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Home My WebLink About21349-zTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~-No, 2134{Z Permission is hereby granted to: .~.~.~..:....~.~./~.....~,~.¼ ..:~.~....~.....~ ...................... .~..,~.,~,~..~.,......~..;.~.:.....}..!.~..~..':{:.. ........... ,o ...~~.....~.....~...~~...~..~...~....~.~. .......... .~...~f~..~.....~ ......... .~ ............ ~...~.:.:-~.....:.~ ...... .~ ....... .;~ ..................... ~._. ...... et premises located at ..~!...O..~....~/¢'~-./..'7...~...~......~...~.;..~.....~J~_: ....... ...~..~.~..~'~.... ...... County Tax Mop No. 1000 Section .... .~..,~, ..~, ........ Block ....... .,~..,,,~.. ..... Lot No ......~,.~, .......... pursuant to opplication dated ~.~3-~0 .... / ~ ........ 19.~,.~, and approved by the Building Inspector. Building Inspector Rev. 6/30/80 ~ ~ The ~wage dis al and w~ter supply fac]h~ies for th~ R~/ //W~ ~a~' F/ZER R~E~ ~ 190 ~ 6UR VEY OF PROPERTY 6 REENPORFSMITH (UUNO SUFFOLK COUNTY ~rot~? L~na NEW YORK ¢ao MEDFORO AVE. ~urvc9 Certified to: /~)~; H4~ITRT FO~ HUMRNI7~ OF ~UFFOLK ~ ~ FORM NO, TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y, 11971 TEL.: 765-1803 Examined ., 19a).~ . ' Approved . . . .,~o..., 19~ .~ Permit No .~ ! .~ .~.~ .'~. Disapproved' a/c ............................. ' . (B uild-i'dCg In sp e c tor ) APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH ......... 3 SETS OF PLANS .......... SURVEY - CIIECK . HAIL TO: Date ................... 19... INSTRUCTIONS a. Tlxis 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 sti-eets or areas, and ~iving a detailed description of layout of property must be drawn on the diagram which is part of this appli- cation. ¢. 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 i~sued 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 describbd. 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 i~'ffeclit~t~.~(7~. ~ . --' E~(Signatur~ of applicant, or name, if a corporation) .. (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Nmne of.owner of premises...~.~.Q~.~..~..~.4...~... ~(... &.~.~.-~. ?.7~... i i .~il;?.'~i~i (as on the tax roll or latest deed) If applicant !~,~12oration, signature of duly authoriied officer. '. (N~~q~,i~;~r ate o ffic er) Builders Lic ~ s ¢~%*~ Plumber s Lzcense No .................. Electrician's License No. Other Trade's License No ...................... Location of land on which proposed work will be'done ........ ' ................ ...... · ........ House Number Street .............. cotmty Tax Map No. 1000 Section ... :.9.~*. ......... Block .... C~... ' Lot.. ~.t/ .............. Subdivision ........ . ............................ '. Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premise.~ and i~ntended use and occupancy of proposed construction: a Existing useandoccupancv d~ ..~...'77. '..~..~z.,z-/~ ,,~ '~ ,,.*~,~,~,~ b. Intended use and occupancy ..... ~. ~ .~Z.~ ~., ~~,,,.,~¢¢ .3. Nature of work (check which ~Pphcable): New Building .......... Addition .. AL Alteration " ~r ...... ~ ........Removal .............. Demolition .... ; ......... Other Work ...... .~ ..... · .. ,. ... ~ I '~ (Description) 4 Estimated Cost ' ' ~ ~? ~' ' ' Fee (to be paid on filing this application) 5 If dwelling numberofd ellin~units Numb ofd · , w ......... eIli its on each fl If gar robe of ....... er w ngun oor . . age, nu r cars ....~ ................. '. ' ............... If business, commercial or m(xqd ~ccupancy, specify nature and extent of,each type of use ...... ~ .............. 7 Dimensions ot xisti g stmctu~es, if y: Fr t Rear ..... ' ........ . .-. ' · e n an on . ~ ............... Depth .... Hight Number fSto les ~ ~ .................. ' ..................... ' ' Di io ofsh tract e ~ith Iteration addition: Font .......... Dmens ns mes ur a sot s r ................. Rear .................. 8 D~pth .... ~ ............... ~... HeiSt ....... '..,: .........'.. Number of Stofies ........... : ~ . mensions of entire new construction: Front ...... ' ........ Height '.~.Nu~ber of Stories ........ : Rear ............... Depth ............... 9 Size of lot: ont ................. ' ' · cr ~" ' Rear ' 10 Date of Purchase ......... 'j .................................. Depth ...................... ' · ....... . ......... ' ..........Name of Foyer Owner I 1 Zone or use district in which pr~emises are situated ........................ rio.late any zoning law, or ' ation: ..... ........................... Does proposed construction, dinance or regul 13. ~dl lot ~regradefl ..... {' ~ ;]~" 't '~' ' '1 '~:~'' Will excess fill heremoved from premises: Yes . No 14. ~teo~uwnero~premises ~V..~'~.g.O'~'tqqa)~g~ddress ~ ~ ~'t' Ph~n.M~ V~7-~ Nme ...... ' ' ~ ~ ' ............................ "~- ~ ' o[ Arcmrec[ ......... i ................. Address ................... Phone No ............. .... Name of Contractor : ........ ~ ................. Address ................... Phone No ............ ' .... i5.' I~ thSs property withSn 300 feet of a t~dal wetland? ~Yes ........ No.~....... · If yes, Southold Town Trustees Permit may be required. PLOT DIAG~ Locate clearly ~d distinctly ~1~ bulldogs, ~heth~r existing or proposed, ~d~indicate ~1 set-back d~ensions from prope~y ~nes. Give street and block,number or desc~ption accord~g to de~d, and show street n~es and indicate whether ~te~or or corner lot. o [[ '/65-1802 9 AM TO A PM FOR THE a ~ FOLL.OW~NG INS~;:CT~ON$: ' FOR POURED CONCRETE ,,; ' ~ ~ ' 3. INSULATION /e' {. ,/f -- ,~ ALL (,ONST~UCTiOh~ SHALl. MEE~ <"~ ~'~.., ~E ~EQt.IIREMENT8 OF THE ' ' "' ' ~ ~ OONSTaUCTION & ENERGV · ' ' C~D~S. NOT' RESPONSIBLE FOR STATE OF NE~m~ [I/~' couscous,.. ,, .... N . . . , ..... being duly sworn, deposes ~d says that he is the applicant ( aCe ofzn&v~dual signiqg contract) J above named. , ... ........... i (Contractor agent ....... ) ............................ ' cofporate officer etc of said owner or owners, ~d is duly ]authorized to perfom or have perfo~ed the said work and to m~e and file this pp[~ca[~on, that all statyments contained m th~s application are true to the best of his knowledge and belief; and that the wor~ will be perfomed ~n the manner get forth in the application filed therewith. ' Sworn to before me this · .... ...... : .... . ~ubllo, 8~ o{N~" .~../. g. {~: 7;'.'. .................. . . - ~o. 4~7a~0~ i ~ / '~ nature of applic~t) · . uuallaed I. ~uff~k Cgq~.. q~ ' ' ,, . ~m~n E~lre~ D~ a, ~e~ I .