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Home My WebLink About19795-z FOBM NO. ~1 TOWH OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. Y. BUILDING FERMIT (THIS PERAalT MUST BE KEPT ON THE PRENIISES UNTIL FULL CONIPLETION OF THE WORK AUTHORIZED) Permission is hereby granted to: / 0 J~ ,f , I , I , /~ ./1 ,o ...~~..~....£~.....~.~........~......~. f~i~ii~[;~,j,~.~[...;..;.~.ily~.i~......[..~/~[[[[i[y..~-[ ........ pursuant to application dated ..... L~......~...~ .................. , 19.~../.., and approved by the Building Inspector. Inspector Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examine P"~-- , 197/. '~pproved .('~...~...'~..~.., 19~[ Permit No.]..~ 7.C/~Y..~ (Buildiug Inspector) APPLICATION FOR BUILDING PERMIT BOARD OF HEALTII ......... 3 SETS OF PLAtIS .......... SURVEY ................... CIIECK ..... t,O', ~ FY ~ CALL ................... NAIL TO: Date ................... , 19... INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 3ts 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 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 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 mil 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 ~all 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 al/ applicable laws, ordinances, building code, housing code, and regulations, and to :lmit auth°r/zed inspect°rs °n premises and in building for necessary inspectio~.z} ~/~' ~--~ (Signature of applicant, or name, if a corporation) (Mailing address of applicant) tare whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. amc of °wner of premises 07...~. ~ .~.6..~. ~ .':..A./.~..~...~...K~..~. ~Z'./.~... /~/.~. ~.~!~. rS..t/?..C.:( .L ..... (as on the t .a~t' roll or latest deed) applicant l'a a co=voration, simo, ature of duly authorized officer. " ..... ...... (Name and title of corporate officer) Builder's License No .......................... PI tuber s L~cense No ......................... Electrician's License No ....................... Other Trade's License No ...................... Locationoflandonwhichpropose_dworkwillbedone..~.c~0...~zA~.....~...4,..~.~.~.0 }~P .~.b¢. ........... ...... .w .... ................ Y ' ' Hamlet House Nmnber Street ................... : .......... County Tax Map No. 1000 Section .... /0~... .......... Block ....~.. Subdivision ..................................... Filed Map No. (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 .. ~ ~.'~.i,.'~ ,.,.? .: ,o..,,J ............... 3. Nature of work (check which applicable). New Building ....... AdditionAlter ion Repot .............. Remo:va .............. Demolition ............. Other · ~ (Description) 4. Estimated Cost ...... ]. ~.~ ...... Fee . . 5 If dwelling number of dwelling ~nits (to be paid on filing this application) · If garage ri'umber of cars ............... Number of dwelling units on each floor ............. 6 ' If busine'ss ....................................................................... · , commercial or mixed occupancy specify nature and extent of each type of use 7 Dimensions of existing structurei if any: Fr;nt Rear ..................... Height Num 'Der of Stories ............................. Depth ............... Dimensions of same structure wiih alterations or additions: Front ................. Rear .................. Depth ..................... I. Height ............. · ......... Number of Stories .................. 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Hight ' ' N ~ f St e ·..,~.,~.~, · ] · ~!.. um .er o ories ...................... ~[~t '~ "'i .......... Rear ................ De 9. Size of lot: ..... ~ .................................. 10. Date of Purchase ......... , ...... pth ..................... 1 1 ' ' · ............... Name of Former Owner ............... · Zone or use d~stnct ~n winch premises are situated ................. ' ............. 12· D°es pr°p°sed construction viola e any zoning law, ordinance or regulafion: 13. Will lot be regraded ........ i ................................ · ' .................... Will excess fill be removed from premises: Yes No 14. Nme of Owner of premises .... i ................ Address ................... Phone No ................ Name of Architect ........... ................ Address ... Name of Contractor .... i. · ............... Phone No ........... , .... ..................... Address ................... Phone No ................ 15. Ia this property within 300 feet of a tidal wetland? *Yes ........ No ......... · If yes, Southold Tdwn Trustees Permit may be required I 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 ndmber or descriptioh according to deed, and show street names and indicate whether interior or coruer lot. TAT Or ....... [ ........ ~' ~¢ ................ being duly sworn, deposes and says that he is the applicant (Name of individual signing qontract) )ore named. ~ I is the ................. .... i (Contractor agefit corporate officer', etc ) ......................... said owner or owners, ~d is duly a~tborized to perfom or have perfomed the said work and to m~e 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 will be perfomed in the manner set] forth in the a~plication filed therewith. yom to before me this ~ [ ........... ...... ,... ,4 ~ '0' ~ ..... ~ ..... 19 . . . f ........................................... ~erm a~'M~ 31~ i~-~~ ~ ', _" CUTCMQG'-~ ~ - N~W-'Y,.SUFFOL,M ~ISTOI21CAL COUNCIL ,INC. LOT I / / d