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Home My WebLink About20859-z F~e NO. TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, bi. Y, BUILDING PERMIT (THIS PERMIT MUST BI:: KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N?N? 2085~Z Permission is hereby granted to: ....................................... ...................................... co~ ,o~ ~o~ uo. ~0o0 s~,o~ ..... t.Z~ ........ ~k ..... ~ ........ [o~ uo ...... ~ ......... Building Inspector. ouilding inspector Rev. 6/30/80 - ' Pou~oA. I FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined ................. 19.. Disapproved a/c ..................................... BOARD OF HEALTH ......... 3 SETS OF PLANS .......... SURVEY ................... CHECK .................... SEPTIC FORM .............. ~L TO: (Building Inspector) APPLICATION FOR BUILDING PERMIT Date ............ 19 . INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 ets of plans, accurate plot plan to scale· Fee according to schedule. 1/. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets >r areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- 'ation. 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 hall 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 hall 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 luilding 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 code, housing code, and regulations, and to dmit author/zed inspectors on premises and in building for necessary inspec[~ons. -- (Signatt/re of applicant, or name, if a corporation) ~.q,/~..o.~..'~.~ .... ~<~-~.-.~d.c~./P.Y.. !!7.57. (Mailing address of applicant) ~tate whether applicant is owner, lessee, agent, arckitect, engineer, general contractor, electrician, plumber or builder. qame of owner of premises...(~m2.l~.'+.O. ~.~/~.Z,~-....)~'ft~)~.~,,, .................................. (as on the tax roll or latest deed) f applicant is a corporation, signature of duly auth~orized officer. (Name and tide of corporate officer) Builder's License No. ' Plumber's License No ..................... Electrician's License No .... '.~..~.......'& ~..~ · Location of land on which proposed work will be done ......................................... ....... ~.&......E~:...'.....u4..~ .s.~. '. ~'g~.z...~....,~ K~,. ...... .c:~ z-. ¢. ~.~,¢ ~,:~ .......... House Number Street Hamlet County Tax Map No. 1000 Section ....... i ]./~. ...... Block ....... ~ ......... Lot .... 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 ........... ~..~.. ~ ~, ~, b. Intended use and occupancy.. ............................... "' · ,*~w,:~ ';,: · '. ;".~,:.';~';.:.~ ~ ' ........ 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Wor k ~./tff.,~...~. 2~. ~'~'O0~ ' ' ~ ___ (Description) 4. Estimated Cost..... .......... ... ............... Fee...~..~.~.~- (to be paid on filing this application) 5. If dwelling, number of dwelling units ............... Number of dwelling units on each floor ................ · If garage, number of cars ..... i ................................................................... 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ..................... 7. Dimensions of existing structure~, if any: Front ..,. . ........ ' Rear .............. .Depth ............... Height ............... Numiber of Stories ........................................................ Dimensions of same structure wilth alterations or additions: Front ................. Rear .................. Depth .................... !.. Height .................. ' ....Number of Stories .............. ? ....... 8. Dimensions of entire new constr¢ction Front ..... Rear ... .,, _ . · ....... · ................. Depth ............ He~ol~t ............... Number ot' Stories'.;'-, .... . ...... :.. .... , -. 10. Date of Purchase ........... l ....: 2.... ......... Name of Former Owner ............................. 11. Zone or use district in which preraises are situated ..................................................... 12. Does proposed construction viol6te iny zoning law, ordinance or regulation' . tC]..O .. 13. Will lot be regraded ........ Will excess ~'11 b ' -'-'; ' ~ ' ..... ' ...... ' ...... ~' ' · · ::: :.' · w · -.. .... , ,u e ~em .o.~u ~rom premises: Yes ~o 14. Name of Owner of premises ~k/3flST~.?/'f.,~. ,tfa.~//~Address .~,~ ./P~,,. ~. ~.~ A/"./.. Phone No."~/.~r.~'lM/..~..~.~..~; Name of Architect . 9~,(~//.~.'4,f. ~. $2'g-~..A. zv&.~... Address ................... Phone No .............. :... Name of Contractor ~.,q~'. q~..~'t~f~' .~. ..... Address ~qc?~.~. ~.o'.21~ ~, .... Phone No..~.../. f.o. ?.... Is t~is property within 3100 feet of a tidal wetland? *Yes.~..?.z.¢ No.. ~ .... · If yes, Southold T:own Trustees Permit m~y 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 fiumber or description according to deed, and show street names and indicate whether interior or corner lot. 15. 'COUNTY OF,. ....... r.,. ,.. (Name of individual signing contract) above named. ..... being duly sworn, deposes and says that he is the applicant He is the of said owner or owners, and is duly huthon~'ffd-I~erform or have performed the said work hnd to make and file this application; that all statements conta nled. in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner s~t forth in the application filed therewith. Sworn to before me this_ No. 4879~ i . ' .......... fl¸