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FORM NO. s
TOWN 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°_N° 2064OZ Date 19-7...
0
Permission is hereby granted to:
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at premises located at AR16A.... . l-m....~.R 1-srt t, .r?C.~( Y!t:S.
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County Tax Map No. 1000 Section Block .0-q....... Lot No.
pursuant to application dated .........n... ......l..R 19J..".., and approved by the
Building Inspector.
Fee S...S.S.::.~n.0
°
Bu ding Inspector
Rev. 6/30/80
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BOARD OF HEALTH
FORM N0.1 3 SETS a~,'P LANS
TOWN OF SOUTHOLD SURVEY .~,Iy
BUILDING DEPARTMENT C11ECF • • • - .
TOWN HALL SEPTIC FORM _
SOUTHOLD, N.Y. 11971
TEL.: 766-1802 NOTIFY
CALL .~l J3.
xamined ...~.14,4 ;~q . 19qq ! MAIL TO:
191 ti. Permit No..~ O
pproved
isapproved a/c
(BuOin,gg n spector)
APPLICATION FOR BUILDING PERMIT
Date ..........s`' 191FA!
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3
is 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
areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli-
dion.
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
all 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
aalfhave been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
wilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
egulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
he applicant agrees to comply with all applicable laws, ordinances, building e, housing code, regulations, and to
Imit authorized inspectors on premises and in building for necessary inspe "o d/h!
- (Signature of applicant, or name, if a corporation)
(Mailing address of applicant)
tate whether applicant is owner, lesse agerytA architect, engineer, general contractor, electrician, plumber or builder.
Jame of owner of premises ..V. /gel r 4~/ . ! G. L ~Ge
(as on the tax roll or latest deed)
F applicant ' r oration, sig ture of duly authorized officer.
.
(Name and title of corporate officer)
Builder's License No. .
lo...
Plumber's License No. /"f ~~7 ~
Electrician's License No.
Other Trade's License No .
Location of land on which proposed work will be done./GY.......~(? . UT.. /!f!rfh..
I...~~ R..... w.1:8A)..l.1~G~ .11
House Number Street Hamlet
County Tax Map No. 1000 Section ........e!t~...... Block el Lot. la
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 ................................'.:f.`...
may` r.. r.''~...``..
b. Intended use and occupancy
3. Nature of work (check which apilicable): New Building Addition Alteration
,
Repair Remo val Demolition Other Work
(Description)
4. Estimated Cost J.Y 21 (kU Fee .
(to be paid on filing this application)
S. If dwelling, number of dwelling units 4NA".77. • • • , Number of dwelling units on each floor .
If garage, number of cars .
6. If business,
g ior mixed occupancy, specify nature and extent of each type of use , , , , , , , , , , ,
7. Dimensions of existing
Height g.... structures, if any: Front ..............Rear Depth
Hei
Number of Stories .
Dimensions o same structure with alterations or additions: Front Rear
$ Depth Dimensions .~of . entire new construction: Number of Stories
Front ):G1..G.... Rear . , ho: • Depth
Height I:7........ Numb erofStories ....ol-t. .....p...:.:.,'...............
9. Size of Rear ` Depth A VO
10. Date off Pur hasa . • , , , , . Name of Former Owner
11. Zone or use district in which premises are situated .
12. Does proposed construction violate any zoning law, ordinance or regulation: 00. , , • , , , , • , , . . . •
S.
13, + of be regraded • • • • • ~y • • • • • t11 exce s fill be removed from premises: Yes NN
14. Name of Owner of premise ~3 ?(il~? fiA JBW 'LAddress 4* R'N,f? 4: q , f~ !?+a Phone No. 244.7.1.;'.{ ,q • , • ,
Name of Architect . , ..,Address Phone No.
~i
Name of Cgropeofy W, iu3 ! d Address /.bh!i/{1c,~A.l., Avth"" • Phone No. •~II~~~.....
15. Is this 90 feet f a tidal wetland? *Yes Nok.
*If yes Southold Town Trustees Permit may be required.
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 according to deed, and show street names and indicate whether
interior or corner lot.
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STATE OF NEW YORK,
COUNTY S
J ~ . .
• • • • • • • • • being duly sworn, deposes and says that lie is the applicant
(Nam . . . • . • .
of individual signing i contract)
g gcontract)
+bove named.
le is the c?rJT~."°~^.~4 pvs ' .I,... .
(Contractor, agent, corporate officer, etc.)
)f said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this
application; that all statements contained in this application are true to the best of his knowledge and belief; and that the
vork will be performed in the manner set forth in the application filed therewith.
;worn to before me this . . day of.
l J~o 19
Jotary Public, . . • , , . vCoun
Co, State ty
Notary Public,
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Term E 22M1fi Suffolk f oun (Signature of applicant)
Term 62246 June 12.19 York
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PLUMBER CERTIFICATION
ON LEAD CONTENT BEFORE
CERTIFICATE Of OCCUPANCY
SOLDER USED IN WATER
XI&EE SUPPLY SYSTEM CANNOT ,p r I t
EXCEED2/f00f 1% LEAD.
APPR VED AS NOTED
DATE; d 3 B.P. k.Lf
E NO3SY T IFYFT 8 ILOING DEPARTMENT AT !~p¢EP MATT1,~ffy
765-1802 g AM TO 4 PM FOR THE S
FOLLOWING INSPECTIONS 1~Q5 k
1. FOUNDATION . TWO REQUIRED
FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING UNDEAWRDERICERTIRCATE
3. INSULATION REQUIRED 1 ~ y ~o
4. FINAL - CONSTRUCTION MUST `f9sin„No. 271710E
BE COMPLETE FOR C.O. dF\i111F S(~P3~ffQ~~~ -
ALL CONSTRUC-TION SHALL MEET THE REQUIREMENTS OF THE ry,y, -
S TATE CONSTRUCTION I. ENERGY
Cot) S NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS PLUMBING
ALL PLUMBING WASTE ' - & WATER LINES NEED
TESTING BEFORE COVERING -
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Vol 27, OF THE BTAtE