HomeMy WebLinkAbout17304-z gosai xo. a
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
CTHIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
No 017304 ' t~
Z Date ~ 19.~~?
Permission is hereby granted to• v
.~t.....,~~~
....r..~- ..,.....~lsw
ct premises located at ...(J..T/...~?.'.~/J.~~
...........................................f.5:.~~~4".'e"C"""...........................................................................................
County Tax Map No. 1000 Section .....~r~.Z.lD....... Block .........L~~...~~.... GLot No.........1.....-~9........
pursuant to application dated ........~./...~.,7 19~p, and approved by the
Building Inspector.
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Fee $....sa'.~! „..y'
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uildi nspector
Rev. 6/30/80
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Q! p y„~ feoilities Por this loo3tioF9 have
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° ,pt ~ to be setisfaetoryQ
{ ~Y ' ~ Chiet,ot"General EnglneF
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TH SERyICE.
1
iFIFDYNE IOSi NJ101
BOARD OF HEALTH
3 SETS OF PLANS
FORM N0. 1 SURVEY .
TOWN OFSOUTHOLD CHECK
BUILDING DEPARTMENT SEPTIC FORM
' TOWN HALL
SOUTHOLD, N.Y. 11971 NOTIFY
TEL.: 765-1802 CALL
MAIL T0:
Examined . 19 .Q }
Approved 1~C/. Permit No....... T~
Disapproved a/c D
! . t~A
% .
• ~ • • • • ( tiding Inspector) ,~N~g$~plp
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•lie 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 inspections. -.3 ~tb'. _ • °Cr•"` ~
(Sigr}ature of a licant, or name, if a corporaLrc;;t~ ~ ~ ,
•_7-.e ....Cn''addlC'~,es 9 a lic,~t)~,~x% ~i~~'U
g ~ ~ 4~~ 11,vv
State whether applicant is owner, lessee, agent, architect, engineer, general ~~'acz~ •~i,~p)ItBt~$~or builder.
XfFt t~Fktlfl~ .f
Name of owner of premises . c .~,4-.~~.~... ~..1.°/.~~j . 1:'~1•~B
(as afi the tax roll o t ~ ~ lA
If applicant is a corporation, signature of duly authorized officer. .Y•~ ~ ~N~
~ ~t Rid ~,i$ P
~~Nif~a189 1RCt ~!ef1E'.ar..
(Name and title of corporate officer)
Builder's License No. • . • • •
Plumber's License No. ....U'. ~?l ~ .
Electrician's License No. .
Other Trade's License No . .
I. Location of land on which proposed work will be done.'....~Y-~~. l~~.Cr~~'?~C ~v
/ f J
House Number Street Hamlet
County Tax Map No. 1000 Section Block ....a.y......... Lot ...G.
Subdivision Filed Map No. Lot .
(Name)
2. State existing use and occupancy of premises and intended use and occupna1nc'y, o,~f pro/posed construction:
a. Existing use and occupancy .......1..... • °•~jU • • • • • . ! . ! .
b. Intended use and occupancy ........:S ~f?1.`E'. • • • • • • • • • • • ..:".....'~Q!-;d`~J/,
• ,¢~`.....f•~~?• . .
. a.
3. Nature of work check which a plicable): New Building Addition Alteration .
Repair , Re o~'val . Demolition Other Work ,~,K~'.
.
(Description)
4. Estimated Cost 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 .....I,. . .
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 , - Nutltiber of Stories .
,
De~tihstons of sa'me'structnr~pwt'th alterations or additions: Front Rear .
.Height Number of Stories .
' 8. Di ~tlsion~icona$r~tction: Front , . • • ..Rear • • .....:....::.Depth . • , . • . , • • . •
He ~ ~.1ut1t erof Stories .
• f'- 3
9. Size offo`I':°"Fiotl~".,;:;:~tM..,:~`.. Rear Depth .
10. Da"ta.of..1'~iircfi'a8e'', ''7 •:1"l"~: Name of Former Owner .
11. Zone or use district in which premises are situated .
13. Will lot be regraded . , , ate any zoning law, ordinance or regulation : .
p p • ................Will excess fill be removed from premises: Yes No
14. Name of Owner of premises viol . . . . .Address ...................Phone No............... .
Name of Architect .................Address ...................Phone No............... .
Name of Contractor , .Address .Phone No .
15.Is this ro ert loca
p p y fed within 300 feet of a tidal wetland? *YSS....NO....
*If yes, Southold TowniTrustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly all (buildings, 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
~ ~ 5~~~
AP~AS NOTEQ ,
DATE: ~ B.P, p
FEE~~
NOTIFY , ING bEPA,
766-1802 g AM TO 4 FOR THE
' FOLLOWING INSPECTIONS:
FouNUatTION TIMD
foRlpcwReo~REO
Z. pOUQM • fRIAMHIa #r'1+41MEINQ
8. IN8UI,ATION
4. FINAL
8! GpIMPLE~Kb11C~~T
ALL C~OMVSi1NJE11ON .
/S~TATE~R „4; .
~vvriN
I
STATE OF NEW YORK, S.S
COUNTY OF
(Name of individual signi ~ ~ ~ • ~ ' ' ' ' ' ' • • • • being duly sworn, deposes and says that he is the applicant
ng contract)
above named.
He is the
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duty authorized to perform or have performed the said work and to make and file this
application; that all statetnents contained in this application are true to the best of his knowledge and belief; and that the
work will be performed in the mannerl~set forth in the application filed therewith.
Sworn to before me this
............a.z. ....day of:'.............,19~5'
Notary Public, , . , I Q. I~!`~-...... County ~q ~ ~j
y
HELEN K OE Vv9~
NOTARYPUBLI&SGte t •~'j~' ' •~r~21:!5-4~-:w .
Na1707878,SuHolkCoa~idlr~ (Signature of applicant)
Term Expires Merch 30, ~e.,.,ky