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TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD, hi. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
No- 20157 Z
Permission is hereby granted to:
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Building I~tor.
Rev. 6/30/80
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL /
SOUTHOLD, N.Y. 11971 NO'
Examined 5~/~/~ "% ., 19 ..~./ TEL.: 765-1802
Disapproved a/c .....................................
APPLICATION FOR BUILDING PERMIT
BOARD OF HEALTH ............
3 SETS OF PLANS ............
SURVEY .....................
CHECK
SEPTIC FORH .
Date ................... 1.9...
INSTRUCTIONS
a. This application must be completely filled in by Wpewriter orin 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
7 or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this applJ-
· 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 Building Permit to the applicant. 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 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 dem0)i.tion, as herein described.
The applicant agrees to comply with all applicalJie laws. ordinances, building code, housing code, and regulations, and to
admit author/zed inspectors on premises and in building for necessary inspections.
'(S:gnat[ire of applicant, or name', if a corporauon)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
... 6-e.n er J C
Name of owner of premises ,~..~. O .~$e../~.....C~. O~ Fl .0._.~. .................
, (asbn the tax roll or latest deed)
If applicant is'a edrporation, signature ofduiy authorized officer.
(Name and title of corporate officer)
Builder's License No. U.~.
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
1. Location of land on which proposed work will be done ................ : ...... .
.....................
}louse Number S~eet, ' ............. ~' ...... t ....
Hamlet
County Tax Map No. 1000 Section ........ Block .................. Lot ..... ~. ..........
Subdivision ..................................... Eiled Map No.
(Nnme) .............. Lot ...............
'~ State ' '
-- exist ng t se and occupancy of premises and intended use and occupancy, of proposed construction:
a. Existin- Use a
·
b. Intended Use and occupancy .. ,~'~. 6~.o... ~ ,. ~ . F~,'~'~e~~- ,.;:j .'J"
. .
3. Nature of work (check %vhich ?pplicable): New Building ..... ' ..... Add' 'on .
Repmr .............. Re~noval .............. Demolition ..... t ......... Alterati9~ ....
Other Work .,~ ....
D sc ption)
4. Est/mated Cost :i .................... '. Fee
Ifd lli6g (to be paid on filing this application)
$. welling, number of dwe un ts ., .
Ifg i i ." ii"]"'i l'lumberofdwelhn units on each
arage, numberofcars ' i. . . g floor ..............
[{b .y o/m. r?' ' ............ t,; .... ..................
6. usm ss, c n e mlorm ed occupancy, specifyna r x .,.~,.uau. t .. .
7. u~mensmns or ex~stmg structures if any Front '[ ,~ ype o~ use ...........
~H.e'gl Nq i pth ......
i It ...... ~ ........ l~ear ............... De ..............
.' .............. mberofStor/es ... ir . .......
witl ........................
U~mensmns of same structure t alterations or additi .........
Depth ohs: Front .............. Rear ...
· ' "-"" ............ *... Height ...... · ...........
· · re new cons~ ' . .............. Number of Stories .........
8. DimensiOns of enti truction: Front ......... Rear ............ De ...
...... · · · pth
Height .............. Nu,?nber
9. Size of lot: Front . ' of Stories ............
10. Date of Purchase . ' .......... ~.' .~( ...... Rear ...................... ~epth ..~ ............
,To. 1~ ....
11. ' ................ Name of Former Owner [f/.~. F. SC..~. O.~.gl..~,_
Zone or Use district in which Plremises are situated ....................................................
12. Does proposed construction violate any zoning law, ordina ' ' '
Will lo~ be re~raded /a ~ ~ ncc or regulation: ..................
13. ~ ' · .. ...... ,.~..v ........ Will exc ss fill be re oved from premises: Y~s '
NameofOwnerofprem~ses,/~.~..U. CiO.~ ~.,~.~.Q.~..~ .~. ,~...~.~.
14. ~'¢ ~"v3' "~I'~'LAd dress
Name ' ~, ... Phone No. .~. ~. ~.5~.
of Architect ........ I .... Address
Name of Contractor. i!~ ................................ Phone No ...............
...... ~ ................. Address ................... Phone No ............ i..
15.Is this property loc ted within~00 feet of a tidal wetland? *YES .... NO ....
· If yes, $outhold Tow]n Trustees Permit may be required.
· " i PLOT DIAGIL~M
Locate ctearl~ and distinctly afl buildings, whether existing or proposed, and. indicate all set-back dimensions from
property lines. Give Street and bloc: number or description according to deed, and show street names and indicate whether
interior or coruer lot.
A~I~ROV~§ AS 80TED . ~'
f EE:~ BY: ~
765-~80~ 9 A~1 TO 4 P~OR THE
FOLLOWING INSPECTIONS:
~, FOUNDATION ~0 REQUIRED
FOR POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING
3. INSULATION
~. FINAL CONSTRUCTION MUST
BE COMPL~E FOR C.O.
ALL CONSTRUCTION SHALL ME~
THE REQUIREMEN~ OF THE N.Y.
STATE CONST~ON & ENERGY
CODES. N~ RES~NSIB~ FOR
DESIGN OR CONSTRU~ION ERRORS
TATE OF NEW YORK,
COUNTY OF..~-- ...-v
Name~(i~ ' ' ~l~Z~:~'~'" ' : ......... being UUly Sworn, aeposes ~d says that he is the applicant
~ .... (mdivid~...~.9~g contract)
aoovc ~am¢o. ~
i (Contractor agent co~orat~ officer ' ) ..............
' ~ , etc.
of said owner or owners, ~d is dulg authorized to p~rform or have performed the said work and to m~e and file this
application; that all statements contained in this application are true to the best of his knowledge and belief; and that the
Work xvfll be perfo~ed in the m~ne~ set forth in the application filed therewith.
Sworn to before me this ~
.....
....
Nota ' ~[~ '
' ~Public' '4~~~.. County
........ [T '~ / ...... ~' ~/'~': ...............