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Home My WebLink About17894-z lrO~ NO. ~ TOWN OF SOUTHOLD RUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 01789q Z County Tax Map No lO00 Sect,on O'-%~.J Block ....... .(~....~. ..... Lot No.....~....1 ......... pursuant ,o oppl,cat,on dated ..~Q-~...~. ................ , 19.~....~., and approved by the Budding Inspector. Building Inspector Rev 6/30/80 ToWN cfi;-. Exammcd~. , 19'~. Approved TOWN OF SOUTHOLD BUiLDiNG DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL.. 765-1802 .~.. la,&C.~l. '~. , 19;~.c} Permit No. I ~ .~?~'~ Dtsapproved a/c ......................... (Building Inspector) APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH .......... 3 SETS OF PLANS .......... SURVEY ................... CHECK .................... SEPTIC FORM .............. NOTIFY CALL MAIL TO: Date ......... .~.., l~i INSTRUCTIONS a. TiNs application must be completely filled in by typewriter or in ink and submitted to thc Building Inspector, wit sets of plans, accurate plot plan to scale Fee according to schedule. b Plot plan showing location of lot and of buddings on premxses, relationship to adjoining premises or pubhc strc 'or areas, and gwmg a detmled description of layout of property must be drawn on the diagram which is part of tNs ap canon. o. The work covered by t~s apphcation may not be commenced before msuance of Building Permit. d Upon approval of ttus apphcatmn, the Bmldmg Inspector will ~ssued a Budding Pe~t to the apphc~t Such pen shall be kept on the premises avadable for inspection t~rou~mut the work. e. No budding shall be occupmd or used m whole or m part for any purpose whatever untd a CeN~ficate of Occupm s~all have been granted by ~e Braiding Inspector. APPLICATION'IS HEREBY MADE to the Bmldmg Dep~ment for the ~ssuance of a Braiding Pe~t pursuant to Braiding Zone Ordinance of the Town of Southold, Suffolk County, New York, ~d other apphcable Laws, Ordinates Regulahons. for the constmctmn of buildings, add~hons or alte~anons, or for removal or dcmoht~on, as hereto descnb The apphcant agrees to comply w~th all apphcabqe laws, or&nances, building code, housing code, and regulanons, amd admit authorized mspecto~ on pzemmes and~m braiding for necessaw msp~c~nons. / ~gffature ot applfcant, or name, Jfa corporanon) ....... : .......... + . . _ . (Madm= address of appho~t) (Name and htle of corporate officer) Builder's License No .............. Plmnber's License No .............. Electrician's License No ................ Other rrade's License No . .... State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or bmld~ .... ................................................................ Name of owner of premises . .~.~-.'.X,.,~.~.~(_-~...'/-.5.qd?lO:f.. t.~~ . ~./ff...~..a~.c/-/t~/~- (as on the tax roll or latest deel~PR0VEO AS NOTED If apphcant is a corporaL,on, s,gnature of duly authorized officer DATE' ..~%~q[~ B.P. # t "~ ~qq. NOTIFY eUILDING OEPA~MENT 766 1802 9 AM TO ~ PM FOR THE FOLLOWING }NSPECTION~ 1 ~OUNDATION ~O REQUIRED FOR POURED CONCRETE 2 ROUGH ' FRAMING & PLUMBING 3 INSULATION 4 FINAL CONSTRUCTION MUST 8E COMPLETE FOR C O ALL CONSTRUCTION SHALL OF ~E N ........... ~TE' ~NS~N &' .~ER~Y. 1. Location of land on Much proposed work wall be done THE REQUIREMENTS }louse Number Street / hamlet co,, w, ,M pSo tOO0S= on ....... .. .& ...... ot. Subdw~smn .......... Fded Map No ......... Lot .............. State eMstlng use and occupancy of premises and intended use and occtlpancy of proposed construction a Ex,sting use and occupancy ...... ~ ~(~/- .~4Z~.~ ........ b Intended use and occupancy ................................................... 3. Nature of work (check which apphcable): New Building ..... ' ..... Additmn .......... Alterat~ ...... Rep:ar .............. Removal ............ Demolition ............ Other Work..zz~ ...... ~ (Descnptl, 4. Esttmate'dCost .~.~.~.O ~ .~,.~O ...... Fee ....................... (to be pa~d on fihng th~s apphcatlon) 5. If dwelling, number of dwelling umts .............. Number of dwelling units on each floor ............ If garage, number of cars .................................................................. 6. If business, commercml or m~xed occupancy, specify nature and extent of egch type of use .. t .............. 7 Dlmenmons of exmtmg structures if any Front Rear ' Depth Hm,,ht Number of Stones Dtmenmons of same structure w~th alterations or addmons Front ................ Rear ......... Depth ...................... Hmght .................. Number of Stones ................. 8. Dimensions 9f enhre new constructmn Front .............. Rear ............. Depth ........... Hmght Number of Sto~e~s ' 9. S~ze of lot. Front ..................... Rear ..................... Depth ................. I0. Date of Purchase ........................ Name of Former Owner ....................... 1 I. Zone or use dxstnct m whxch premmes are mtuated .............................................. 12 Does proposed construction violate any zomng law ordinance or regulatmn' 13. Will lot be regmded .......................... Will excess fill be removed from premises' Yes 14. Name of Owner of premises .................. Address ................... Phone No ............. Name of Architect .......................... Address .................. Phone No ............. Name of Contractor ......................... Address .................. Phone No .... 15.Is this property located withln'qOO feet of a tidal wetland.* *If yes, Southold Town Trustees Permit may be required. PLOT DIAG RAM Locate clear]y ~nd d~stmctly ~d! buddings, whether ex~shng or proposed, and indicate ~dl set-back d~mens~ons f prope~y ~nes. G~ve ~treet ~nd block number or descmption according to deed, and show street names and mdmate who intoner or comer lot. ~ ~,~5'- ~'1~ 14 ,'q o ~.D STATE OF NEW YORK, S.S COUNTY OF ............... (Name of md~duai signing contract) aboue namect 1 being duly sworn, deposes and says that he is the apphc tte ,s the ....~., ........................................................................ ,, *w (Contractor, agent, corporate officer, etc.) of sa~d owner or owners, and ~s duly authorized to pe,rfc~'m or have performed the smd work and to make and apphcatmn, that all statements contained m this apphcatjk)n are true to the best oflus knowledge and behef, and that work wdl be performed m the manner set forth tn thc apphcatmn flied therewith. Sworn to before me flus ..................... ................ NotaryPubhc, . ............................ County (S~gnature of apphc;