HomeMy WebLinkAbout20197-z IPOZZM_ lqO, 0
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD, N. ¥,
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
20197 Z
· ./o
Date ........ /.~.. ...................................... 19...~/
Permission is hereby granted to: _
. ..~~~.,.~.~. ........... ././.~.~
,o .~~ ..... .~i....~..~iii~. .... ~~. ..... ~~~~.~ ................
at premises ,~at~ at..~.~ ~ ..... ~~. ~/
......................... ~~~ .....................
cou,~ T~x ~,p No. ~0o0 Section ..~ ............... m~k ...~..~ ............ Lot No. /' / ~
Building Inspector.
Fee $... ~..~
Rev. 6/30/80
· MOORE'S
NIO/F JOHN A. COSTELLO
CEDARFIELDS DRIVE
LANE
~44.~~
Exami!lq
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1803
Disapproved a/c .....................................
. (Buil, dingz~ector)
APPLICATION FOR BUILDING PERMIT
BOARD OF HEALTH .........
3 SETS OF PLANS ..........
SURVEY ...................
CllECK ....................
SEPTIC FORH ..............
MAIL TO:
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3
iets 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
Dr areas, and giving a detailed description of layout of property must be drawn on tile diagram which is part of this appli-
ration.
c. The work covered by this applica{{on may not be c})mmenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit
;hail 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
,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
~uilding 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.
file applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and
:dmit authorized inspectors on premises and in building for necessa~sq-nspeq,tions.
-- (Signature of applicant, or name, if a c~rporation)
.....
u.V,
'l l~(~ing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
O.. c) e C: ·
Name of owner of premises. [..~...(~..f~ i.~..[ . . .~.....~...~l.~..~'.~....0.(?...V~...t~..i} 0. 5f ....... i .............
(as on the t.a~x roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No .... .¢....~/..~/.~...~. ...........
Plumber's License No .........................
Electrician's License No .......................
Other'Trade's License No ......................
Location of land on which proposed work will be done_ ................................... , '
. . t .o. ................ : ...... ¢ ,: .......
llouse NumberStreet ............
90
County Tax Map No. I000 Section .................. Block ............. ". .... Lot .............
Subdivision ..................................... Filed Map No ................ Lot ...... ·. ........
(Name) '
· State existing use and occupancy of~emises and/intended use and occupancy of proposed construction:
a. Existing use and occupancy .... .~ .~.~..(...~. ?.Ft. ?..~. ............................
b. Intended use and occupancy ................................... .., ,.
3. Nature of work (check which apiphcable): New Building .......... Addition .......... Alterat~ ..........
Repair .............. Removal .............. Demolition ......... Other Work..~.'.~ .C,.I~..
(Description)
I (to be paid on filing this application)
5. If dwelling, number ' ~ ·
of dwelhng umts ............... Number of dwelling units on each floor ................
If garage, number of cars .
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 .............. Number of Stories ......................
f i~h It dditi ..................................
Dimensions o same structure w a era[ions or a ons: Front
Depth .... ~ ............... ' ............... ~ Rear ..................
................ ·. Height ... . ·.. Number of Stories ......................
8. Dimensions of entire new constrUction: Front ............... Rear ............... Depth ............
Height ............... Number of Stories
9. Size of lot: Front ........... ~ .......... Rear ...................... .D_.~pth . .-n-, ..... t .........
10. Date of Purchase . .~[.~.~fl~ i~../ ]c~ ''
Zone or use district in which pre' ises are situated .........................
12. Does proposed construction violam ...........................
te any zoning law, ordinance or regulation: ... ~1~ .......................
13. Will lot be regraded ......... i .................. Will excess fill be removed from premises: Yes
14. Name of Owner of premises ... i ................ Address ................... Phone No ................
Name of Architect .......... , ................ Address ................... Phone No ................
Name of Contractor ......... ; ................ Address ................... Phone~blo ................
15. Is this property within 300 feet of a tidal wetland? *Yes ........ No.t'~ ......
· If yes, SouthOld Town Trustees Permit m~y be required.
PLOT DIAGRA~
Locate clearly and distinctly all
property lines. Give street and block
interior or coruer lot.
bu!ldings, whether existing or proposed, and. indicate ali set-back dimensions from
umber or descriptioh according to deed, and show street names and indicate whether
'TfilB,'~80,~ 9 AM TO ~'~ PM FOR THE
FOLLOWING INSPECTIONS:
"t. FOUNDATION fWO REQUIRED
FOR POIJRfSD C[)NCRI~TI~
2. g~OtJGH .. FRAMING & PLUMBING
3. INSULATION
4 FINAL CONSTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET
THE r~IEQUIREMENTS OF THE N.Y'.
STATE CONSTRUCTION & ENERGY
CODES. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
;TATE OF NEW YORK,
:OU~FY OF S.S
(Name of individual signing contract) being duly sworn, deposes and says that he is the applicant
bore named, i
is tile,'
(Contractor, agent, corporate officer, etc.)
said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this
;~plication;. that all statements~ . contained in this application are true to the best of his knowledge and belief; and that the
'ork w,l be performe~l ]n {.he manner set, forth in the application filed therewith.
woru to before me [his !
........... .--,... day of.. ~ m
, .....
Otary Public, .. < i. Co . ,
Jo¥cE M. 1.
· , Sutlalk qa~unt~ (Signature of applicant)
Term Expirel June I,~ 1~