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Home My WebLink About17379-z FORUM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, H. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 017379 Z Permission is hereby granted to:. _ ~ ¢ .,9 ~~~....~,./...x:..~~...~. ~,) ~....~...../...~. ......... . ......................................... ~_ ~ ..... ~..~~,..x:~.,......:~..xx~...~-- ot p,emls, ,oca,ed o, ...~.~..~......~:....~/,.. ................................................................. ....................................................... ................................................... County Tax Map No. 1000 Section ......... ./..,~......~..... Block .......... ~. ....... Lot No .......... ./.....'~. ....... pursuant to application dated ................ ~.././..~.. ........................ , Jg...~...~'., and approved by the Building Inspector. / Bu~ng Inspector Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.; 765-1802 Examined .., 19... Disapproved a/c ..................................... BOARD OF HEALTH / 3 SETS OF PLANS i.'~.',[]....... ....... SURVEY ......... Oe~-~; . . C.ECK .......... 45 ......... SEPTIC FORM .... ./. .......... NOTIFY CALL ..................... MAIL TO: ,("B u i I ding Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS aJ Tiffs application must be completely filled in by typewriter orin 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'~reas, and giving a detailed description of Dyout of property must be drawn on the diagram which is part of this apph- 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 throu~hout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy sMll 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 Buffding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, ~gr the construction of buildings, additions or alterations, or for removal or demolition, as herein described. he ~ipplicant' agrees~c~jllll~l~!~-~lAapplicable laws, ordinances, building code, housing code, and regulations, and to admit autllgrlged msp~l~{b?~ ign premises and m building for necessary inspections. ~l~"~i~'" ';3i;~i~t~Sif'~:~' '?' ¢~:: (S~gnature ot apphcant, or name, if a cgrporanon) ,>},i ,1XVf't,' ~¢ ,t,~l ~ ...... ' ....................................... ~iffi~J~l~ O'~'t ~C;~d~it~ ~ * (Mailing address of applic~t) State whether app ica~ IS'p3yger .~geO,.0.gegt. architect, engineer, general contractor, electrician, plumber or builder. ................... ~,?~ ............. , ................... , ..................... ' .... .y,~ ~ ~g ~Xrl~ x~!~ (as on the tax roll or latest deed) If apphc~nt Is ~a~a~t~e,~l~*~!horized officer. t (Name and title~f co.orate 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 ................................ 5 ': /-/ ................... House Number Street Hamlet County Tax Map No. I000 Section .... /.~(?x ......... Block ....~. ............. Lot../.?) .............. Subdivision ..................................... Filed Map No ............. Lot .. (Name) 2. State existing use and occupancy of premises and intemted use and occupancy ofproposed construction: b. Intended use and occupancy ....... . ' / ........ '~" t · · 7 ........................... 3. Nature of work (check which applicable): New Building ..... ' ..... Additi n .......... Alteratio/~ ......... Repair .............. Removal .............. Demolition ....... o.. ?/her Work. .~ .... 4. Estimate'd Cost ...... O ....... - 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 ears ....... If business, conunercial or mixed occupancy specify~atnre and extent of each type of use ....... 7. Dimensions ofexistin'~stmctures, ifanv. Front ' '- ~ ..... ' ............ v, · ,. -' -' ................... '~' .............. ~eptn nmgnt ............... Number of Stories ............................... - .................. Dimensions of same structure with alterations or additions: Front ..... pth ................. Rear ............ De ...................... lie ~t ....... NumbcrofStories ................. · ~imensions of entire new construction: Front ............... Rear ............... Depth .......... igl f St .... e ~t ............... Number o orieSsi ...................................... of lot: Front ................. Rear .................... ~.. pth ..... De Date of Purchase ............. ' .................... · · .............. Name of Former Owner ................... ./4.4 5. .... Zone or use district in which premises are situated ..... t ...... NWilm~l leO; fb;~ng; e~ ~7:,~_.~.~.~ . · Will excess fill be removed from premises: Does proposed construction violate any zoning law, ordinance or regulation: ................................ ad ' ' '. ...... J ...... '] Yes Nc r et premises ./V.z?~!.c... ~.~/.(...LV..~,4. Address ..../~...~..t.7~...6(e-7 .... Phone No.. ~...v~.%~..r/..~... Name of Architect ........................... Address ................... Phone No .......... ~. ....~. Name of Contractor .......................... Address ................... Phone No .............. '~' 15.Is this property located within 300 feet of a tidal wetland? *YES .... NO .... · If yes, Southold Town Trustees 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 comer lot.~ 10. I1. '12. 14. FOLLOWING INSPECTfONS: I, FOUNDATK)N ~ REQUIRED FOR POURED CONCiqEI~ 2. RO~H - ~AM~ INSU~ffi 4. FINAL BE COM~ ~ C.O. ALL ~NST~ ~E REQUIR~ STATE CONS~ ~ ~y CODES. ~ DESIGN OR STATE OF NEW YORK, COUNTY OF .............. S.S ................................................. being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. ftc is the ...... (Contractor, agent, corporate officer, etc.) 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 statements contained in this application are true to the best of his knowledge and belief; and that the work w~l be performed in the manner set forth in the application filed therewith. Sworn to before me this NOTARY PUBLIC, State of New York .... No, 470787g, Suffolk County ? 4'