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Home My WebLink About17441-z FOBI~ NO. i~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. Y. BUILDING PERMIT (THIS PEI:~VdT MUST BI: KEPT ON THE PREMISES UNTIL FULL C:OMPLL:TION OF THE WORI(AUTHORIZED) N~ 017441 Z ........ ................... at premises l~ated at ....... ~..~;..:..~ ............................................................... CounW Tax Map No. 1000 Section ..... Z~.~ ..... Bl~k .... ~. ............. Lot No....~ ............. pursuant to application doted ........ ~ ................................ , ]9:;~ and opprov~ by the Building I~spector. Rev, 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined. ~..'~. t'/~. ....... ,19 .~.~.~ Approved ......... , ... ermit No ............ BOARD OF HEALTH ~... 3 SETS OF PLANS . . ~ ...... ...... i' CHECK ............... SEPTIC FORM ................ NOTIFY CALL ..................... MAIL TO: Disapproved a/c ...................................... ............................. o B APPLICATION FOR BUILDING PERMIT Date INSTRUCTIONS a. Tiffs application must be completely filled in by typewriter 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 Of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of property 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 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.d. ditions or alterations, or for x:emoval or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing c,o~de, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. ,, ~ 0t/,,dJ?_d. ' (Sign~t~fe ot applicant, or name, if a c~q_q~oranon) ----. - · (Mailing address of applicant) (-~, State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ....~44~.....&). ~..~.. ..... ". (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder 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 Num bet Street County Tax lVlap No. 1000 Section ....... /..~..~. ...... Block .......... 4 ....... Lot ..... lt'. .~. .......... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and o.ccupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy : b. Intended Use and occupancy Rennet ,.-, .......... ~, .......... ~ma t on~x...4 .... A~teratlon :. ; ..... -,- .......... : ..... ~ernoval ............. : Demolition .......... ~...: 0~o~~.. 4. stxmated Cost ........ ff~ .... Fee ' ~ ................. ,:~ L , i ~ ~n (to be pazd3ag~g~.~a.lion) 5. If dwelhng, number of dwelling units ............ ~ber of dwelling units on each floor ........ } ....... If garage, number of cars 6. If business "~ ..................................... ,conlmercial ormixed occupancy spec fy nature and extent of each t e of us .... 7 D ...... . , yp e · m~ensmns of ex~st~ng structures if any: Front ..................... Height NuMber of Stores · · · ...... Depth .............. ..... Rear . Dimensions of s~e structure With alterations or additions: Front Rear Depth ~ tIei~t ................................... ............................................. Number of Stories ...................... 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories ............................................. siz oc o : i ........................... ..... :2 .............. ..................... Rear .............. ' ..... Date of Purchase ....... .......... ~ ........... Name of Foyer Owner ............. Zone or use district in which p~emises are situated Does proposed Construction vi~late any zoning law ................................................. 2 ' ' ' Will lot be regraded , ordinance or regulation: ............................ ~ ....... ' ' '.' ' ' ~' .... 3' ' '~ ' ',V' ~' · Will e[~esLff~e~remoged from premises: Yes Nmeof~wnmotprem~ses H~...~.~..Address[(~ ~ ~ PhoneNo.~ Nme of Architect ; ' .... · ......... ~ .................. Address ........... Phone No. Nme of Contractor ~ ....... ~ .................. Addre~ ................... Phone No. ........... i... 15.Is this property loehted within 300 feet: of a tidal wetland? ~YES .... NO~ · If yes, Southold Town Trustees ~_ermlt may be required. PLOT DIAG~ Locate cle~ly =d distMctly ~ buildMgs, whether existing or proposed, ~d. indicate MI set-back d~ensions from or description accordMg to deed, ~d show street nines and Mdicate whether 10. 11. 12. 13. 14. property lines. Give street and block: number interior or comer lot. STATE OF NEW YORK, COUNTY OF ........... ;.S (N fi .... L; .................. amc o ndividuals m contract) above named. fie is tile i (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 contaihed in this application are true to the best of his knowledge and belief; and that the work will be performed in the manneriset forth in the application filed therewith. Sworn to before me this Notary Public, .~e.~e4~..~.,...~.~ ~.t~.....:. HELEH K, DE . No. 4707878, Suffolk ~untyoc, o (Signature of applicant) tm'm Expires Uarch ~0, being duly sworn, deposes and says that he is the applicant