,,',; -.,:' ; . -...~ ...... ....... [.,?., . %:,. ~'. .... , J ......... Nature of work (check wh]c~ apPlicable'~- New Building . ' .. ; ..... ' Repair ............... Removal " o~ · ,~: .... ,~aamon .......... Alterati.~ol). ...... ! ............... uemont]on .. Other Work q~"'~_~.~.~_.~. 4. Estimated Cost .... ' . escr on .... I (to be paid on filing tiffs application) 5. If dwelling, number of dwelling units ............... Number of dwelling units on each floor ..... · If garage, number of cars . .J . · ......... 6. If business, commercial nr,,i',,~. .............. .; ............................................ ., ..... --'"."~:u°ccupancy, spec,~ynatureandextentof~ffcht,,~,.,,r .... ii .... /. unnenmons ol ex~gting struc!~ures if any. Front ,~ .~ .,~. ......... ~ ............. N ................. lxear .............. Depth ........ I leight ...... . ......... umber of Stories ..... 2 .......... ' · Dimensions of same structure with alterations or additions: Front ...................................... Di f ..... i .... Height ........... "": .... :.. umberofStories ..... ' mensions o entire new construction: Front ... . ' H igl N~ b f St ............ Rear .............. Depth e it ............... m er o or/es...' ........ ' ............. S' fl lZe o or: Front ....... '1 ' . .. .............................. ' ' D ............. lqear ..... Depth .......... ~." ' ' ate of Purchase ................ Zone ...... ., ......... , . ....: ........ .. Name of Former Owner . ~ ~ . . .......... ~,, u.~u uiatrlcl, tn wnlcll premises are situated .............. · ......... . .....~. Does proposed Construction v olate any zoning law, ordina ce or regulation: .............................. Will lot be regraded ... ' · 5 ........ j ........ Will excess fill be removed from premises: f p i Yes ' Name of Owner o remises .~ ........ Name of Architect ..... i ....... Address ..; .... ; .' .......... Phone No ............... .... I" ............. ' ....; Address . .. · .'Phone No ........... Name of Contractor .... ~ · · ~ ................... Address; ........... ; ...... Phone N0: ......... :.. .... I.s this property withi] 300 feet of a tidal wetland? ~Yes ........ No..F~ · If yes, Southol Town Trustees Permit may be required .... .... PLOT DIAGRAM Il buildings, Whether existing or proposed, and. indicate all set-back dimensionJ fron ~ number or description according to deed, and show street names and indicate whethe I0. II. ,12. 13. .14. 15o ' Locate clearly and distinctly ~ property lines. Give street and bloc interior or corner lot. STATE OF NE~ff'g'~R~[¢..~ [ t ~$ S ' ......... 3.( .,. i.. A...ffe. h above named(.Name of individual signi~ng contract) ..... [ being duly sworn, depose? and says tliat he is the applicant I (Contractor, agent, corporate officer ) ................... , etc. ~f said owner or owners, and is du Yi anthorized to perform or have performed the said work and to make and file this ~pplication: that all statements contained in this application are true to the best of his knowledge and belief; and that the york will be performed in the manneriset fortli in the application filed tlierewith. ' ;worn to before me this '. ....... ...... Notary Publl~. NO. 4879508 i ,'~/~ ' · ' - .Clu. Mlfled In $uffolk C.Ou._W ~,mnmlwo. ~]q~lre~ December 8; lO,J_ I .