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TOWN OF SOUTHOLD ~ I
lUILDING DEPARTMENT
' TOWN HALL
SOUTHOLD, N. Y.
N~7" ~~tl h
BUILDING PERMIT
ffHIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N ~ 18 4 ~ ~ Z Date .....~s.,L.? ~ 19....~..~
Permission is hereby granted to' Tae
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of premises totaled at .......G~~G~I.fF!:..,u~~..........................................................
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County Tax Map No. 1000 Section Block .............rte....... Lot No.........1~..............
pursuont to opplicotion dated .......l..~w~ 19~, and approved by the
Building Inspector.
Fee 00
f~i
di nspector
Rev. 6/30/80
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AP D AS IibTED
DATE._ B.R ti l _ -
NOiI)1^'SCi1lDNOG UEPA AT - 1
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FOLLOWING, INSPECTIONS:. _ , N e,,,~
i. FOUNDATION - TWOREOAIlREO ~-Z• pec% ~
FOR POURED CONCRETE . _ - l`'f
2. ROUGH -FRAMING $ PLUMBING;..... I '
3. INSULATION ~ , - ~ ~ ~ --j,. . ~
4. FINAL - CQNSTRUCTION MUST - ~ . y 2
BE COMPLETE FOR C.O. L 12 ~ (E~ -
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ALL CONSTRUCTION SHALL MEET
THE REQUIREMENTS OF THE N.Y.
STATE ~ CONSTRUCTION $ ENERGY-
CODES. NOT NSIBL`'~ ";FOR '
DESIGN OR CONSTRUCTION ERROI~~ - _ - ~
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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 8 4 31 Z Date ....~~z ~ 19.
Permission is hereby granted to~ s
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to . ~1~SG r...fts....~.~L6:~.... ...f../.2~/~d/..ur.:
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of premises located at ~ ~..............~e...................
County Tox Map No. 1000 Section Block .............r`2....... Lot No.........`~
pursuont to opplication doted 19 and approved by the
Building Inspector.
Fee 019
B di Inspector
Rev. 6/30/80
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P,OUGH FRAME & ``~OJ
PLUMBING
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IlJSULATIOP! PER N. Y.
STATE ENERGY
CODE
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BOARD OF HEALTH
3 SETS OF PLAIJ~
FORM NO. 1 SURVEY ,t/../. ,
TOWN OF SOUTHOLD CHECK • • - • V
BUILDING DEPARTMENT SEPTIC FORM
TOWN HALL NOTIFY S~~y?
SOUTHOLD, N.Y. 11977 CALL • .~~•v
TEL.: 765-1802
MAIL T0: j~~,
Examined 19~~ V T
Approved ~/~S , , , , 19~ Permit No.~~.~`~~~ D ~ ~
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Disapproved a/c
AUG I ~ k989
..............................................e...p
BLDG. DEpT.
Qy, 70WN OF SOUTHOLD
(B ding ns ector)
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 occupied or used in whole or in pazt 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 inspections. ~
(Signature of applicant, or name, if a corporation)
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~ . 3.
Via. a~~':c?~:0 ~ ././%f~
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
..............Q.t..r/.l.~E'. Y........................................................................ .
Name of owner of premises (it-e(;C[ ~....GI /?d....//~~ /~it7...~// ~!~l. T!~!! /.1 .
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
ALL CONTRACTOR'S MUST B -~SU~~,,FFOLK COUNTY LICENSED
Builder's License No. C~.~O~~!<.......... .
Plumber's License No . .
Electrician's License No . .
Other Trade's License No . .
1. Location of land on which proposed work will be done . .
House Number Street Hamlet Gy
County Tax Map No. 1000 Section Block , , Lot 1 .
Subdivision Filed Map No. Lot...............
(Name)
2. State existing use and occupancy of premises and/intended use and occupancy of proposed construction:
a. Existing use and occupancy .....QTY...!/ 6 . .
b. Intended use and occupancy Ul'.....`'J.OC~I~ .
k
3. Nature of work check which ap ~ P ~ ~ W % /1p 0 W
( plicable): New Building Addition Alteration ..11...... .
Repair R/em/gval Demolition ..............Other Work .
4. Estimated Cost ..~1, ~ C7.?~4C . u!!~?"}:~dw, , , . Fee . . . . (Description) ? .
(to be paid on filing this application)
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5. If dwellin , number of dwellin 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 tt ~ .Height Number of Stories .
8. DimensioPef~tire new construction: Front Rear ...............Depth
Height Number of Stories
9. Size of lot: Front Rear Depth .
10. Date of Purchase . Name of Former Owner .
p ~isesaresituated
12. Does ~ o osed constru thon viol
P P
g 'ate any zoning law, ordinance or regulation : .
13. Will ]ot be re raded .Will excess fill be removed from premises: Yes No
14. Name of Owner of premises ~~101.7~~ ~~Z~Zn.~f, (y~li.;(/Address~(/;/jhX •3~~..~.~fK!2(. Phone No, a.~.S:
Name of Architect ...............Address , ................Phone No.............. .
Name of Contractor
P P y Address .....Phone No.. .
y
15. Is this ro ert located within 300 feet of a tigidal wetlandY *Yes No .Y
*If es Southold Town Tru~tees PermitPLOyT DIAG1tAMed.
Locate clearly and distinctly all ~Ibuildings, whether existing or proposed, and. indicate all set-back dimensions from
property lines. Give street and block number or description according to deed, and show street names and indicate whether'
interior or corner lot.
I
I
STATE OF NEW YORIC, S.S
COtiNTY OF .
(Name of individual si ni ~ ~ ' ' ' ' ' ' ' ' • • • being duly sworn, deposes and says that he is the applicant
g t~g contract)
above named.
He is the
' (Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly'i authorized to perform or have performed the said work and to make and file this
application; that all statements contained in t}tis 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
~5 .day of .I',,.~/C C;~~ 19 ~.9
Notary Public, ......./..,ZL :.~Z.f./.~:-... County /p~~
HELEN K DL VDE Sin pp
~o~g701878,Su Ikf~unY~ ( g ature of a licant)
Term Expires Merch~30,1