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Home My WebLink About19160-z FOF, M NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWI~ SOUTHOLD, N. Y. BUILDING PERMIT CTHIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) NO_ 19160 Z Permission is hereby granted to: ........ .~ ...... ~....~_~ ...... · ~, ,o..~~_...~ ........ ~.~ ...... ~ ...... ~~....~ ................. at premises I~ated at .....~......~~ ...... ~~...~ .......................... .................................................. ........................................................................ co~ **~ ~o~ uo. ~0oo s~,o~ ........ ~ZZ.. ~,~ ...... ~. .......... [o, uo....~ .............. pursuant to application dated ~P.~..~.... Building Inspector. Fee $..~..~ 19..~..~.., and approved by the Rev. 6/30/80 BLDG. DEPT. TOWN OF ~OUTHOLD~., FORM IqO. I TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL ~OUTHOLD. N.Y. '1 lg71 / '' Disapproved a/c ........ i ' ' ' ..... APPLICATION FOR BUILDING PEFII~/IIT BOARD OF HEALTH 3 SETS OF PLA?~S SURVEY CIIECK NOTIFY ~ .................. Date ' .... . ..... , I.~... , INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building fixSPector, 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 or areas, and -' ' ,, cation, o~vm= a detnqed description of layout of property must be drawn on the diagram whichislaa~ of this appLi- ¢. The work covered by tiffs 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 shall 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 a.ny purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY IvlADE to the Building Department for the issuance of a Building Permit lanr~uant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws. Ordinances or Regulations, for the construction of buildings, additions or alterations, or for ::emoval or demolition, as he~in described. The applicant agrees to Comply with all applicabJe laws. ordinances, building code, homine code, and zrgntauons, and to admit auth°rized inspectom on premises and in building for neces:a.r~. ~,~ (Mailing address of applic~t) ....... State whe'ther applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner ofpremiseli/~ .~.. (as on thc tax roll or latest deed) ' ' ' If applicant i* a corporation, signature of duly authorized officer. Builder's License No..,~. ~ ........ Plumber's License No ........................ Electrician's License No ..................... O/her ~radc's Liccnsc No ...................... L°catioo o£land on which proposcd 3,Kordg will be done; .. . ~ /. .. ...'. '/??." Number Street, ................. C°unty ax,"ap o:,OOOS c,,on .4: .... :B, ' 4. · ' ' ~ 0c~:'"7' ' · ......... Lot ....... Subdivision .......... · ..... : ¢ ... ........... ' Eilcd Map No. '-, (Name) .............. Lot ......... ' State existing use and occupancy o,5 premises and intended 7sc and occupancy of proposed construction: - a'Ex'st'nguscandoccupancy ...~~ ................................... . ......... b. Intended doccupancy .................................. ,, , ., .:~ ~ 3. Natoreo£work(ch¢ckwhichapplicabl¢): New Building .......... Addition ......... ~,kl,lc_rahon~=.~ ....... Repair. '6 ............ R~moval .............. Demo}}tip, ....... ' ...S~~t ~,; ....... Tennis pure ........ Accesser g .... ' ...... ' ' ~. ' , y ua. Jazng .......... Fence ....... OCher Nork.~.. 4 Estimated Cost "~'-~' ?. ~'-' ~ Fcc ' , (to be paid on filing this applicati~on) $. If dwelling, number of dwelling 4nits .......... .. ....Number of dwcUing units on each floor ......... If garage number of cars 6. If business, commercial or miscall occupancy, specify nature and extent of each type of use ...,: .......... 7 Dimcnsionsofexistingstructure~ if any: Front , Rear Depth Height ............... Number of,Stories ................. Dimensions o£same structure with alterations or additions: Front .. 2'] ''' ] ......... ......... l~'ca'r' ] ] ] ] ]]'; ] ] ]. Depth .................... }.Height . -- Number of Stones 8. Dimensions of entire new constniction: Front ............... Rear ............... Depth . Height Nuln 6er of `stories 9. `size of lot: Front ...... , · ..... · ,:: ., ..... ;:... Rea..' ;: i/a;',;,; gl-'F ;r &;v D p,h . 10. Date of Purchase ..... I ..................... 11. Zone or Use district in w~ich premises are situated .... ~ ......................................... ' ' ' 13. Will lot be regraded .;... ~... i .................. Will excess flu be removed from premises: Yes , o. I 1. Name of Owner of premises ' ' Address Phone No ' Namc'of Architect .......... ~ ................ Address ........... Phone No ..... Name of Contractor , . · ......................... Address ................... Phone No ..... ¢". .......... IS.Is this property located within }00 feet of a .tidal ~etland? *Ills .... NO ..... ~If yes, Southold To~n! Trustees Per'm~r may he required. PLOT DIAGRAM Locate clearly end distinctly ~ll !buildings, whether existing or proposed, told. indicate all set-ba=k dimensions from property lines. Give street and b!ock ~umber or description according to deed, and show street names and ~ndi=ate whether interior or corner lot. .... ." ......... ' ............... : ................... being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above nam'cd. He is the { . ' (Contractor, agent , corporate officer, etc. ) ' of said owner or owners, and is dulyI authorized to pqrform or }lave performed the said work and to ma~e and file this a~plication: that all statements contaii{cd in Ihis applic:~tion are true to tile best of his knowledge and belief; and that the ~.Vork will be peri'om:ed in tile manner isct forth in tile application filed therewith .... ~wom to before me this ' ' ] ' ' ...... da,, ..... ........ Zq '" .......................... County · I%1~.1~, ~ ~ ~ ~ (Signature o f applic~n t) _ ~. 4707878, Suffolk ,C~miy~, Tefra F. xl~ir