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Home My WebLink About21130-z IPORH bO. ft TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~N? 211~0Z Permission is hereby granted to: .~.~...~....£~....~.:. ..... W~_~~...~ ................. ...~., ~- ..,...~.... ............ '~.~ ............... ,,~ ~.~.... ,, ~~....~....~.~~..~....., .......... ~ ...... ........~ ........... :, ................. · ~,,... ~ ,,~' ...~.....~. ....... at prem,ses located o* ....-2..i~.~lt..~......Y..~ ......................................... .~-..~.-J~ ........... Coun~ Tax Mop No. 1000 Section ...... .~...~.~. ....... Block ...... ..~..~. ....... Lot No....'~.~..:....! ....... pursuant to application dated~~..~ ....... ~ ............ , 19..~.....'~., and approved by the Building Inspector. Fee $..~....:...~. Rev. 6/30/80 .... a'ef Approved~. FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1805~ ., 19 .~.. Permit No...~-.I.I..~:~O....$.... Disapproved a/c .................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS BOARD OF HEALTH ......... 3 SETS OF PLANS .......... SURVEY ................... CHECK .................... SEPTIC FOKH .............. CALl. .................. Date ......... [~f/'?..., 19 .~...~- a. This application must be completely filled in by Wpewriter or in ink and submitted to the Building Inspector, with 3 sets of plans, accurate plot plan to scale Fee according to schedule ~ . ' · 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- c~ion. 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 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, ordinan.~E.~Eces, building code, housing-opde, and regFl~tions, and to admit authorized inspectors on premises and in building for nec~ry~'t~specti,ons, r~ c'~ .. . -- ~]~_~ignature of applicant, or name, if a corporation) " . .'. . (Mailing at'dress State whether applicant is owner, lessee, age'nt, architect, engineer, general contractor, electrician, plumber or builder· Name of owner of premises ....... x. ~... .q>.~x., ..~ ........................... (as on the tax roll or Ia'test deed) If applicant is a corporation, signature of duly autt?rized officer. (Name and title of corporate officer) ? Builder's License No .......................... Plumber s hcense No ......................... ; Electric. ian's License No .................. .- .... Other Trade's License No ...................... . 1. Locatio~ of land on which proposed work will be'done .... "'/. ,x~,. House Number Street '. Hamlet County Tax Map No. 1000 Section .... . .~..~ ......... Block '....~ ............ Lot....~...~:. i ......... Subdivision ..................................... Filed Mhp No ............... Lot ............... (Name) State existing use and occupancy of premises and intended use and occupancy,~ proposed construction: b. Intended use and occupancy .... ~ ~"~' ....... ' · ........ ii f. 'i :', ~.'.i):J-'~ i:- ,'. ...... 3. Nature of work (check which aDplicable): New Building .......... Addition .......... Alteratigm .......... Repair .............. Remioval ..... ,~... ...... Demolition ....... .~.~ .... Other Work· .[..'-~%.~__~... · - '-2- '-'(:)~Z) - . ~.._~ ~ (Description) 4. estimated Cost ....... -%-) ~2~ ~ ~. g{ (to be paid on filing this application) 5. If dwelling, number ofdwellin units ............... Number of dwelling units on each floor ............ · If garage, number of cars .... i ............ ' .... 6 Ifb d ...... ................................................. · usiness, commercial or mixe occupancy, specify nature and extent of each type of use .................... Di i i R 7. mensions of ex sting structur s, if any: Front ............... ear .............. Depth .............. Height ............... Number of Stories ............ ........................... Dim ions ofs stmct re with alt atio r addition F ' ' ens ame u er ns o s: ront ............. Rear ................ pth i ight De ...................... He ...................... Number of Stories ....... 8. Dimensions of entire new construction Front ........... Rear ............... Depth ........ H 'ght n~ b e~ ............... Nu er of Stories ..... -. 9. Size of lot: Front ........... i ........... Rear ...................... Depth ......... I0. Date of Purchase ...... i . Name of Former Owner ............... ..... ! ........ it' i ' ' ' ' 1 I. Zone or use district in which pr raises are s u ........... 12. Does proposed constructzon vzolgte any zomng law, ordinance or regulation: ................. 13. Will lot be regraded ......... l ................... Will excess fill be removed from premises: Yes No 14. Name of Owner of premises ...I ........... Address .......... Phone No. ... Name of Architect .......... i ................. Address ................... Phone No ................ Name of Contractor ......... l ................. Address ................... Phone No ....... ~00 , · ........ 15. TS this property within feet of a tidal wetland? *Yes ........ No ......... · If yes, Southold ~own Trustees Permit may be required. PLOT DIAGRAM '. Locate clearly and distinctly all ibuildings, 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 comer lot. 2. ~OUGH - FRAMING & PLUMBIN(~ 4, F~N;hL CONSTRUCTION MtJttT ALL CONSTR{JCT{O~ SHALL MEET TME ~EOUIHEMENTS OF THE N,Y, $I;~TE CONSTRUCTION& ENERGY CODES. riOT' RESPONSIBLE FOR ;TATE OF NE,g~YO R~; t\~- e b DESIGN OR CONSTRUCTION ERRORS .................. ' .... ~ ................. being duly sworn, deposes and says that he is the applicant (Name of individual signin~ contract) hove named. le is the ............. a ........ ~ ................................................................. I (Contractor, agent, corporate officer, etc.) f said owner or owners, and is duly duthorized to perform or have,performed the said work and to make and file this pplication; that all statements contained in this application are true to the best of his knowledge and belief; and that the 'ork will be performed in the manner set forth in the application filed therewith· worn to before me [&is ......... ........... .... , 'ota ry P u bl~ .~, ./~_)~ .~-q.[ ....... (Signature of applicant) t~rm Ex,res May 31,19 ~