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HomeMy WebLinkAbout21649-zFOBM NO.3 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HAU. $OUTHOLD, N.Y. 21649 Z BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Coun~yTax Map No. 1000 Section .......... ~..¢~. ........ Block .......... ./..,~.... ....... Lot No ...... ~.:...~.. ......... pursuant to application dated ......... ..~/...~ .................................. 19,,~ .~... ..... Building Inspector. Fee $.,.~..~ .... and approved by the ~~ding Inspector Rev, 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 Examined ......... , .o ..... Disapproved a/c ..................................... ~mo Inspector) ........ APPLICATION FOR BUILDING PERMIT INSTRUCTIONS BOAgD OF HEALTH ......... 3 SETS OF PLANS ......... SURVEY .................. CI1ECK ................... SEPTIC FORH ............. CALL .................. MAIL TO: 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 loc&tion 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 with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. · 7.5-.~ h ~..fbi..~..~':. B~.~ .t~.~. c..-~4qc~.- ......... --' (Signature of applicant, or name, if a corporation) .... I..~v..~.~..~?v...©..o.(, p. 6.~.%~ !ff .... .... (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder· U (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...~.~ q.q~.. ~ ~ ......... Plumber's License No ......................... Electric?n's License No ....................... Other Trade's License No 1. Location of land on which proposed work will be done .................. ' . ................. House Number Street Hamlet County Tax i~ap No. 1000 Section ....~..0. .......... Block .... /..~. ........... Lot ..... .' .?~).. '..(q. ........ Subdivision 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ........ I .... t ............... b. Intended use and occupancy .................................................................... 3 N fork ( hock hich ppl' able) N B ildi Additi Alt ation · ature o w c w a lc ew u ng .......... on .......... er ......... Repa/r ............ RemoVal .............. Demolition ............ Other Work .............. 4. Estimated Cost ..... ~ ................. F (to be paid on fi ' ' ' i lhng this application) 5. If dwelling, number of dwelling u, nits ............... Number of dwelling units on each floor ................ If garage, number of cars ' 6. If business, commercial or mixed!occupancy, specify nature and exteht of each type of use ..................... 7 ..... . Front Rear · D~mens~ons of ex:sting structures! ffany' . · ............................. Depth ............... Height Number of Stories Dimensions of same structure with alterations or additions: Front ............... Rear ................. Depth ' Height Number of Stories 8 Dimensions of entire new constrffetion: Front Rear ..... ' . ............................. Depth .............. Height ............... Number of Stories .................................................. 9 Size of lot: Front ' Rear ..... ............. i ................................ Depth ................ 10 Date of Purchase ' · Name of Former Owner ..... · Zone or use district m wh.,ch prer0~ses are muated 12. Does proposed constructmn viola!cony zoning law, ordinance or regulation: ..............FZ{............... ............... 13 Will lot be d d . W 11 fill b ed fr is · regra e ..... , ..... .~ .................. i excess e remov om prom es: Yes No 14. Nagoo of Owner of premises .... i ................ Address ................... Phone No Natme of Architect .i. Address Phone No ................ Naxne of Contractor ' Address Phon0 No 15. Is this property within 300 feet of a tidal wetland? *Yes....~/. ~.. No ......... · If yes, gouthold T6wn Trustees Permit may be required. .... : PLOT DIAGRAM Locate clearly and distinctly all Suildings, 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 inter/or or corner lot. STATE OF YOR cou y .......... APPROVED AS NOTED DATE: ...... 8,R # FEE: _, BY: ........ NOTIFY BUILDING OEPARTMENT 76~-~802 9 AM TO 4 PM FOR THE FeLt. OWiNG tNSP~CTIONS: 1. FGUNDKf~ON 'i~O REQUIRED FO~ POURED CONCRETE 2, ~OUGH - FRAMO~G & PLUMBING 3. [NSU LP;i'ION 4, FINAL . -CONSTRUCTION MUST BE COMPLETE FOR ALL CONSTRUCTION ~HALL THE REQUIREMENTS OF THE N.Y. STATE CONSTRUCTION& ENERGY CODES. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS ........... being du sworn, deposes and says that he is the applicant (Name of individual signing contract) above hame& He' isthe (COntractor, agent, corporate officer, etc.) of said owner or owners, ~d is duly huthofized to perform or have perfo~ed the said work and to m~e ~d file this application; that all statements contain'ed ~ this application are true to the best of his knowledge and belief; and that the work will be perfo~ed in the m~ner s~t forth in the application flied therewith. Sworn to before me this ................ day of..i ...... ,. ......., Nota ublic, .................... ~1.~,~,~ ~ 8ERN~I)E'ffE L T~ NOTARY PU~I~ ~3 Shted New York R~iding in Commission ~lr~t (Signature of applicant) C Ld