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TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
CQMPLETION OF THE WORK AUTHORIZED)
u 19897
N_ Z Date ............)!).'~.~....~.8 19a.1.
Permission is hereby granted to:
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a premises located at p.....~!!^.a...... .............1~4!::S:~r.C~e.?~Il`.'.->........
County Tox Map No. 1000 Section Block ......~e~......... Lot No..~4.:.~~.......
pursuant to application dated 2'2 19.1..., and approved by the
Building Insp~e7ctor.
Fee 3..L.'~r..~..1..!.5~.~
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wilding Inspector
Rev. 6130180
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r~ ~m~_~~~\,'~?~,~;:.~,j BOAFD OF HEALTH
FORM NO. 1 3 SETS OF PUNS
SURVEY
Z TOWN OFSOUTHOLD
MAY 2 ~~y~ ~ BUILDING DEPARTMENT CIIECI: . • ~ . ~ • ~ ~ , ~ ,
TOWN HALL sErric Poart
~#LLG.~Ohs-''P. , SOUTHOLD, N.Y. 11971
TOWN 0~ ~
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Examined . a-~..., 19~.~. q q^~ AIL T0: • • .
Approved ~ 19q I .Permit No.l . l 1 • • _ - - .
Disapproved a/c .....~~Vll .
...................................1.~...o+.... ~ "
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date 19 .
INSTRUCTIONS
a. This application must b'e completely filled in by typewriter or in 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
~r, areas, and giving a detailed description of tayout 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 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
3uilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
(Zegulations, for the construction of buildings, additions or alterations, or for remov demolition, as herein described.
Che applicant agrees to comply with all applicable laws, ordinances, building co , hou ' g od nd lations, and to
admit authorized inspectors on premises and in building for necessary inspections
(Signature f applicant, or name, if a corporation)
aok .50 la~.~Tr~r~c;~..s~y lf9.s2-os~o
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises i9NTO~~JETTE . ,CD ~e'~sC/O
(as on the tax roll or latest deed)
[f applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No. ~ W/GG /,v/rOr~ae ?itritD~a4 t~'~T. ~ef/e~? ~c~7T/i!~
Plumber's License No . .
Electrician's License No . .
Other Trade's License No . .
I. Location of land on which proposed work will be done.
D71~
~r~t3E.~d ~~~T.~/.®~:~ .
House Number Street Hamlet
County Tax Map No. 1000 Section Block Lot Zo°.~~
Subdivision ~/~i~jJ/,SGT b
y Filed Map No. ~T.~,3 Lot .
(Name)
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy X~~f~..
r „r,., . '
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b Intended use and occupancy ~'/i?dL~ ~,.y~i>7?~~ ~,lv~vp t ,
ass ~ i
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c:zr..~.lQnn. S. -a Y. I.1. afi. Y.L i 4,k1 ~r~;h.~a*'N..EY{,x3k+:{~51..FdvbY..daE~}~ Vm ri s~ "Y #.aW tyl.f a'~..dfa'e4E$~ a
3. Nature of work (check which ap II licable): New Building Addition Alteration
Repair Remo al Demolition ..............Other Wor~Cd:.~:. • • .
r~-¢~o ~O ~ / Description)
4. Estimated Cost i Fee . ~.5~, ~5, .
(to be paid on filing this ap~cation)
g .nits , Number of dwellin units on each floor .....lA .
If garage, number of cazs , , ,T/f.Qa,''E, ~,2 g
6. If baseness ommercoialdor mixed';occupancy, specify nature and extent of each type of use ...../.v~1~ .
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7, Dimgensions of ex~stm stru Nu'rnesby if any: Front , , , , . ,Rear Depth .
Hei ht , , , , er of Stories , , .
De th , h alterations or additions: Front Rear .
upensions o same structure wit Height ,~O , , , , , , , , , . Numbe Stories .
8. Dimensions of entire new construction: Front 7, , , ,~r~Re
Rear Gar ~ Depth .
Height Number of Stories .
~
9. Size of lot: Front .......7~ ; '
N
~ De th ZZ .
! 0. Date of Purchase , ..............Name of Former Owner ...!~9~/.`~!~'!~?,r+...G,~+!T • , ,
] 1. Zone or use district in which premises are situated . , , , , , , ; .¢Q,
12. Does proposed construction viola a any zoning law, ordinance or regulation: !U`? . • , •
13. Will lot be regraded ......,~(G~~ ,Will excess fill be rer~poved from.~,Premises: Yes
14. Name of Owner of pre ses f,N~/~r~.~4 /-~~~!Q, Address ~4 7N~~.'X~!/~/P?phone No.. ~.~4'. ~>~~9~
Name of Architect ..~Od4~~;~.1!~lfE~9!~,J''E., • Address 4'~~KS~~ /?~?T!~~Kphone No.. ~8
u~;l9Q, , ,
Name of Contractor . u .Address . ,Phone No..
15. Is this property within 3Q0 feet of a tidal wetland? *yes,• No ~
*If yes, Southold Town Trustees Permit may be re',quired.
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. ' •
STATE OF NEW YORK, S.5
~OUNTY OF
' ' • ~ • • • • ~ ~ • • • • • • • • • • • • being duly sworn, deposes and says that he is the applicant
(N~ e of individual signinglcontract)
above named.
ie is the ........C~~~•`'~ •
1~..~!~~G~j
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(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.
sworn to before me this I
.(day o/f !'y~ G4~..........., 19 Q/. .
JotaryPublic,®~%~u!cc~.b-Y.•.~~T4Swit2 , ~ry~~/',N/ lty
/ ~/:e-KCew '
HE4EHE 4. HORNE ~
Nma?VPuN t
~Stsa~te3afHawYbdt f
CuelMled In $u}IW~ , , > (Signature of applicant)
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