HomeMy WebLinkAbout17801-z Foaas xo. s
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MU5T BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N 017 8 01 Z Date ~:~3 19..19..
Permission is hereby granted
~~,so ~
//9 d'y-
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ct premises located at ...~L~:C/7...~...~-~.~.,r./
..............................................4~./.
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Caunty Tox Map No. 1000 Section .......~',~...i'~....... Block Lgot No.......
pursuant to application doted ..........~~'.~.....7 19..~f„ and approved by the
building Inspector.
tt O~
' Fee $.~:l.~..
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/ Buil g I actor
Rev. 6/30/80
:'1cLD I;:S:'EC;ION (llliiir. ~ COMMENT° ~
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ItJSULATI0P7 PER N. Y.
STATE ENERGY
CODE
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ADDITIOPIAL COMMENTS: x~
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(Ur[=~C~~VV~!L`=_',~~~~ BOAFD OF HE.ILTH
3 SETS OF PL.1NS
v FORM NO. 1 SURVEY
JAN 2 ~ TOWN OF SOUTHOLD CHECK
<~4 BUILDING DEPARTMENT SEPTIC FORM
d,.<~_„~..~,. ~ ~ TOWN H A L L
t3t.i>~_~. 17i:pa. SOUTHOLD, N.Y. 11971
TOt~tS~[j! `:;_~.HC°sFit ~ NOTIFY
- • _ TEL: 7G5-1802 CALL 1,,,,
Examincd.~~.3........ ,19A~p MAIL T0: f~•S6 ~°~'a~iP~«~s~~.
Approved O/ 17~6~ ~ ~1a.J~e,®.r~t~.L
19 Permit No. .
Disa
PProved a/c ~ q
lla7'~4
~Bu mg nspecror)
APPLICATION FOR BUILDING PERMIT
Date ~ :7...~°~, 15 . .
' INSTRUCTIONS
a. Tltis application must be completely filled in by igpewriter or in ink and submitted to the Building Inspector, with`
sets of plans, accurate plot plan to scale. Fee according to schedule.
Plot plan showing location of lot and of buildings on premises, relationship ~o'adlomin~ premises o;,public stree
or areas, and giving a detailed description of layout of property must be drawn..an .th~,dTat'~m which~is part of this appl
cation.
c. The work covered by this application may not be commenced before is~U3ijae"o.f uil~m~,F~rrriit..
d. U on a ~:,~~w .
p pproval of this application, the Building Inspector will issued a);~rildjn'g:Pe~~t tb=ttae'ap~lie',~n"t. Such perm
shall be kept on the premises available for inspection throuehout the work. - r:.
e. No building shall be occupied or used in whole or in part for any purpo~e,~v~gtever. until a',CertPfii;ate of Occupant
shall have been granted by the Building Inspector. , ..,,1 , , ,
a4".;~.~« s+
APPLICATION IS HEREBY MADE to the Building Department for the i'ssu'ancero~' 3` )~inldingF7?errpit'putsuant to th
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances c
Re:ulations, for the construction of buildings, additions or alterations, or for'reiifoval o~ demoJitiog;,: as herein describes
The applicant aerces to comply with all applicable laws, ordinances, building coc}e~, houslr}g,~o,¢e,;apd;r~gulations, and tc
admit authorized inspectors on premises and in building for necessary inspections','`'' ,
<li ~
i<~, ~y~s,~,
( rt.,• F. ,p .
~ignature~r~~cif`iat;'c3'$ naihe, rf "a cor or non)
(Mailing address of applicant) ,
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
~6.~%w~~.~...c .
Name of owner of premises .....r`K.IJ(t
!1,.~~~ , , , . , ~~q,~~,tj /
v^ it
as on the tax roll or latest de )
If applicant is a corporation, signature of duly authorized officer.
~ l,6
(Name and title o//f corporate officer) Q
Builder's License No. /..J~,1..oZ,oZ, ,J,'/,z, , , , , , , , , ~ ~ 1~
Plumber's License No . ~ ~ ~i~~A~
Electrician's License No .
Other Trades License No . .
1. Location of land on which proposed work will be done. ,l~Q1r7~,L-AS/ :(nplV,2I/~ /S',Sz.e•_
,e,
.`~~o .:~C~~~.....~......
House Number Strcet~
..Ha'
~nlet
Count
Tax Alap No. 1000 Section ~G Block ...02,....... Lot . .
Subdivision Filed 1\tal~ No. Lot . .
(Name) ,t,
State exisun~ use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy
b. Intended use and occupancy ...a~"n~~`D . ~
_
3. A'ature of work (check which applicable): New Buildin5 • • • • • • • . Addition ..~f.. ,'Uteration
Repair Rcnjoval Demolition Other 1Votk • ~ • • • • • • •
4. Estimated Cost ,~lJ~,a bl, ~ ~ ~ ~ F'~ (Description) .
Fee......................................
(to be paid on filing this application)
5. If dtvclling, number of dwelling
units Number of dwelling units on each floor , , ,
IC gara,e, number of cars
.
6. If business, commcrctal or mixc
d occupancy, specify nature and extent of c,ach type of use .
7. Dimensions of existing structures, if any: Front .Rear Depth
Height . Nurjtbcr of Stories . . .
Dimensions of same structure ~Yith alterations or additions: Front Rcar . •
Depth . Ilcight . Nuntbcr of Stories . • • . • .
8. Dimensions of entire new constntction: Front . Rcar , .Depth • • •
Height Nurjtbcr of Stories .
9. Size of lot: Front Rear ...................Dc~th.......................
l0. Date of Purchase , , Name of Former Owner • • •
1 1. Zone or use district in which r ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' • • •
l3. Nill lot beoregraded tructron v~ocmises arc situated .
~ p p late any zoning law, ordinance or regulation: ~ _
Rill excess fill be removed from premises: Yes No
14. Name of Owner of premises . ; , , , , • • , , • , • , , , , ,Address . .Phone No. .
Name of Architect ~ ,Address ' • ................Phone No... , • • , • • • • • • • • .
Name of Contractor 5~~,~ , , • • , , , ,Address/2SA ?i'~?H~-:ti-, 7yl,~~KEphonc No. a7~~'y`fas__? yy~~'' • •
IS.Is this propert located within 300~feet of a tidal wetland? *YGS....NO./!..•••
*If yes, Sputuho~~~Touwn Trustees Permit may be required.
PLOT DIAGRAbI
LoDti~ B,Itrt~~~• s, whether existing or proposed, and. indicate all set-back dimensions from
proper~~Eljn i e~td b r or description according to deed, and show street names and indicate whether
interioq~~q NG DER4 AT
786-1$02 8 AM TD d PM FOR THE
FOLLOWING INSPECTIONS:
1: FQUNDATION • T1A10 REQUIRED
FOR POURED GQNCRETE
3. MSULATION AMING A PLUN191NG _ - - ~
4. FINAL CONSTRUCTION MUST
BE COMPLETE FOR C.O. !t ,
ALL CONSTRUCTION SHALL ~ItEET ~ ~j
THE REQUIREMENTS Of THt, N.Y, ~
STATE CONSTRUCTION ~ ENERGY
CODES. NOT RE5PONSISI:~ 'FOR ~
DESIGN OR CONSTRICTION ERROR$ r u~
/ /~7
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COUtiT~' OF S.S
• • • • • • • " " " " ; ' " • ' ' ' ' ' ' ' ' ' ' ' ' ii ' ' ' ' • • • • • • • • • • • • • • . being duly sworn, deposes and says that he is the applicant
(;\am~ of individual si~nirg contract)
above named.
Itc is the ~r~I-tR:':~:C-.~.~!~-r-~'°~" . . .
,f (Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly, ;tuthoriacd to perform or,~havc performed the said work and to make and file this
application; that a!I statements contatncd in this application arc true to the best of his knotvtcdgc and belief; and that the
'•vork will be performed in the manner~,set forth in the application lilcd therewith.
Sworn to before ate this q
• ..............ot .7 . ....day o~f/~~
. ~o~r:/w-r........ , 19~~,1•
`otary Public, .....~x-iryS/, , , Jf,'„ , ~;2,//,(~6'e_• • • County ,
HELEN K. DEVDEI "J••
NDTARY PIIRtIC, State of New York
Nn. 4707878,SuffalkCuunry 9 (Signaiurcofappticant)
Term Expires March 80,19/
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