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Home My WebLink About17456-z ~OR~f NO, 0 TOWN 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) Rev. 6/30/80 193T. FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 BOARD OF HEALTH SURVEY ..... -...,~. ............ CHECK .......... ~ .......... SEPTIC FORM ................ CALL ................ HAIL TO: Disapprov~ ............. " .....~ ............. ~ .......:¥~ .a~. ,,.~../..~~' ................. , (Building m~ctor) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date . .] ........ 19 .~.~ · a. Ti,ds application must be completely filled in by typewriter or in ink and submitted to the Building 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 l&yout of property must be drawn on the diagram which is part of this appl~ cation. o. 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 penni 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 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 tht Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances o: Regulations, for the construction of buildings, a~ditions or alterations, or for i'emoval Or demolition, as herein described The applicant agrees to comply with all applicable laws, ordinances, building code, housin~ code, and regulations, and tc admit authorized inspecto~ 9.n practices;and, ~tbuilding for necessary inspections. .......... ~ j~.(S~gnature ot appbcant, or name, ifa corporanon) :c?: ', ~'. ' .. ~ ', ,,~,; ~ ti '~ e~ (Mailing address of applicant) or owner or ...... ' .... ..................... r -8 i40lx;'~)~t'8t'~O'''~ -JTJ'~ (as on the tax roll or latest deed) Ir applicant is a omcer. ~.r~ame Builder's License No ......... ~ ~ ............. Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No .......... : ........... I. Location of land on which proposed work will be done, , ~., .,~,-. ~...,.,~-. ............................... ' ..... House Number Street Hamlet ¢.¢. - / County Tax Map No. I000 Section ............... ~ Block ..... Lot , . .... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intemted use and occnpancy o(~roposed constroction: a. Existing use and occupancy ............................. [ ....................................... b. Intended Use and occupancy 3. Nature of work (check wluch app cable). New Bu Idin' '. 5. If dwelling, numberofdwellifigtnts .. Numberofdwellin un'~] If garage, number of cars ~ ......... g ~t~ ~ ' ' v4... . If business, commercial or mi ed occupancy, specify nature and exten~ of each type of use .... m~ens OhS of ex~stmg stn~ctures, if any: Front .......... .... Rear .............. Depth .............. Hm ht Nmnber of Stones Dim ' ~ ' . ............................... ~", ....... ~ ............. ensmns of same st~cturelw~th alteratmns or additions: Front ~ ~ ; Rear Depth ~ lleight ......... ' .................... Numfier ~StoMes . Dimensions of entire new con~tn~ction: Front Rear ' ' ' .............................. Dept~ .............. Height Nfiln ~er of Sto~es Size of lot: Front .... ' ............. Rear '~ Depth Date of Purchase. . ''. '~ .... . ................ Name of Fo~er Owner ........................... Zone or use d~stnct ~n which premises are situated ' Does proposed Construction violate any zoning law ................................................ , ordinance or regulation: ............................... Willlot be reeraded . ,, -~ ~ ~, · · · ~., ..... ~ ....... Wdl excess fill be removed from premises' Ye ....... · ·. ~ouress/~.Odg ~ 1K,~ ~ ~~ ~ ~.~ 15.Es this property Ioe~ated within 300 fee~ ~If yes, 8outhold To~n TrUStees Permle may be required. PLOT DIAG~ Locate cle~ly ~d dist~ctly fll bulldogs, Whether existing or proposed, ~d, indicate fll set-back d~ensions from prope~y Enes. Give street ~d bloc number or description aecord~g to deed, ~d show street n~es and indicate whether interior or comer lot., 10. 11. "12. 13. 14. STATE OF NEW YORK, N~ BUILDING D~'P~ 7e54eo2 9 AM ~ ~ PM FOR THE FO~owING INSPECTIONS: 1. FOUNDATION . ~0 REQUIRED FOR ~UREo CONCRETE ' 2. ROUGH. ~AMING & PLUMBING 3. IN~U~T/ON 4. FINAL CON~U~ION MUST' ACE coMPLirre FOR C.o. LL CONIITRUCTION ~HALL ME~T & ENERGY COOlIS. NOT RESPONEIBLE POR DESIGN OR (~:)NSTt~U~ON ERROR8 COUNTY OF... S.S ·. ~..: l ........................ being duly sworn, deposes and says that he is (Name of individual sign, lng contract) the applicant above named, He is the .......... i ................................................................ (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have perforated the said work and to make and file this application; that all statements contfiined in this application are true to the best of his knowledge and belief; and that the work xv~i be performed in the manne~r set forth in the application filed therewith. Sworn to before me this .............. ....... ofi.. ............. Notary P.b.e ...... ..... County HELEN K. NOTARY PUBLIC, State Of New York ,. Ne. 47078711, Suffol~ Coui~ty~9 lerm Expires Msrch (Signature of applicant)