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Home My WebLink About21634-zFO~M NO.3 BUILDING DEPARTMENT TOWN HALL $OUT~OLD, N.Y. NO_ BUILDING PERMIT [THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 21634 Z Date .....~ ............................................... 19..~...~,... Permission is hereby granted to: ~ ./,...~.,,/~,~.;. ~/...,. ................. ...~.~..o.....~~..../..~.......'. ................ ..... ~~......~....W....,..¢...:....,...../.../....¢..~' ........ ........................................................................................................... County Tax Uap No. 1000 Section ...... ~..~.. ........... Block........~... ............... LotNo, ./,.,..~... .................. Building Inspector. Fee $.., ,~.,...~./., ..~. Rev. 6/30/80 and approved by the FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1802 Exanffned ........... 19~.. Approved ............. 19 Permit No ....... Disapproved a/c ..................................... ....... APPLICATION FOR BUILDING PERMIT INSTRUCTIONS BOARD OF HEALTH ............ 3 SETS OF PLANS ............ SURVEY ..................... CHECK SEPTIC FORH ................ Date ................... %'~//~5> 1.9 ...9'~ ~. 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 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 BuiIding 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 Reeulations, for the construction of buildings, ad~ditions or alterations, or for/'emoval or demolition, as herein described. Tb~ 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. (Signature ot ap~Iicant, or name, if a co}po'r~fic;n')' ' ' ........ i/&li g ;7 h, ii k t' ') ..... : - State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ............ · .............................................................. (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ..... . .~...~,~L ........... Plumber s L~cense No ......................... Electrician's License No ....................... Other Trade's License No ...................... I. Location of land on which proposed work will be done ............. ' tlouse Number Street, Hamlet County Tax Map No. 1000 Section ..(~. .......... Block ...... ?.~)O Lot Subdivision ..................................... Eiled Map No. (Name) .............. Lot ............... '~ Statee ' · ~- mst ng use and occupancy of premises and intended\ use aod occupancy of proposed construction: a. Exist no us :' l ~ t~ t~ ~ e and occupancy ..D..~..c~l~. .... ~ ......................... "'i ..... i ....... b'Intended Use and occupancy ..~..~ .... (.~ .... .~.&- ...fi(. ...... .c~....,.,,.,:..,.'"';°' C~ , i5~.~.'~.~." '...,... .. 3. Nature of work (check whit.?. [applicable): New Building ..... ' ..... Addition .......... Alteration ...... Repair ............ lqe oval ............. .. gr~$Jcqi! "'- o~ ?_ · Demolmon ..... Other Work. ra~.~./~_~ t ~v'~L ~ et+~._ ~/ , , . . c, ~'51"' 75" ~ 5'" ' (Dcscnpt,on) 4. Estimate'd Cost ........ ,,,~. ...................... Fee $ It'd~ elli lliig nits (to be paid on filing this application) nb ofd Nt b fdw Iii its ' · v nh. nm er we u ............... m~ er o e ng un on each floor .... If garage, number of cars .. I .......... 6. If business, Commercial or mi~ed occupancy, specity nature and extent of each type of use ............. mensions of existing structures, · ...... 7. Di if any: Front ............... Rear ............... Depth .............. e gilt .. .,A . H ............ aumoer of Stories.. Dimensions of same structure with alterations ,-.- ,aS:',..'~' '-' ~' ' ' '~ ........................................ .eight.. .r:. ' ....... Dimensions of entire new conitruction. H ' ' ................... Rear ............... Depth e g It ..... 'M"lmoer o~ otorle$ ...... · 9. Si ofl F ..... i . ' .... · ze or: ront ...... R ......................................... 10 Date of Purchase ~ .... ..... ear ...................... Depth .......... il z di ....... ;;r; ' 'm'i ................ Name of to=er Owner ................ · one or use strict in whic re scs are situn*,,a ' ' ' ' ' ....... Do d tio i01 i ............ · es propose construe nv ate any zon nglaw, ordinanc ...... ; ...................... ..... 13. Willlot be regraded . . 14, Name of Owner ofpremi ..... ' ............ i~. ,. Will excess fill bezemov, ed from premises: _ Yes . Nc Name of Architect scs. 'i' '.~...a.~..~.~.. I~.%/d..~ddress ~ ~0. ~.~..~ [7~l~ghone No .7.~. 5/. ......... ' .................. Address ................... Phone No ............... Name of Contractor i . ...... , .................. Address. .................. Phone No ......... .x~- .'- · 15.Is this property lochted within300 feet of a tidal wetland.* /eYES .... ~If yes, Southold Togn Trustees Permit may be required. PLOT DIAGRAM Locate clearly and distinctly a~l buildings, whether existing or proposed, and. indicate all set-back dimensions frorr property l/nes. Give street and block number or descnptl0n according to deed, and interior or corner lot. ..---- ~ ~ ~ ~ ~.~ show street names and indicate whethe: I' .09` l=e~e STATE OF NEW YORK, COUNTY OF ... · (Name of individual signing contract) above named. NOTIFY 765~802 9 AM ~ 4 PM FOR THE FOLLOWING INSPECTIONS: l, FOUNDATION ~O REQUIRED FOR POURED CONCRETE 2, ROUGH ~ FRAMING & PLUM~ING 3. INSULATION 4. FINAL CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL TNE RBOUiREMEN~ OF THE N,Z STATE CONSTRU~ION & ENERGY CODES. N~ RESPONSIBLE FOR DBSIGN OR CONS~UCTION ERRORS · being duly sxvorn, deposes and says that he is the applicant lie is the .O .O/. W..~ ~ i (Contractor ..................... agent corporate officer etc) ......................... of said owner or owners, and is duly authorized to pexrform 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 perl'ormed itl tile mannerfet forth in thc application filed ttierewith. Sworn tO before me this ................ day o .......... 19. Notary Public ..... I ............. County N. UNDAJ COOP~ ~o, ta~ Pubflo, State ~'f · ~ ~°a4822563, Suffolk mrm eXPires December (Signature of applicant)