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Home My WebLink About17412-z I~OR~ NO. ~ TO~N OF $O~THOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y, BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N_O 01T412 Z ............................................ ........... County Tox Map No. 1000 Section ..... ./....Q'~'./. ........ Block ......... ~ .......Lot No......~......~..e../. ..... pursuant to application dated ...... .~./ ........................................ , 19...~.~., and approved by the Building Inspector. Rev. 6/30/80 Examined . .~. -~/'~· · · ...... ..., 19 .6~.~' Approved .......... 19... ennit No .......... Disapproved a/c ..................................... FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 (~dildin~fispector) APPLICATION FOR BUILDII',IG PEFIMIT INSTRUCTIONS BOARD OF HEALTH ............ 3 SETS OF PLANS CHZCK .... .~' ................. SEPTIC FORM ................ NOTIFY CALL ..................... MAIL TO: Date ................. I . a. This application must be completely filled in by typewriter or in ink and submitted to the Buildihg 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 street or areas, and giving a detailed description of lhyout of property must be drawn on the diagram which is part of this appli cation. ¢. 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 perrai shah 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 xvhatever until a Certificate of Occupanc~ 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 th( Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances o~, Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described The applicant agrees to comply with all applica~ie laws, ordinanc?e~uil.ding code, housing code, and regulations, and t¢ admit authorized inspectors on premises and in building for nece~ry insp.~tions ~[]lJ~ ~1[ Q~i~,'~q~$ ' (~ 'thie'o'f a~hcant, or ~ ''' -' ..... ._.~.-.~-".-a; ..e~ta raja /r,,t. ~, ~/' (Mailmo address of~pplicant) ' "'~'~'" ~ ~ Olr ~'~ ~ ~ )~ ' ~' genera contrac't~lectrician, State wr~Ae~l~ ;F~lt~,~q~[~.~,ssee~< agent, architect, engineer, ~} ..... plumber or builder. ......--- ......................... . ............ Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... l. Location of laud on whichj,ropo[~;d wo/.k will ~be do. nh...~'~...~. ...... :. .... o.. . ......... :.,. r '".".."" House Number Street Hamlet /q/ County Tax Map No. I000 Sectiou ................. Block ............ Lot ...'. ! Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises~se and~.,occ, up~cy of proposed construction' a. IntendedExisting use and occupanCYUse and ......................... ~ ~' ' ' ': "~' ' ................ "~ ......... i ..... ,b. occupancy ........... ,__ ................ ' :" L' ......... ': ............... 3. atur. e ofxvork (check wluch;apphcable): Ne~v Building ..... ' ..... Addition . ~... ~. . Alteration " : ' 'Oo be ~ .... 5. If dwelling, number of dwelli0g onits ~"-- Number of dwelling units on each floor .,~. ..... ~... If garage number of cars 6 If busine'ss .................................................................. · , commercial or nfl.xed occupancy, specify nature and extent of each type of use i ~i ~ · mmns OhS ofexmtmgstn,ctures finny: Front Rear ............ ' Depth Heiglit Numl~er of Stories ........................................... Dimensions of same structurelwitb alterations or additions: Front Rear ' Depth I IIeight ........................ .................. ' ................ Number of Stories 8 Dimensions of entire new conitrnction: Front .......... ' ................ Height : Nfimber of Stories ............... Rear ............... Depth ........... Size of lot: Front . .. '' : ............. Rear ...................... Depth ..................... Date of Purchase ......... I ............... Name of Former Owner .......... Zone or use district in wliicb Premises are mtuated .... ' ................ Does proposed construction violate any zoning law, ordinance or regulatio Will lot be r g ad d , n ........................... e r e ...... . .................... Will excess fill be removed from premises: Yes Name of O~ f p i . N vner o rem scs ~ ............ Add Pt No Nam fA hit '~ · · ..... ress ................... rune e o rc eot ........ · .............. , .................. Address ................... Phone No ............... Name of Contractor ....... : ............ . ....... Address ....... : ........... Phone No .......... .Is this property lo~ated withxn 300 feet of a tidal wetland? *YE$.. 15*If yes, Southold To~n Trustees Permit may be required. ~''' Locate clearly and distinctly all buildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. Give street and bloc number or description according to deed, and show street names and indicate whethe~ interior or corner lot. I0. I1. "12. 13. 14. STATE OF NEW YORK, IS.S COUNTY OF .... . ............. ..... b i d lysworn d d th thei .......... ('I~ ................ ~ ............... cng u , eposesan s s a s cant amc of individual signing contract) ay the appli bo d ' He is tile ~ , - (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'hnd file this application; that all statements contained in this application are true to the best ofliis knowledge and belief; and that the work wHl be perfomned in the mmme: set forth in the application filed therewith. Sw0m to before me this ~REN · DE ~E ' ~ARY PUBLIC, ~e of ~w ~ . ~ 470767[ ~lk ~ , :' '