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HomeMy WebLinkAbout20573-z 11~0~ NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTNIENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Co.nb/ Tox Mop No. 1000 Section Z~..~..]...//~y ..... Block ....... i.~.. .......... Lot No.......~.t.....Z Building Inspector. Rev. 6/30180 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined ................ ,19... Approved ~...~. ~2.~., 19,~-~ermit No...~...~...~..73 Disapproved a]c ..................................... BOARD OF 8EALTIt ......... 3 SETS OF PLANS .......... SURVEY ................... CIIECK .................... SEPTIC FORH .............. CALL ................... HAIL TO: (Building Inspector) APPLICATION FOR BUILDING PERMIT Date ....4/,2.1. ........... 19 ~9.2. INSTRUCTIONS a. 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 Buildli~g Permit to the applicant. Such permit sliall be kept on the premises available for inspection throughout the w6rk. 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 ir. lAtkec~orts. ~ .... ........ -- (Signature of applicant, or name, if a corporation) · ?:. 7.87,. $9.u.t~. 9.1 .d, .N·e.w..Y..o.r.k..1.177.1 ...... (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ........ Owne.r. ................................................................. ~. ................ Name of owner of premises F.i.r.s,t..C.h...u:K.c.h' .C9.n.g.r.e.q.a.t.i.qn' 9.r..S.og:' .i.n..S.o¢..tl)9.1.d' 9.r..F.i.r.s.t..P.r.es..b.y.t.e.r.i.an.. C.h..u.v.c.h.. (as on the tax roll or latest deed) If applicant is a corporation, signature of duly autt?rized officer. (Name and title of corporate officer) Builder's License No .......................... Plumber s L'cense No ......................... Electnglan s Lmense No ....................... et mr Trade's License No ...................... Location of land on which proposed work will be'done... ~....,~.~.. ................................ Southold ..... ~e3&~. a.v. er~ue ~ ......................................................................... llouse Number Street Hamlet County Tax Map No. lO00 Section .... 4~'../ ......... Block .... ~ ............ Lot,. 'R-" .2 ......... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy No Occupancy Dwellings - Unused Land-Vacant Barn b. Intended use and occupancy ...Cle~n .up..site.-;cerao.v.a .two..am~l;k. ,qg:~ hu.~.~.dS_'nqs!; 3. Nature of work ' ' · (check which applicable): New Building .......... Additiou .......... Alteration .......... Repair .............. RemovaI .............. Demolition . .2g ........... Other Work ?lean-ult. (Description) : (to be paid on filing this application) · 5. f dwelling, number of dwelllug units.. N..~ ......... Number of dwelling units on each floor. N.Ar · If garage, number of cars .... N..A. ' ............. 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use .... ~ ............ 7. Dimensions ot Xmtlng tructures, ifany: F/~ .@no..Sxl0 ..... x~R~x .©no .20x0.0 ·. l~e~R ............... Height ............... Nmn. ber of Stories .......................... Dimensions of same structure with alterations or additions: Front .............................. D pti ' Hight ................. Rear .................. · · ' . · N b of St ri 8 D~meI .................. '. e .................... um er o es .............. . ....... ' H nsions of entire new consfiuction: Front ............... Rear ............... Depth ............... eight ............... Nmfiber of Stories'. .............. 9 Si fl F ' zeo or: ront .... !x ...... ' ...................... · . Re Depth ....... 10. Date of Purchase ............................. .......... , ......... ' ......... Name of Former Owner 11. Zone or Use district in which premises are situated ............................. D ' oes proposed construction violate any zoning law, ordinance or regulation: ................................ 13. Will lot be regra'ded ........ i .................. Will excess fill be removed from premises: Yes No · 14. Name of Owner of premises ................... Address ................ Phone No ................ Name of Architect ......... ' ' ' ~ ................. Address ................... Phone No ................ Name of Contractor ........ ~ ................. Address ................... Phone No ................ 15. Is this property within ~00 feet of a tidal wetland? *Yes ........ No. x · If yes, Southold zown Trustees Permit may be required, ' ....... PLOT DIAGRAM Locate clearly and distinctly ali buildings, 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 interior or corimr lot. j Items ~ thru 14 not applicable two out buildings to be d!emolished because they are considered hazards. sizes: 8 x 8 20 x 30 STATE OF NEW YORK, cotr rv ....... .......... ('~ ..................................... e duly sworn, deposes and says that he is the applicant amc of individual tgnmg contract) s' .~ b ing ' above nanlcd. ~ (Contractor ...................................... )f said owner or owners, and is duly[ authorized to perform or have perfo~ed the said work and to m~e and file this lpplication; that all statements contained ~ this application are true to the best of his knowledge and belief; and that the ~ork will be perforated in the manner'set forth in the application filed therewith. gWom to before me this ........ ...... ..... ota, Public ..... :/~~. [ ........ "7~ y ~ 472~, ~Ol ~U~" (Signature of applicant)