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Home My WebLink About17443-z 1~0~ NO. fl TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK ^UTHORIZED) N~ 01~;;3 Z Permission is hereby grante~ to: ...~.~.~....~~..~......~..~ ..... ...~/~~...,...~.,.?~. ......... ./~- ~ County Tax Map No. 1000 Section ....... .//..,,~.. ....... Block ....... .~...~.. ..... Lot No ......./..~/ .... pursuont to ~ppltc~tion dotod ...~./.~. ............................................ , 191~.., ~nd ~pproved by tho Fee $.. ~.~ Rev. 6/30/80 FORM NO, 1 TOWN OF SOUTHOLD 13UILDING DEPARTMENT TOWN HALL ~OUTHOLD, N.Y. 11971 TEL.: 765-1802 E, amined ? ......... Approved ............ , 19 . ermit No ........... Disapproved a/c ..................................... .... (~u i! d i~'I n ~tp e c t o r ) · APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH ............ 3 SETS OF P~L~NS ............ SURVEY7~: .~..~ ............ ' CHECK .......... SEPTIC FORM ................ MAIL TO: Date .............. 1 INSTRUCTIONS a. This 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 areas, and giving a detailed description of I/~yout 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 removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessarg insp~eg~iq.n.s~ . . .~-~ ~ .~ i .... ... ......... (Signature o~ applicant, or nam e, if a co[p~ora~pn) . (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ............... O..c¢0.eg. ........................................................................ Name of owner of premises ~ /~ (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 License No ........................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. Location ofland on which proposed work will be done. ~.1~ .~ q .'j~.¢~ ~M .~.~/e_~/ . j¢. ...... '" ................... ._..,.,._. ....... ,~. ~..~... ~. .... .~ .... ( .... ..__ ,,, ..... . .... House Number Street Hamlet County Tax IVlap No. 1000 Section .... 'i !i3. ......... Block ....0..9 ........... Lot .... /.~. l ......... Subdivision ..................................... Filed Map No ............ Lot .......... (Name) 2. State existing use and occupancy of premises and intemted use and occupancy ofproposed construction: a. Existing use and occupancy .,...._............-....---.:. .................................. ..... .. .................. X' 3. Nature of work (check which applicable). New Bu din- · ' Add'" 2 . Repn,r .............. Removal .............. Demolition ........ ] .......,Qther Work...~ 'i ' Es' ' ,,~ [ ~ ~-, i fi-~OtC~_ (Description) 4. t~mated Cost . .s.,/...I.) .~ ................... Fee ~:~'~ . . (toibe paid on filing this application) 5. If dwelling, number of dwelling units ............... Number of dwelling Units on each floor If garage number of cars ................ 6. If business, commercial or mixed occu'pancy, specify nature and extent of each] type of Use 7 .... if any: Front Rear I ..................... · Dm~ensmns ofex~st~nl} structures Height Numl~er of Stories ................... i .......... Depth .............. Dimensions of same structure with alterations or additions: Front I Rear Depth Height... ' ........ ' ......................... ...................... · ................... Number of Stories ...................... 8. Din~ensions of en2ire new construction: Front Rear ' ~ "P.'~ .'~.-~-. Nmnber of Stories Depth Height .................... ~ ........ ~ .... ' ............ Size o£1~: Front ' ' · .................... I ............ Rear ~ Depth ...... Date of Purchase ............................. Name of Former Owner ......................... .... Zone or use district in which premises are situated Does proposed construction violate any zoning law ordinance or regulation ' ' 'J~0'~ ......................... Will i ................... .' ~.. lot be regraded ' ' , ........................ ............................ Will excess fill be remc)ved from premises: Yes No fp . Name of Owner o remises .. ............. Address ............. i ' ' ' Phone No ............... Name of Architect ........................... Address ......... , Phone No ....... Name of Contractor .......................... Address ' Phone No ........ :... 15.Is this property located within 300 feet of a tidal :wetland.* ~YgS .... NO .... ~If yes, Southold Town Trustees Permit may be requ~_red. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and,!indicate all set-back dimensions from and indicate whether 10. 11. 112. 13. 14. property lines. Give street and block number or description according to deed, and show street names interior or coruer lot. STATE OF NEW YORK, COUNTY OF .............. S.S (Name ofiu ual signin ontr above named. being duly.sworu, del3oses and says that he is the applicant Itc is the ............ ' (Contractor, agent, corporate officer, etcli} !; .: .................... of said owner or owners, and is duly authorized to nerform or apphcatmn, that all statements contained in thi .... m...,~ ..... · ....... ;{/~ ~ q,!~ - ~. and file this work will be performed in tl~e manner se* e~.,..? ~.I:*,[ ..... ;y-.?,~ [rue, [o me oest o~ ms:~.n'bw~,dgd'and belief; and that the c,.,~ · ~..~ . . , ,m,, mule appucailon Bleu therewith· o..u,,, ~o ucIore me tills ................ ~. ....... day of.../~/. ............ , 19 .~.e~. HELEN iL DE NOTARY PUBLIC, State of New York ,.. No..,4707878, Suffo k Courfly~, · , ~errn I:xpires Ml~rch (Signature of applicant)