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Home My WebLink About17378-zTOWN OF SOUTHOLD BUILDIHG DEPAR'Ir/~REIqT TOWN HALL $OUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK. AUTHORIZED) 017378 Z County Tox /Viop No. 1000 Section ..... ~....~.....~... .... Block ........ .~... ......... Lot No ....... .~...~.. .......... pursuont to opplicotion doted ................... ..~...~../..~ .............................. , 19...~....'~., ond opproved by the Building Inspector. Rev. 6/30/80 I ~= MONUMENT 9 Examined .............. , 19 Approved .: . .~/~../.. FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1802 " 19(~Permit NO /7..~ 7.~.~ Disapproved a/c ..................................... BOARD OF HEALTH SURVEY ......... :: CUEC ..... .............. SEVT C ............ NOTIFY CALL ..................... MAlL TO: ~ ~. ~g~ . . (Bflildini~qnspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS ?./../q Date ........... a. This application must be completely filled in by Wpewriter orin ink and submitted to the Building Inspector, with 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 l~zyout of property must be drawn on the diagram which is pan 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 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, a. dditions or alterations, or for removal or demolition, as herein described. 'The applicant agrees to comply with all applicaJ~ie laws ordinances, building code housing code and regulations and to admit authori~t~r~l~li~ ffl~m~ses and m building for necessary ~nspecI~ons " ....... . ~ ~ (Signature of apphcant, or name, l:f a co~-l~o'r~t'~c~n')' ' ' ' - - ' . '"" ' ~ (Mailing address of applicant) State w:I/~'tti~'h~?.l~jgt is ~9¢,{ae~r,,418~]ge, agent architect, engineer, general contractor, electrician, plumber or builder. Nameof6v}h'~i'b~i'' ' i es ',~~ ~ ~ p)' p),, ~ .... ,: .;.~.-.¢ ......... , ................................................... ' ' · * ' " (as on the tax roll or latest deed) If applicanBis II, d'orp~rat, i~}'ri;'}~,n~ti.re o:f duly authorized officer. Budder s L~cense 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 .......... ' House Number ~Street .~ Hamlet Lot, / / Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises~and intended use and occupancy of proposed construction: a. Existing use and occupancy ~..~ 9. 10. 11. '12. 13. 14. Name of Architect ......... i ....... Nam fC , · .......... Address ................... Phone No ..... e o ontractor ........ , .................. Address ................... Phone No. . ty ~t .... IS.Is this proper loc ed within 300 feet of a tidal wetland? *YES... · If yes, $outhold To~n Trustees Permit may be required. ... PLOT D I AG ILar'Vi Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dhr property lines. Give street and block number or description according to deed, and show street names and indic interior or comer lot.. Nature of work (check wluchiapphcable): New Building .... ' .... Addition .......... Alteralior (.i~i oval .............. Demolition ~V ~ ........ Repair .............. Rein ' ' Other ~r .'~. ~:&~ Estimate'd Cost ........... 1 ......"' .................... Fee .. . [ (t; b'e p~iU on filing this app~cation) If dwelling number of dwelling units Nunlber I ' ' ............... of dwelling units on each floor If garage number of cars ...................................... ' ............. If business commercial or mi.~ed occupancy ..... ' ........... l i ........ ' specify nature and extent of each type of Use Dimensions ofexistin~ stmctqres if any: FrOnt 'Rear Depth Heiglit Nmnl~er Of Stories ................................. [ ...... Dimensions of same structure tvith ........ ~ ................................. { ......... Depth alterations or additions: Front ................. Rear { ' Ileight Number of Stories ................ Dimensions of entire new construction: Front ........ I?ight ............... Number of Stories ....... Rear ............... Depth [ S~ze of lot. Front .. ~ · ........... Date of Purchase i ....... Depth ............ [ ....... ...... T . · ............ Name of Former Owner ............... ~ ~one or use instruct ~n wtuch premmes are situated /fl: .~'? z,t/~'-~.f 2~-- ' ' ' '[ .......... ,~,oes proposed constructmn wolate any zoning, law or~ n~,, ........ ,~,;~. ,~ z~ ~ ....... Wall lot be regraded ... adq... , ....... · ......... ~, ' .~,z~t2~ ~* ...... ., ....... Will excess Ii11 Deremoves irom premises' ?'es No l'~ame of Owner of premises .... fPF.'~.~'? . ---~ ~'~-~TFz rr~/¢ ' -- "', ~ -- ........ ^aaress Ir.' ...... Phone No ~.~.<~ -V<9*° ~/ FEE: N~~ OEPA AT 766-1802 9 AM ~ 4 ~ FOR FOg ~URED CONcg~ 3. 4. FINAL CON~T-"-- ' "u~ON MU T BE COMPLETE FOR C,O. CONSTRUCTION 8HALL T~L~ REOUIR~E~ OF STATE CONS~UCTION CODES. N~ RES~NSiB~ DESIGN OR CONS~U~ON ~RRO : applicant is the ...................... i ............. ........................... I (Contractor, agent, corporate officer, etc.) 1 ........ of said owner or owners, and is duly authorized to perform or have performed the said work and to make id file this application; that all statements contained in this application are true to the best of his knowledge and belief; a~id that the work will be performed in the manne set forth in the application filed therewith. Sworn to before me this ........... ...... nsions from ate whether STATE OF NE~VcYOR~) COUNTY OF.. c.~(,(._.{..~...[. ~.. ~.S ........ .... ' ...... : ................... being duly sworn, deposes and says that he is th (Name of individual signing contract) above nam'ed.