HomeMy WebLinkAbout18117-z rows xo a
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 ° ~ ~ ~ ~ Z Date 19
Permission is hereby granted to:
. ~9
to .~~.~?~.Fib'~.~....~........~.........:':.•~.~~"t~..........~•?...
of premises located at ...~ia~.~~.o......~~'1.......N..~
r~ ...~~..Gz................................................................
County Tox Map No. 1000 Section ........~1...... Block Lgot Na...........,/...........
pursuant to application doted .........4~~~ 19.Q./.., and approved by the
Building Inspector.
Fee
uiidiv~ Inspector
Rev. 6/30/80
~ ~ BOARD OF HEALTH
3 SETS OF PL.1NS
y~~ - i ~ FORM NO. t SURVEY ? .
A!1 9~ TOWN OF SOUTHOLD CHECK .I:z~m....... °
BUILDING DEPARTMENT SEPTIC FORPt . .
~o.....~.p.,..=%L TOWN HALL .
TOWNIUFSOUtiOLp SOUTHOLD,N.Y.11rJ71 NOTIFY
TEL.: 765-1802 CALL
Examincd~~`~ 19 yy~!. / MAIL,-T 0 L. .
\pproved`~~~u~~........., 19//.~ Permit No. ~~~f. 7~ O ~-~C 13
Disapproved a/c ~ ~ ~ ~ ~ 3q
L
( ildin^ nspector)
APPLICATION F R BUILDING PERMIT
Date 15
INSTRUCTIONS
a. Tltis 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 t}tis 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 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 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 inspectors on premises and in building for necessary inspe ns-
. y~K~~ ~P~~~ ~
T ignatttre of applicant r na tf a corporation)
' (Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
. . .~il~ . ~ S .
Nameafownerofpremises ~
(as on the tax roll or latest deed) _
If applicant is a corporation, signature of duly authorized officer.
(Name and title of cc-orporate officez)
Builder's License No. ..T~~~ TZ~~..~~!':~ ~ ' ~ ~ ~
Plumber's License No . .
Electrician's License No .
Otfter Trade's License No . .
1. Location of land on which proposed work will be done. '
Ilouse Number Street. ~ • ~ • ~ " " " " " " "
/ / Hamlet
County Tax Map No. 1000 Section :-3 ~ Block ~ , , , , • , , , , , Lot .
Subdivision Filed t•tap No. Lot .
(Name)
• Stale existing use and occupancy of prem~{is~es and intended use and occupancy of proposed construction:
a. Existing use and occupancy ......!11``.,V, v~ • • • • . .
b. Intended use and occupancy JJ.r'.~ S. G ....//.r!. ~ T h` , , • • • c~.. • • • . • • • • •
3. Retsir of work check which applicable): New I3uilding '
( • • • .Addition .Utcrati
P Removal Demolition ~,y,
,GCE.
~ Othct:+l~d~..
4. Estimated Cost ~ d (Description)
.t Fee....................................
/ (to be paid on filing this application) .
5. If da=allmnumbcr of carsvclling units , , , , Number of dwelling units on each floor ,
If ~ ~ :
~..~9.2~ . .
6. IG business, commercial or mixed occupancy, specify nature and extent of each type of use . . . . . . . . .
7. Dimensions of existing structures, if any: Front , , ,Rcar
Hci~ht Nutrtber of Stories . • Depth .
Dir,_ifensions of same structure with alterations or , dditions: Front • • • • ~ • ' ' ' ' ' ' ' '
Depth ' . Ilcight . Rear
Dirt~ensions of entire new construction: Front , ~ ' ' ' ' • • • • Number of Stories • , ,
Hci~ht Number of Stories Rear Depth .
9. Size oflo[:Front/ Rcar.•..~~~~•~••~~•~••••••~•~•••~•••~~'•""'•"
10. Dat~ofPurchase •f•~~ Depth
' ' ' p ...Name of Former Owner .
~ p emises are situated , , , , , , ' ' ' ' ' ' • • •
1... Doe
pro osed construction violate any zoning law, ordinance or regulation: ~ •
13. Hill lot be regraded y~
14. N e of Owner oct c whic t r Will excess fill be removed from premises: Y~ N
f p mrses .Address . °
N eofArchitect ~ "•'••••••••••••••PhoncNo
_ N e of Contractor . ' • .........Address ...................Phone No............... .
.....Address .Phone No..
IS.Is this property looted with in~00 feet of a tidal wetland? *YES. .N0..7~
*If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
Loco a clearly and distinctly alj buildings, whether existing or proposed, and. indicate all set-back dimensions from
property ~i'nes. Give street and block',number or description according to deed, and show street names and indicate whether
interior o corner lot.
. ,
STATE O NEtV R
COUNTY F[;_~,~~ S.S _
• • • ~ • ' ' ' ' • ' ; ' ' ' ~ rt't >9- •^i''k•~'•'~• • • ~~T.
~S.... being duly sworn, deposes and says that he is the applicant
(i\amc of individual signiri,g contract)
above named.
![e is the . .......................p.tc,ttY.e.~.............
(Contractor, agent, corporate officer, etc.) • ~ ~ • " " " "
~f said ow er or owners, and is duly';authorizcd to perform or have performed the said work and to make and file this
-Pplication; that all statements contairjed in this application are true to the best of his knowledge and belief; and that the
,vork will bo performed in the manner set forth in the application filed therewith.
swam to be~forc me this
...~~:....dayof. .....~..r<1:1.2...., 19~.
rotary Publ c, , , , . .~1-~r,~~County
EL HStateof
New
York (S/ ig re of applicant)
Note PU ic,
No. 6~•8A 2 860, Suffolk Couu~~ttY~~~
Tres Qctober 3t, tB,Zdl
Term Sxp,
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