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Home My WebLink About21377-z ~OWM' NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) ~? 21~77 Z Permission is hereby granted to: ~...~...~.~' ~ ~ .~.r.~....£~.~.....£.~.. , ,o ............ ......... ...... at premises located at ............ .~......~.....~.~ ./..~....~..../..~.~. ..................................... ................................................. ~..,~../...~.....~...~../....~.~....~....~ ............. Count,/ Tax Map No. 1000 Section .... ./..~....~.. ...... Block ........ ..~... ........ Lot No ......~... .............. pursuant to application dated .............................. , 19. and approved by the Building Inspector. Building Inspector Rev, 6/30/80 ,co.o ~ 4q'~ 6.71'39 ' 7_..0"~, ' FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N,Y. 11971 TEL.: 765-1802 Examined ................. ]9... Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDInG'PERMIT BOARD OF-HEALTH 3 SETS OF PLA~S SURV£Y .................. CIlECK CALL .................. HAIL TO: INSTRUCTIONS a. Tl~s 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 sliowing location of lot and of buildings on premises, relationship to adjoining premises or public st~'eets or areas, and giving a detailed description of layout of property mu~t 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 issued a Building Permit to the applicant2 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 l?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 otker applicable Laws, Ordinances or Regulations, for the constrdction of buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable taws, ordinances, building code, housing code, and regulations, and to admit author/zed inspectors on premises and in building for necessary inspections. -- (Signature of applicant, or name, if a corporation) az .v..~....A,..~.....d~........~.~.~".3. ~.'../~. (Mailing address of applicant) /lq ~'-'a. State whether applicant is owner, lessee, agent, architect, engineer, generai 'contractor, electrician, plumber or builder. N~me of.owner of premises .~t/~/~.../~... ~.../~.O.a,f..~.Z'.'.~..r3~..-.~-? ..4,5t9~.. ~ .... ~./.~7..ff~2. 6~./f...o-7/..~:zS..~ ........ (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 .......................... Plumber's License No Electrician's License No ......... ~...../..-/ ...... Other Trade's License No.. .................... 1. Location of land on which proposed work will be done .................................................. .... ............ ' '. ..... ..... House Number Street Hamlet Con~t~*~× Map No. ~000 Soc~on /~.~...~. ......... B~ock : ....... .~.....' Lot....~-...4 ........ Subdivision . .' ......... '. Filed Map No. . .............. ..... · ".'" .............. .............. Lot (Name) · 2. State existing use and occupancy of premises a/id intended use and occupancy of proposed construction: a. Existing use and occupancy ............ ." b. Intended use and occupancy .... fi~2C~ tl/~.~ . · t heck whmhlapphcable): New Building . ~ .... '. · .' ,'"- "· · Alteration P ...... Removal .............. Demolition . ~. '..: .......... Other Work .............. 4 Estimated Cost ' ' lliig (to be paid on filing this application) 5. If dwelling, number of dwe units .......... Number of'dwelling units on each floor ....... Iff cars . ~ ..... ' ..... arage number of :! .................................. 6. usm ss, c e iai or mt. ed occupancy, spec nature and exte o eac tvn 7. ~nnens,ons el ex,sting structures /f any. Front . .,. ~ ......................... Height ............... N~mber of Stories .... . . . .... Depth Dimensions of shine structure with alterations or additions: Front ............ Rear Depth . .. ~ ........ ~ .... 8. ~ ' · ................. ... 10. Date of Purchase . ~ . ......... , .................. .. Name of Former Owner ........... 11. Zone or use district in winch premises are mtuated ......... ' 12 Do sp d etio iol Y inglaw ordi r~ceo 13' W e repose constru nv ate an zen , na rregulation: ........ ' ...... . · 11 lot b d d I mi~es~ ............... 14 ~ e regra e ............................. Will excess fill be removed fro re Name of Ow fP mi [ mp Yes No · Name nero re scs .., ......... ~ ........ Address ...... .. ..... Phone No ........... ;... of Architect " ' · ..... ' ......... I ............. · .....Address ........... . ........ Phone No ...... ·. Name of Contractor ........ i .............. 15.' 19 this property w±th±n 1300 feet of a .... Address ............ : ...... Phone ~ ........... ' .... tidal wetland? *Yes ........ No...w~. .... ' . *If yes,'Southold ~Town Trustees Permit may be required. ' I' PLOT DIAGRAM Locate clearly and distinctly ali buildings, Wh~th~r existing or proposed, andlindicate all set-back' dimensions from property lines. Give street and blockinumber or description according to deed, and show street names and indicate whether interior or corner lot. . ,"L) co.. -ot2xs I ............................ (Name .... ' · · · · · being duly sworn, deposes ~d says that he is tlie applicant of~nd~wdua mgmn¢ contract) hove named. , ' [e is the . ...... ............... ~ · ontractor, agent, cor'porate officer, etc.) f said owner or owners, ~d is dub, iuthorized t~ - . . J g o pertain or have perfo~ed the said work and to m~e and file this ~pbcatmn, that all statements conta ' ' 'n.ed M this'application are true to the best of his knowledge and belief; and that the ork will be perfomed in the manner s~t forth in the application filed therewith. ~vom to before me this ~ " ' (S=gnature of appI c~t · ~mmi~lon ~p~res Decembe;~8, 19~ ' , ) ·