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TOWN OF SOUTHOLD
BUILDING DEPARTM@NT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON 7HE PREMISES UNTIL FULL
GOMPLETION OF THE WORK AUTHORIZED)
N°- X 8 4 4 2 Z Date ~9,1~,~
Permission is hereby granted to:
.
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at premises located of ...~d.
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County Tax Map No. 1000 Section Block Lot No....~.'•1...`.t'.`.d..
pursuant to application doted .~~l.~r' 19s~~., and approved by the
Building Inspector.
Om
Fee S•••••;~~.~~
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~Buildin for
Rev. 6/30/80
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BOARD OF HEALTH
3 SETS OF PLANS
FORM NO. t SURVEY .
TOWN OFSOUTHOLD CHECK
BUILDING DEPARTMENT SEPTIC FORM
TOWN HALL
SOUTHOLD, N.Y. 11971 NOTIFY ~
TEL.: 765-1802 CALL • - •7• • -
MAIL T0:
Examined . R f
f d 19 ,~i
Approved ~/~d........, 19~ Permit No.~~.r~.~?, S~ D ~ ~ R n nn
Disapproved aJc L5 IJ l!
AUG ! 81~g
• • : • ~f ~ • • • • • • • • • TOWN OF
SOOTHOLq
~(B 'ding Inspector) w>w.
APPLICATION FOR BUILDING PERMIT
Date %
fG6UST'../~ 19 b'.~/
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 necess inspecti
~VIAZZAF.ERRO 'BRO3„ ~N~:. ignature of appl an ,
of r name, if a corporation)
?k : „~Y
~ 7th ~ gown Sts.
izz~
,~~,~,~~~~~:.~~:U. ~Eox~ H ~ .
(Mailing address of applicant)
, Green~o~t, NY 11944 , °
State whether ap licar~t is. owner, lessee,:agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner ofp~e~isgs, . y ~ . ~ROrS (!VC° .
, (as on the tax roll or latest deed)
If licant is orpdid~io ~;'~t~nafure of d~l~.authorized officer.
`s N
tr~t y r i
(Name afi• it ~"~`'c`x~~'porat"e.of_fi~c•,er)
ALL CONTRACR`~';~~ ST ~ ~SUF~OLK COUNTY LICENSED
Builder's License No. .7~ . .
Plumber's License No . .
Electrician's License No . .
Other Trade's License No . .
1. Location of land on hich proposed work will be done .
G"i:~ is ~a .
CA.~Zt~~(Z...QF...B.RO.w.N..A~.N.~..7.'.57.~((~G-~-~'.......~~.RC-C-rV/??I.Z.l
d
House Number SQQt~~reet s~ Hamlet 7 pa~
County Tax Map No. 1000 Section P.......... Block 3 , . , , , , , , , , , Lot ~q(....~'.~.4.. .
SubdivisionG~EEN.~0.~J•, „'A~2.(UTAJ) Filed Map No. ~.b.q........ Lot
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
, .
a. Existing use and occupancylNAUST.2(R
may-
b. Intended use and occupancy ~/~/.~.V~ i .R,V:r.~ .
i
3. Nature of work (check which applicable): New Building , Addition Alteration .
Repair Removal Demolition Other Work .1~~ !~liC.G... .
(Description)
4. Estimated Cost ~~.~"'~~..I Fee .
(to be paid on filing 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 lAer~~/'9~........ .
7. Dimensions of existing structure ~s, if any: Front ,t ,~!~~li
,('Rear Depth .
Height ...............Number of Stories l V ...G........................................ .
Depth . , , , , . 'th alterations or additions: Front . Rear .
~ .Height Number of Stories .
8. Dimensions'~f~ntiresnewtconst1 ction: Front Rear Depth
Height ...............Number of Stories .
9. Size of lot: Front Rear Depth
10. Date of Purchase ...........:.................Name of Former Owner .
11. Zone or use district in which pre(ises are situated . . . . . . . . . . . .
12. Does proposed construction violate any zoning law, ordinance or regulation : .
13. Will lot be regraded Will excess fill be removed from premises: Yes No
1`4. Name of Owner of premises ~ ................Address ...................Phone No............... .
Name of Architect , i ................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 Permit may be reqgu~ired. ~
PLOT DIAGitAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from;
property lines. Give street and block r}umber or description according to deed, and show street names and indicate whether
interior or corner lot. ~i
~3iQOw N s
~ ~ lNSlOE or= piedP~,~t-Y 1..~,VC
mat
F'i~?c~ 'l' F~',a~~
S
r F P~ AS NI1TE'D
R E BATE: ° ~ B.P, k
N FEE: _°e1
Ht FEiuCrr ~~I ~ NOTIFY 13U1L0 G DEPART
766.1802 8 AM TO A PM R THE
FOLLOINING INSPECTIONS:
j t. FOUNDATION - TWp REQUIRED
FOR POURED CONCRETE
I rE N I 2. ROUGH -FRAMING & PLUMBING
3. INSULATION
4. FINAL - CONSTRUCTION MUST
j BE COMPLETE FOR C,p,
ALL CONSTRUCTION SHALL MEET
THE REQUIREMENTS OR THE N Y
STATE CONSTRUCTION ~ ENERGy~
CODES. NOT RESPpNg?g~ ~R
I, DE51GN pR CONSTRUGTIf)N EppOR9
STATE OF N°7~ S~ S
COCliN/T•Y OF .
~e Nai~f~
i~ vide
1 signip • ~ ~ ' ' ' ' ' ' ' ' • • • • being duly sworn, deposes and says that he is the applicant
g contract)
above name/dy., ,C~
He is the .4 a ~'.r~.~f4h' ~~t~C .
(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 statements contained in this application are true to the best of his knowledge and belief; and that the
work will be performed in the manner &et forth in the application filed therewith.
Sworn to before Itye this ~ar~^
.dayrof . 19 .~l
Notary Public, .....~~,<.Q , County
CLAIRE L. GLEW , •
ew Vork ~ . .
Notary Public, State of ~ . .
No.4S79606
Qualified iro Suffolk County (Signature of applicant)
Commission Expires Decem7or 9. 1 A~~