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HomeMy WebLinkAbout19614-z FO~-~' NO. ~ TOWM OF SOUTHOLD BUILDIHG DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Building Inspector. Fee Building Inspector -- Rev. 6/30/80 b 'FORM NO. 1 TOWel OF SOUTHOLD BUI L'D. ING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.; 765-1802 ^pprove~ ........ ,~?~. Pc=it So.../.,q.& (. ~ ~-' Disapproved ale ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS BOARD OF HEALTH ...... 3 SETS OF PLANS SURVEY .......... CHECK .......... SEPTIC FORH ............. NOTIFY CALL ................ MAIL TO: a. This application must be completely tiffed in by typewriter orin ink and submitted to the Building Ir[specter, 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 adjokning premises or pubLic streets or axeas, and giving a detailed description of layout of property must be drawn on the diagram which is part of tls appli- cation. ~ c. The work covered by this application may not be commenced before issuance of Bui2ding Permit. , d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit s~':fl.l be kept on the premises ava~able 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 appl/cable Laws, Ordinances or Regulations. for the construction of buildings, additions or alterations, or for removal, or demolition, as herein described. The applicant agrees to comply with all applicable laws. ordinances, building code. housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. ,,' .~:V~ ,~- _.~-..-, ................ ~.- . . y~, ........... : (Signature of applicant, or name, ff a ddrporation) ©~ .~¢, . ., , .~. ~. l.;~¥ ......... (?,failing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ......................... ~:~. ~.. ~:~r ~ ........................................ N2~ne of owner of premises ........ ~. ???~?2.~.q:'.~;~.~.r~. ~.~. (~../~ ~.~.r'~r.~7./.~+/.."<~-.~..~/.~.~.~. ........... '{as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. ..... .............. (Name and title ofcorporat~r'6fficer) · ALL CONTRACTOR'S MUST BE SUFFOLK COUNTY LICENSED Builder's License No ....... ~a~/.. <<z~. ........... · ,,. .. ~/~-.~ /- Plum~er .~ ,..;ccn~. N'o ......................... Electrician's License No .... ' -/: ........... / Other Trade's License No .... .; ................. Location of land on which proposed work will be donc~ ~'.<,~..o.~.w~ ~, "' -6: House Number Street Hamlet ,,.,.., ~.~ ~( County T~x M~p No. ]000 ~ection ..... ~. Block ......... Lot , ...... " ~ubdivtsion Filed Map No · Lot (Name) [l~le ~xisl~ng use and occupancy of premises and intended use ~ud occupancy of proposed construction: a. Exnung use and occupancy ......~'~ . '. ............................. .. .. b. Intended he k hich applicable): N 21. Nature of work (c c w ew Building . .. ' ..... Addition .......... Alteration .... R pair Roma?al D ~nolition Other ¥, ork ...... 4. Est/mated Cost ....... '~'~'4 ........................ Fee ...... ~.~ ........... ~ ~ (to be paid on filing this application) 5. I~dweIling. number of dwelling u~nits ............... Number oFdwclling units on cach floor ....... If garaee, number of c~ ..... ~. ~. ~menstons o~ existing stmctures~ i~ any. Front ~g ~ ~ '~'~'~ '" · y ~ .... ....., ..... near .,,.,. .., ,~.~ Hmght .... ~ ...... Num er or ....... ' ~ '~ "~ ~ ...... ......... .................. ~ ...... ~ ............ ~. Hcmht /& ' ~, ;''': L' ' ~ ....................... g ~; .... : .... ~ .. .,-~ ~ . ~ ....................... ~umoeroi~tones .......... ~. ~..~.~u.a die.ute n~Const~ctlon: Front . , ~ . ~ :~'~ ~; ....... , ~ei-h~ · ., ,, __ , · ............ near ............... Depth ...~. "~ .................. ~uul~erolbtones ........ ~" '''.*. 9. Size oflot: Front ............ I ...... ~.., Kear ~ · : ." · ..... I'. .............. :.~a~; wn;; Depth 1. none or use dastrlct in which premises are situated.. :: ..... Does proposed construction violale any zoning law. ordinance or re-ul ' · .. 3. W~I lot be regraded ..... ] . ... ~ anon ........................... -,-~- -~ ~ .... ~iL',!'.: 2 ' ~ ~2~' .......... W~ll ex~sy fill be removed from premise~: Yes ' 4. ~.m.¢ m ~wner oI.prem~ses~e~ff/~ .... Address ~.~ ~.. Phone No, ~ ....... Nme of Architect ..... I ... .......... ............... ' ~o~e 1~O .............. ~ u&u property ~ocaeea w~thxn 300 fee~ o~ a ~dai wee[and? ~Yes~.... No ..... .q~ ' ~f yes, Soucho[d To~ Trustees Pem~r may be reouSrod. .. ... i Locate elegy ~d distinctly ~I ~u~d~gs, whether existing or proposed, and, indicate ~ set-back d~ensions from rope~y Hnes. Give street ~d block number or deschption accord~g to deed, ~d show street nmos and indicate whether ~tchor or comer lot, 3L;N-I'Y OF ..... ~ ~'? ' .... ~" · ~ ....... being duly sworn, deposes and says that he is the applicant (Name of individual slgmng contract) : is the. . ............. .. I ntractor, agent, corporate officer, otc ) said owner or owners, and is duly ~uthohzcd to perform or have performed tim said work and to make and file this ,~lieation: that all statements contained in this application are true to the best of his knowledge and belief; and that the ,rk will be performed in the manner s/et forth in the application filed therewith.