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1 TOWN Of SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N X 8 4 6 2 Z Date ~'.~-?:~t~.~......~2 19.E 4
Permission is hereby grout (J
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ct premises located at 3..k.A.~.~'?'.~.4t..~^r:.....~............J.....R,S.A':!br.~.
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County Tox Map No. 1000 Sectio Block Lot No...L.S~••...•••.•••,~
pursuant to application doted ....r~. ...~...'~^.3, 19~.~..., and opproved by the
building Inspector.
Fee S.•~~.:..
V ~T~' +w-1 Buildlnp Inspector
Rev. 6/30/80
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' - BOARD OF HEALTH
3 SETS OF PLANS
FORM N0.1 SURVEY
TOWN OF SOUTHOLD CHECK •%~cxl~ta. .
BUILDING DEPARTMENT SEPTIC FORM
TOWN HALL NOTIFY
EOUTHOLD, N.Y. 11971
TEL.: 765-1802 CALL
qq~ MAIL T0:
Examined , , , , . , ?3 19,1
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Approved . 19~. Permit No. ~ ~ ~b ~ S ~ s? f
3 i ~,ur.: 2 319E ; ~.f i 1
Disapproved a/c F'
w ~ ~ Ord r~
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date 19 .
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with
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 street
or azeas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli
cation.
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 permi
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 any purpose whatever until a Certificate of Occupanc-
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 th~
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances o
Regulations, for the construction of buildings, additions or alterations, or for re oval or demolitio , a herein describe?
The applicant agrees to comply with all applicable laws, ordinances, building e, housing code, nd egulatibns, and t~
admit authorized inspectors on premises and in building for necessary inspecti
(Sioof applicant, or n e, 'f a corporation)
(Mailing address of a licant) / (7'2~
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Name of owner of premises .~~.°~OT"-S r~3'r-~ ~ ~a N bs
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
~~o (t r~ e`I--off
(Name and title of corporate officer)
ALL CONTRACTOR`S MUST BE SUFFOLK COUNTY LICENSED
Builder's License No. ..p. .
Plumber's License No . .
Electrician's License No . .
Other Trade's License No . .
1. Location of land on which proposed work will be done.
.............:3 ~f.:~.~.......~1~.~z~ - .
House Number Street Hamlet
County Tax Map No. 1000 Section Block , , , , , , , , Lot . . - .
Subdivision Filed Map No. Lot - .
(Name)
2. State existing use and occupancy of plre~mises and intended use and occupancy of proposed construction:
a. Existing use and occupancy U.I.Ay.G'~~RD . . . .
b. Intended use and occupancy F~.?M.. ~ ~ a SELL ~,q~t S -
Ff4KA^ .STAB"' O ~ w
3. Nature of work (check which applicable): New Building Addition Alteration .
Repair Removal Demolition Other 1York
(Description)
4. Estimated Cost ~ oo-9a Fee
` (to be paid on Oiling this application)
5. If dwelling, number of dwelling units Number of dwelling units on each floor .
If garage, number of cars
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use .
7. Dimensions of existing structures, if any: Front ...............Rear Depth .
Height ...............NumberofStories.......................................................
Dimensions'of same structure with alterations or additions: Front Rear .
Depth Height Number of Stories .
8. Dimensions of entire new construction: Front Rear ...............Depth .
Height ...............Number of Stories........................................................
9. Size of lot: Front Rear Depth .
10. Date of Purcltase .............................Name of Former Owner
1 1. Zone or use district in which premises are situated .
12. Does proposed construction violate any zoning law, ordinance or regulation : .
13. Will lot be regraded ......................:.....Wilt excess fill be removed from premises: Yes N~
14. Name of Owner of premises f`I ERbD.oJPS..A~!'!~A!`t°SAddress 6 ...Phone No.7.3 U. ; 6 ~ co, .
Name of Architect ...........................Address ...................Phone No........ .
Name of Contractor ..........................Address ....:..............Phone No.............. .
15. Is this property located within 300 feet of a tidal wetland? *Yes No
*If yes, Southold Town Trustees Perc:itPLO~DIAGFIAMed
Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions fror~
property lines. Give street and block number or description according to deed, and show street names and indicate whethe
interior or corner lot.
~4
STATE OF N 'yYO S.S'
C ~NTY OF .r~Y~~r~
.~.L'~-f?~ • • • ~ !9 being duly sworn, deposes and says that he is the applican
(Name of individual signing contract)
above na~~m~'ed~~~~
}ieisthe...ls~~ Q.~.?~
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to make and fife thi
application; that all statements contained in this application are true to the best of his knowledge and belief; and that th
work will be performed in the manner set forth in the application filed therewith.
Sworn to before ~t rs day of 4:.~C~........, 19
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\o[ary Pubif~ County ~ n
lllCltlE @Hkf7
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fy at+lic, State of AJew Voile (Signature of applicant
f:o. 4669631
Qualified in Suffolk County y,,,
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