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Home My WebLink About17400-zTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 017400 Z County Tox Mop No. 1000 Section ......... ~..,, .~.,, .... Block .............. ,,~,,... Lot No...,,,~.,...~ ..... pursuant to application dated ............. ~:.....~... ......................... , 19...~....~,, and approved by the Building Inspector. Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL,: 765-1802 Examined..?/~. ......... , 19 .~..~ Approved .:. ~ .~.~, ..... ':.., 1 9~ee rmit No. ~..~ .~..~...~ / Disapproved a/c ..................................... APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH .......... .. 3 SETS OF PLANS ............ SURVEY ......... ~ ....... CHECK ....... ~ ............. SEPTIC FORM ................ NOTIFY CALL ..................... MAIL TO: Date ................... 19... INSTRUCTIONS a. Tttis application must be completely filled in by Wpewriter orin ink and submitted to the Building Inspector, with t 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 street.~ or areas, and gi,~ing a 6etailed description of l&yout of property must be drawn on the diagram which is part of this aiSp-l~- cation· c. The work covered by tkis 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 inspecti9n 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 l~ave 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 laws, ordinan%q.sr4m'it3ding code, housing code, and regulations, and to admit authorized inspectors on premises and in building for neces~,Yry ins/s/s~_efftion~4 · '(~g/llture'o'f a~l~lic~r~t, ;; fia'n~e', ~f'a' c'o¥o'r~f~c~n') ' ' ' · . '~-. (M ailin/ffadd ress of applicant) ~ / '' State wl}etl~l,~p~Satt~py, t33~r,' lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. 3~ aOl I~ $ ,0~ tO,~ ~ g~.~ ,5~i / (as on the tax roll or latest deed) ............. aP~]~l~O/:,at/i~!~al~o;;. , . au y autnorizea onmer. .... ~4~fi~m'~'~'al'~',' 1,~*~ ................ ...... '. ~lt4t .............. i~i'"~~ll~ · .a~t~;~ ............. :.¥. ............. 1 Location of land on which proposed work will be done .......... .x. .... Z ?/ . . . . . ( : . .a. .... . . .:. . . . e . . . ........ House Number Street Hamlet County Tax Map No. 1000 Section ~../7{. Block <~ Lot v~?~;:~ ....... Subdivision ................................... ..................Filed Map No. .~. ~f,f' Lot .~.~. ......... (Name) - 2. State existing use and occupancy of premises and~ intended usc and occupanc, Y of .roposedn construction: a. Exist n,, u ~ ~ ~'~ - - I ,:~, ~ t / ....... ........................ ' ' b Intended ! (. : ~ (>. / · use and occu ancy .......... -~,,,(:;~:'¢s~ ...... ?,; .... 3. Nature o[work (check whichlapplicable): New Building ..... ' ..... . * ~ Repot .............. RemovaI .............. Demolition . ' .,~ 4. Estimated Cost ................. Fee , · ..... ~. ~ ~ ...... ~ .......... (to be paid 6~'h'Jing this application) 5. If dwelling, numberofdwelli4gunits · ~ ..... Numberofdwelling nnitson each floor.. If garage, number of cars . .i. . ~. &~ business commercial or mi~ed occupancy specify nature and extent or each type of use 7. ~imensionsofexistin~stmct~res if any:Front.. ". ....... Rear .................... Heiglit N~mber of Sto~es .... · · ... · · · · · · ·... Depth ............. Dimensions of same structure With alterations ~ ................................................... Depth IIeight additions: Front ................. Rear ................. .............. · · · ..................... Num bet of Stories 8 Dimensions of entire new con~tmction: Front Rear ..................... .............................. Depth .............. Height Nu?ber ~f Stories 9 Size of lot: Front ....................................................... ' ' ........ ~ ............ Rear Depth 10 Date of Purchase ................................... ......... ' ................... Name of Fo~er Owner 11 Z .................................. . one or Use d~stnct m w]nch ~rem~ses are situated 12 Does proposed construction violate any zoning law ..................................................... , ordinance or regulation: .................. 13. Will lot be regraded ....... ~ .......... -- ......... Will excess fill be remove~from premises: . Yes Nc 14. N~eofOwnerofpremises. ,~/~.~ .Address .~q~g~PhoneNo. N~e of Architect .... i ................... Address ................... Phone No ....... 15.Is thxs property located ~ithin auu feet o~ a eida1 ~tland? ~gS...~... ~If yes, Souchold to~n Trustees Permit may be required. .. [ PLOT DIAGRAM Locate cle~ly ~d dist~ctly ~1 bu/ld~gs, whether existing or proposed, ~d, indicate ~1 set-back d~ensions from prope~y ~nes. Give street ~d block number or description accord~g to deed, ~d show street n~es and indicate whether interior or comer lot.. STATE OF NEW YORK, COUNTY OF .... ............................................. being (Name of individual signing contract) above nam'ed. ,lIT fie is the ...................... ! ..................................................... . ... ' (Contractor agent corporate officer etc ) .......... of said owner or owners, and is dul~ 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 manne~ set forth in the application filed therewith. Sworn to before me this I ....... ....... ....... .......... ~ ,,~,~ ~ .............. H~EN~DE~E · ~C~~ :. NOTARY PUBLIC, ~ of ~W Yo~ N0. 4707878, Suff01k C0uWff~ (Signature of applie~t)