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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 o 18 6 6 Z Date ..lo~/ 19.
Permission is hereby gr ted to:
ta .~~~.~~:......~~f...-~..~..~~.'...... y~.~'
at premises located at ~T...r..7..1~......~.. ..............~.e!~f(!.!fry
..............................................m"~".,...~~.r
.~..r..........................................................
County Tox Map No. 1000 Section ...r,/..~....... Block .......l...°~:Z....... Lot No........°-:~'~.........
pursuant to application doted ........../.A.~s`~ 19.~, and approved by the
Building Inspector.
Fee
~
Bui in I or
Rev. 6/30/80
' TOWN OF SOUTHOLD
BUILDING DEPARTMENT ~
TOWN CLERK'S OFFICE ~`1
SOUTHOLD, N. Y.
Examined ........~G..`.'.....°~..~.... 19. APPlication No...........3..~~
i ~ J'
Approved 19........ Permit No.....`.:3.......~~-.....
Disapproved a/c
(Building Inspector)
APPLICATION FOR BUILDING ERMIT S
~-+1
..J /
Date 19~Ag.... °
INSTRUCTIONS b
a. This application must be completely filled in by typewriter or. in ink and submitted in triplicate to the Building
Inspector, 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 Z
areas, and giving a detailed description of layout ofproperty must be drown on the diagram which is part of this application. ~
c. The work covered by this application may not be commenced before issuance of Building Permit. r
d. Upon approval of this application, the Building Inspector will issue 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 port 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 n
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 removal or demolition, as herein described.
The applicant agrees to comply with all applicable lows, ordinances, building code, housing code, and regulations, and to
admit authorized inspectors on premises and in buildings for necessary inspections.
..~...~„r:.,,...:...,~~L...~...,~
(Signature of applicant, or name, if a corporation)
.
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
................~.,`3..~r~;~a
v......~~..JJ..~~.........................................,................................................................................................
Name of owner of premises ...:.!CX...l.... ~...Q.~~/.~/
If applicant is a corporate, signature of duly authorized officer.
(Name and title of'c~o'r"p~oratLe officer) ~ \
Builder's License No. ......lt.`.~'..^..:7j ° \~~`J
Plumber's License No .
Electrician's License No.
T9-~~ ~
Other Trade's License No
1. Location of land on which proposed work ill be doe p No . ~ Lot o....~...............
' ~l ~ Q
Street and Number ....~f:f..~...Q......clr'..4-
^~..:.R7" ....,~/.:t1......... ~W ~i
nicipality
2. State existing use and occupancy of pr~~eec~mgyqises and intendeod use and occupancy of proposed construction:
a. Exisiting use and occupancy ........0(...1.Y.v~.e.~Lt4+eer.VF .
~NNNNNI ...........~y
t~'
b. Intended use and accupancy
3. Nature of work (check which
Removal I applicable): New Building• Addition Alteration ,
Repair Demolitioc...,................ Other Work .............~.~,:P'v!~'.LrK..............
(Descyip~ion)
4. Estimated Cost .....................';............~.Q.~,:~.~.........Fee ........................1,~..a.P..Q..,......,...,...................................
I (to be paid on filing this application)
5. If dwelling, number of dwell~ng units ............................Number of dwelling units on each floor
If garage, number of cars ....1,..........
6. It business, commercial or (mixed occupancy, specify nature and extent of each type of use
7. Dimensions of existing structyres, if any: Front Rear Depth
Height Number of Stories
Dimensions of some structure with alterations or additions: Front Rear
Cepth 'Height ............................Number of Stories
8. Dimensions of entire new construction: Front Rear Depth
Height of Stories
9. Size of lot: Front ....Number;...~.r71 Rear .........~.7.,........................ Depth ...,...a,:Z.}:...............
10. Date of Purchase ................~.......................................Name of Former Owner
11. Zone or use district in which (premises are situoted
12. Does proposed construction,~vi~olate any zoning law, ordinance or regulation :
13. Will lot be re raded
14. I•Jame of Owner of remises .1Ct' Wtll excess fill be removed fro premise : ( Yes ( ) No
p ~..C.d:drL Addressl/~.~G.~,t .s1t.Sr.?:, Phone N~,$Y...:..~Y.~1.a
Name of Architect Address Phone No.......................
i
Name of Contractor Address Phone No.......................
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 blgci< number or description according to deed, and show street names and i dicate
whether interior or corner lot.
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STATE OF NEW O t S r
COUNTY OF ..........:.......f
S„ e~h„n,,,,,~;.,, P~ ,x'i Og~~,,,,,,,,,,,,,,,,,,,,,,,,,.,being duly sworn, deposes and says that he is the applicant
(Name of individual 'g ing contracih
above named.
~9~trraG.:~.Q.r
He is the (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 file
this application; that all statement's contained in this application are true to the best of his knowledge and belief; and
that the work will be performed in the manner set forth in the application filed therewith.
Sworn to before me this
Q
...........~4:~Y),... day of .....5>.l~' 19..:x.6.
Notary Public . ...................~IFhY:Okli~:Q7.JS.......... County .......l~.l~.. .1.. "~IZI.kGlff:~-:.........................:......
i Signature of applicant)
EuznnETN N u
NOTARY Pfl ~~565~ i SulloikNCoy9)Y', k
No 5-' l`~
Term Exnrtes March 30.1 .
` BOARD OF HEALTH
3 SETS OF PLANS
~FORMN0.1 SURVEY
TOWV OF SOUTHOLD CHECK • • • • _
BULL"D.INGDEPARTMENT SEPTIC FORPI
TOWN HALL
EOUTHOLD, N. Y. 11971 NOCALL • •
' TEL.:7G5~1802 -
MAIL T0:
Examined 19 .C?~ ~~JJ''''/
Approved l,'a~~, , , 1 ~Pcrmit No. ~P. ~ (5 O V 15
Disapproved a/c 0
~T3 i~ u
ice... Y~~'{.!...... BLDG. DEPT.
Buil g nspec or) TONMOFSOl1THblb
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 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 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 permit
shall be kept on the premises available for inspection throughout the work.
e. No building shall be occuoied or used in whole or in part for any purpose whatever until a Certificate of Occupancy
shall have been granted by the Building Inspector. K
APPLICATION IS HEREBY h1ADE to the Building Depaztment for the issuance of a Building Permit pursuant 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 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 inspectots on premises'and in building for necessary inspections. ~ ~,~~y//~J/~ ~
r 7-~*"': • 7.x'1.
~ , ; ~ (Signature of ap licant, or name, ' corporation) • •
y ~ ~ ~ ~ ~ (Mailing address of applicant
State whcth~tt'ta i,~ ~.l 'q",•-,+~~' ~ '
~}3'i nt rs owner,;;}essee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of own
c~'~ ANS b~t3lt:r.. t'.,4:da1a = ~ ~ -7 / -
YLlt# ~ Ntril'~A7f1T«'4~!.~ dYr;~ ' (as on ee
ta~~latest deed) .
If applicant ior~!llN~:~tu~` f~djil' ~au'thorized officer.
• • • • • • (Name and title of corporate officer)
ALL CO1fTRACTOR'S MUST BE SUFFOLK COUNTY LICENSED
Builder's License No . .
Plumber's Liccnsc No . .
Electrician's License No . .
Otlrcr Trade's License No . .
1. Location of land on wttich proposed work will be done. , , , ,
House Number Street r7 Hamlet ~ ~ ~
County Tax Afap No. 1000 Section ~1,~ , , , , , , Block ~p', , , , , , , , , Lot . ,„o~,`;~, , , , .
Subdivision Filed 11ap No. Lot .
..(Name)
State existing use and occupancy of prem//irinses and intended use an~•d//o//ccupancy of proposed construction:
a. Existing use and occupancy .......4%%'L.e:G~~~°P!y/;t,~e~Y,
b. Intended use and occupancy ~ih; e_-. (//;JT e:2:'~, .
L/
3. Nature of work (check which applicable): New Building Addition Alteration
Rcparr
~o• oval Demolition , . , .Other 1Vork cam.
(D cri
4. Estimated Cost em ° cs •Plion)
Fee
g' (to be paid on filing this application)
5. If dwellin_, number of dwcllin units Number of dwelling units on cacti floor........'
!f garage, number of can • • • • • • • •
6. I(business, commercial or mixcl~i occupancy, specify nature and extent of each type of use . • • • • • •
7. Dimensions of existin; structures, if any: Front ...............Rear Depth . • • • •
Haight . , .,.,.N.~unjber of Stories , .
~D F~ sions`pf'samesttu~~ a tv'th alterations or additions: Front Rear ~
8. "D en • .:..Height ......................Number of Stories • : •
€ irtt ~f>inneiyz~i strjuction: Front Rear Dc th . ; •
Height umber of Stories p " •
9. :Size;~.,1PG_~rontF._...~.~ ` Rcar ~~~i
0. IDate fPt li .~~.l.Bl7~:. Depth
,f?_~.. )'!w, .~Fi~•... ~ Name of Fotmcr Owner .'l`~/.t.F?.«. :Y;
:~:ti:`:
1. 'Zronc or use district in wTitc premises are situated . ~ ~
2 Does proposed construction violate any zoning law, ordinance or regulation: /?~O. , _ • •
3. \Vill lot be regraded . a!~ ,will excess fill Jae removed from premises: ,Yes • No
4. Name of Owner of,premises . , r~cP;
;~i
;e~;~. , ,Address l:f~P ,t+J.-Zr: ?:Phone No. a?~~.~~~v?, ,
Name of Architect . , .Address . V .Phone No.. • •
I~'ameofContractor........ ••,•.Address.•••'~••••~••-~~~~ PhoneNo..
5. Is this property located within 300 feet of a tidal wetland? *Yes a:.. No •'t•
*If yes, Southold Town Trustees Permit may be reggwired.
! PLOT DIAGitAM
Locate clearly and distinctly all,buildings, whether existing or proposed, and. indicate all set-back dimensions from
roperty lines. Give street and block tiumber or description according to deed, and show street names and indicate whether
tterior or corner lot.
k
~i
APPR9V~ED AS NOTED
DATE: ~~~~~~r o , Ei.P. q l6
FEE: ~ ®d EIY; '
NOTIFY iL 0 DEPART
L 785-1802 8 AM TO 4 PM fOR THE
FOLLOWING INSPECTIONS:
1. FOUNDATION - TWO•REQUIREO
FOR POURED CONCRETE
2. ROUGH - FRAMING ~ PWM91N0
• 8. INSULAt1gN
a. FINAL - CONSTRUCTION MUNT
BE CAMPt,@iE FOR G.Q.
i ALL CONBTIiUCTIQI~, N11A1d, MES"1'
'i THE RE4UIIINi<'i ELF 7I~ I~.,Y.
STATE CgNAi'RLIC11QIy. ~
DESION Oh
CQ~Vlgll~;
• ~r
i
I
SATE OF NE«' 1'ORIC, SJS
• s ,
bcin~ duly sworn, deposes and says that he is the applicant
(\amc of individual si.,ni contract)
ovc named.
:isthc .......................1!I................................ .
(Contractor, agent, corporate officer, etc.)• • • • • • • • • • • • • • • • • ~ •
said owner or owners, and is duly 'authorized to perform or have performed the said work and to make and file this
alication: that all statements contaitjed in this application are true to the best of his knowledge and belief; and that the
rl: will be performed in the manner set forth in tltc application filed therewith.
orn to before me this
..............31 day o/f.1..P~-°'~'!':':........,19~f'.
tart' Public, `~...j~,S,., ~ ~ vK-"...... County
7-~..~ •
~ NELENK.DEVDE t^ ••..•..'p..••.-
hDTARYPUBLIG,StateofNewYork mature of a plicant)
No. 4707878, Suffolk County
Term Expires Mery'h 3D,19..~ i
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