The URL can be used to link to this page

Home My WebLink About21635-zFORM NO.'~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL $OUT)4OLD, N.Y. NO BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) ~,e..~./..~ ............................................... ~9~ .... 21635 Z Permission Is hereby granted to: ....... ............................ ....... Z~.~/.~-......_~~/...~.......~...¢..., ....... ....... .................................................................... CountyTax Map No. 1000 Section ....... ....,,~. ,/. .......... Block ............. .,/'. .......... Lot No..,.~.. ..................... pursuant to opplicotlon doted ....... .?.~../.. .......................................... ~9.~ ......... and approved by the Building Inspector. Fee $.~:~'~,~...... Rev. 6/30/80 Exanlined o~_/~;~. · , Approved ........... FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Disapproved a/c ..................................... · .,.(~uildig(.t~ Inspector) APPLICATIOI~I FOR BUILDING' PERMIT B~ARD OF HEALTH .3, SET$,:OF. PLA~$ ........ ' SURVEY CIIECK CALL ..... · . HAIL TO: Date ' 19 .. INSTRUCTIONS · a. Tiffs application must be completely filled in by typewriter orin 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 publ/c sti'eets or areas, and giving a detailed description of layout of property muir 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 shali 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 I?y 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 with all applicable laws, ordinances, building codp, bourns/code, and regulations, and to admit authorized inspectors on premises and in bu il ding for necessary inspec~.ff///~ · . (Sign~f applicant; or name, if a corporation) applicant is~wn_er~l~ssee,('~e~'""-'"-" ~ architect, State whether (Mailing address of applicant) engineer, generai contractor, electrician, plumber or builder. N;me ofownerofpremises '[.~.'~..1~ _/~. ~C~'-~'~I .lkJ ' (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authoriied officer.' (Name and title of corporate officer) ilder's Li No. '. ' cense ........................ PI mber s Lmense No ....... , ................. : Electrician's License No. Oth r T d ' L' N e ra es zcense o ...................... I. Location of land on which proposed work will be done. . ..... ' House Number Street Hamlet County Tax MapNo. 1000Section ...~] ........... Block .1. ' Lot..~ .............. Subdivision ........ . ............... . .... '... ~ ...... Filed Map No ............... Lot ............... (N;nne) 2; State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing Use and occupancy .... ~.., ~.~. ~:~ ..... ~ ~ &~ (,~ - , . - ~ :,;,.;;,,, ;, .. - :. · .................. ,,e ...... ..... :d.,,: 5'%;:': . . ' / " ' ~,~ ~-':, ";[, ~," ": ", :~ ,'.':' 3 .............. · .3. Nature of work (cheek wh]cl~ applicable): New Building ......... Addition .. . Repair 0'../~. :.~'~'e~.~.0..._Removal ............ ~, ...... ' ....... Alteration ....... ~. )ri,?, ~,,~.o P't.,t~t. ' : ,ucmmmon ..... ; .......... Other Work. 4. EstlmatedCost... 2..o. · ' ..... ' ' ' · r ........................ Fee ................. ~ (to be paid on filing this application) 5. If dwelling, number of dwelliilg units ............... Nurhber of dwelling units on each floor: ... · If garage, number of cars .. i. .. ' ......... i!x dc'u;'a}l~; t o'f ~lty; f' s'e ::: ' ' fy .................. 6. If business, commercial or m ed o spem nature andexten .eec e o u ........ 7. Dunenmons ct existing structures, if any: Front ...... · ...... igl ~ ..... . ......... Rear ......... Del~th . He ~t .... N-,ocr ct ~tori ' ' ............... Dimensions of shine structure with alterations or additions: Front ........ pth ' igl ' De .... ' .............. i ....He ~t , · ................ Rear ..... · , . ' ....... ~" ........ .' · · Number of Stories ....... ;. 8. Dimensions of enhre new conltructmn Front ............... Re r ........... De He ~t .............. tuber of Stories ............... ' · · · Size of lot: l~ront , , · · ................. ~ . i ......... Rear ............... Depth Date of Purchase ....... Z.Z _. . ': .... .'"! ........... ' ........ .. Name of Former one or use alStnCt ~n wlnch premises are situated . . .................................. uoes proposed construction Violate any ~ ~'~'" ' ;:" .......... ' .................... Will lot be regraded ~ _~ -~,,,m~ ~uw, ormnance or regulahon: ............................. f P ....... : ..................... Will excess fill ~: removed from premises: Yes ," Nc Name of Owner o remises . i i ......... ' ........ Address ..; .... ' '. ......... Phone No .... Name of Architect . ..,.. ' . . . · ..... ,. · .......... ' .....Address Phone No ........ Name of Contractor ....... , ...... · · ·. Address ........... Phone No ......... . 15. I.s thi.s, ifproperty wJ_th~n 300 feet of a tidal wetland? *Yes ........ No.. ' ...... yes, SoutholdlTown Trustees Permit may be required ....... i ' ' 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 accord/rig to deed, and show street names and indicate whether interior or corner lot. I0. I1. .12. 13. ,14. 765-1802 9 AM ~ 4 PM FOR THE FOL LOW~NG INSPECTIONS: % FOUNDATION - 'BNO REQUIRED ~OR POURED CONCRETE 2, ROUGH - FRAMING & PLUMBING 3; IN[;LIt ATION .4. FINAL CONSTRUCTIQN MUST B~: COMPLEW' FO~? C.C. ALL CO~STMUCTiON SHALL ME~ TME REO[IIREMENTS OF THE N.Y. 'STATE CONSTRUCTION & ENERGY CODES. N~' RESPONSIBLE FOR DESgGN O~l CONSTRUCTION ERRORS STATE OF NEW YORK, COUNTY OF...,~,~.~r~Z.g... .8.S ............ /tr~t~.... ~;~i~J. ................ being dnly sworn, deposes and says that he is the applicant (Natfle of individual signing contract) above named. He is the . 5' ' · ......... ~ ........... . ...... .. (Con tractor ....................... ' .............. , agent corporate officer etc ) ' ~f said owner or owners ~d is dulyl authorized to perform or bare perfo~ed the said work and to m~e and file this ~pp cation; that all statements contai~md ~ this'application are true to the best of his knowledge and belief; and that the .york w~l be perfomed in the manner forth in the application filed therewith. ' ;worn to before me this .............. ~°'ta~Public',''"~'~ r~~'COu~'ty J~Cl M. WI~IN8 . .' · ..... ~o. 49522~, 8~k ~u~ la~ ~JU~'}[ 1~ (Signature ~f applJc~t) .