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Home My WebLink About19794-z ~u~ NO. ~ 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) No- 19794 Z County Tox Mop No, 1000 Section ...,~,,~,.cj. .......... Block .......~.....~. ........ Lot No......~....:..J ........... the Building Inspector. Fee $ ........... : ............ Building Inspector Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 ×amined 19 {pproved ...~- ' ' '~...~...17.., 19~l.. Permit No./. .9. 2 .?q..~. Disapproved a/c .... . ......................... i i .~.. i i../,~ .(~..'~ ................................ (Building Inspector) APPLICATION FOR BUILDING PERMIT BOAgD OF HFAL'r}t ......... 3 SETS OF PLANS .......... SURVEY ................... CIIECK . . CALL ................... FLAIL TO: Date ................... 19... INSTRUCTIONS a. Tiffs application must be completely filled in by Wpewriter or in ink and submitted to the Building Inspector, with 3 ~'ts 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 layout of property must be drawn on the diagram which is part of this appli- ~tion. c. The work covered by tiffs application may not be c'bmmenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit zail 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 roll 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. he applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to tmit authorized inspectors on premises and in building for necessary inspec~,~ns} /,)ff . .~__t~.~.. (Signature of applicant, or name, if a corporation) ............ (Mailing address of applicant) rate whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. .................. .... .................... --. ....................... 'amc of owner of pre nses .... .~,. '.,~..~".~..C~?....~....~)..~....~..,~... ~,'.(~/~../.~..~ ........ (as on the t.aI roll or latest deed) · applican~t isa, corporation, sigca.~re of duly authorized officer. ,' ....... (Name and title of c;~;r~i~ ;fficer')/'' ' Builder's License No .......................... Plumber's LicenseNo ......................... Electrician's License No ....................... Other Trade's License No ...................... Location of land on which proposed work will be done .................................................. .3,5,5 House Number Street County Tax Map No. 1000 Section .../~.f .......... Block ..... ~ ........... Lot...~.,/ ........... 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 .... ~./~;..F'.O~. '~'" ~' "'6f~'2/" - , , ~ ¥~i~'"* .......... b Intended use and occupancy .............. Y'~ ~s7 ,;' 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration' Repair .............. Rem~ .............. Demolition .............. Other Work ............... 4. Estimated Cost ~/, ~'~7) (Description) (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 busine'ss ...................................................................... · , commercial or mixed: occupancy specify nature and extent of each type of use 7 Dimensions of existing structurei if any FrOnt · ' Rear Db~'th Height Number of S~ories ............................................ unensmns of same structure with alterations or addit ons' Front De . · ............... Rear .... . pth ............... He ght . . x, ...... ' ..... 8. Dimensions of entire new constr~ ................ lntlnloer oi 3[orles ...................... ction: Front .............. Rear ............... Depth .............. Height .... .. ~. ~ Nu.. ~. .... .... ¥~' ~; '.~t~! ...... ~er m ~rones .......... ' 9. ~lze oi1o[. '~'ront ' ' .............................................. ........... I .......... Rear ...................... Depth ...................... I0. Date of Purchase ........... , ..... Name of Former Owner 11. Zone or use district in which prer~mes are situated ............ ' ...................... 12, D°es pr°p°sed construction violate any zoning law, ordinance or regulation: ............... 13. Will lot be regraded .......... i .................. Will excess fill be removed from premises: Yes No 14. Name of Owner of premises Name of Architect ,. 'i ................ Address ................... Phone No ................ ....................... Address ................... Phone No .......... Name of Contractor ' Address .............. Phone No .............. 15. Is this property within 3Q0 feet of a tidal wetland? *Yes ........ No ......... · If yes, Southold Tqwn Trustees Permit may be required. 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 nt mber or descriptioh according to deed, and show street names and indicate whether interior or coruer lot. f (Signature of applicant) !TATE OF NEW YO ,OUNTy oF ......¢..,,.. s.s ......... /' [ /. ............... ~ '~' ........... being duly sworn, deposes and says that he is the applicant (Name of ~ndividual signing Contract) hove named. (C ) .... ontractor, agent, corporate officer, etc. ' ' said owner or owners, and is duly auitborized to perform or have performed the said work and to make and file this ~plication; that all statements containe~ 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, ,yom to before me this