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Home My WebLink About17360-z ~0~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL PULL COMPLETION OF THE WORK AUTHORIZED) N~ 017360 Z Permission is hereby granted to: ............................... ..~Z ............................................... County TOy, Mop No. JO00 Section ...... -- ~ 3 Block / Lot No ........... ../.....~...... pursuant to application dated .............. fi/../...~.. ............................ , 19~..~., and approved by the Building Inspector, Rev. 6/30/80 J. FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Disapproved a/c ..................................... ............................... ...... APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH ............ 3 SETS OF PLANS ............ SURVEY ..................... CHECK ...................... SEPTIC FORM ................ CALL ............ MAIL TO: 'Pa 7 ,.~OU'W'ff-et-O ~, N.y. 11'~'7! Date ................. INSTRUCTIONS a. This application must be completely filled in by Wpewriter 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 9f buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of properW 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 parr 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, a,d. ditions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable taws, ordinances, buliding code, housing code, and regulations, and to admit authorized inspecl~t~l~ ~tle~fitfiqn building for necessary inspe/gh'6~, .-~ .- ~ , -~_/~ 2~.~l?,':~:tq ;z~.t ;'W-?'r., ~ ,Jr', 1 (Mailing address of applicant) State whether applicant ~tll~~,tarchitect, engineer, general contractor, electrician, plumber or builder. .......... 13. W. tY.~,. ! .~ ......... ~O~'~.~41 ..£ ....................................................... Name of owner of premises~l~.lq~.~J ......................................................... ~ ~ ~::~I~ ~ f~ (as on the tax roll or latest deed) ............. ~.~~ ~ ~O~ne~ ..... ( Nam q'~fl'd~iYgF ~'6'~ oi~ t ~ officer) Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done .................................................. ................... v. . . ...................... House Number Street Hamlet CountyZax Map No. I000 Section . .~.~. ............ Block .... / ............. Lot. ~.1.~. ...... Subdivision ..................................... Filed Map No ............... Lot ............... (Nmne) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy .~...~.--? ~..~...~. !-,, b. Intended use and occupancy · ~--"~l~.lr..~.'~ .~'& .ll~lk.. ~4~__ Nature of work (ch?ck which applicable): New Building . ' Addition - Alteratior~ .......... Rep:fir ............ Removal .............. Demolition ......... Other Wor~.. ~ .... Estimat e'd Cost .... * Fee ......... i (to be paid on filing this application) 1 5. If dwelling, number of dwelliffg units ....... f ........ Number of dwelling units on each floor ......... If garage, number of cars ... ! ............................................................. 6. If business,/comtnercia, 1 or mixied occupancy, specify n~ature and extent of each type of use ............. 7. Dimensions of existing structures if any: Front ~ .. . . 'Rear ..... Denth .eq..~.;. ' Height ..., ............ Nu!mber of Stories )~'~.~i. ~].~... ' .'' 'j. ''~'. ~ ..:: '' Dunens~ons of same structure th alterations or additions: Front ~ .......... Rear ........... Depth ~ Hei~xt .......... ' ....... ; ........ Number of Sto~es 8 Dimensions of entire new construction: Front ...... ' Rear Depth Height Nulnber of Stories ............................................. 9. Size of lot: Front '~.'...( ..... Rear...~0 ................. D p~ .7~/ ....... ? ........... 10.Date of Purchase ' ~ ................ Name of Foyer Owner ........................ 11. Zone or use district in which premises are situated 12 Does proposed construction viClate zoning ..................................................... · any law, ordinance or regulation: 13 W'lllotbe eg d d ~ ' 14' N~e of Or ra e ...... . ..................... wm excess m~ oe removed from premises: Yes N · wner of premises .~. N~ f A hit ....... e o rc eot : Add Phone No Nme of Contractor ........ i ................ Address ................... Phone No ............ '... 15.Is this property loc~te~ ~ithln 300 feet of a tidal ~etland. *YgS .... ~O.~. ~If yes, Southold Tow~n Trustees Permit may be required. PLOT DIAG~ Locate cle~ly ~d distinctly ~1 bulldogs, whether existing or proposed, ~d. indicate ~I set-back d~ensions from prope~y Hnes. Give street ~d block number or description accord~g to deed, ~d show street nines and ~dicate whether interior or corner lot. STATE OF NEW YORK, COUNTY OF ................. · (Name of individual signing contract) above named. FOLLOWIN(~ INSl~Crrlof~l: being duly sworn, deposes and says that he is the applicant He is tile ~ (Contractor agent corporate officer ere ) ........... 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 state~nents contained in this application are true to the best of his knowledge and belief; and that the work will be performad in tile manne~ set forth in the application filed therewith. Sworn to before me this ............... /.6 ...... day ofl ...... Notary Public ...... ~...~'..~..~. ~. · .~'~'~..' . . . County NOTARY HELEN lC DE'JOE PUSUC, S~..~ of .New. Yolt . No. 47078781 :SunolkCoumws,~ ~erm Expires Mf~rch