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HomeMy WebLinkAbout17531-z FOEM[ NO. fl 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) Permission is hereby granted,l~'~., ~ j , · © , ....~.~L~,_..~..:.?..:..../.~.~..~.~..~..;... ,-~ ...... ......................... premises Iocoted ............................................................ ~ ........................ County Tox Map No. 1000 Section ...... ,J..(~.....:~m.. ..... Block ........ .C)...~ ...... Lot No ..... ,.'~....~. ........... pursuant to application dated ..... .(~..~,..~.....~ .................. , 19.~..~., and approved by the Building Inspectar, Fee $.....~. ,./.:.....'~.... ..... Rev. 6/30/80 ~L--~io~' O~ou~'"- TOWN OF $OUTHO FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N,Y. 11971 TEL,: 765-1803 BOARD OF HEALTH ............ 3 SETS OF PLANS ............ SURVEY ........ ~1~ .......... CHECK ...................... SEPTIC FORM ................ NOTIFY CALL ..................... MAIL TO: .... ~ ?z~. ~/:.~ Approved ~...°'~'4~...I.~.., 19~. Permit No. ~.7...~.a.I. .~. Disapproved a/c .............................. ......,/'~ ................................ .... (Building Inspector) APPLICATION FOR BUILDING PERMIT Date ................... 19... INSTRUCTIONS a. This application must be completely filled in by Wpewriter 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 9f 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 tkis 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 tb-e Building Department for the issuance of a Bttilding Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New Yorl~, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions 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 necessary inspections. ~. (Signature ot applicant, or name, if a corporanon) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. 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 of land on which proposed work will be done... ~. ........ ~.~,:.~,~ ..... ~. ~. ~d., ....... ~/~/. ~. , ~.~. :<.,~,~. House Number Street Hmnlet County Tax Map No. 1000 Section ..... /.~. ~ ....... Block ..... ~ .......... Lot... ~.~ ........... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: ~. ~x~,.~ u~ ana o=~,,..'~..-:~ ...... z... :4~..~>~ ,.....,'.. x ~.c :. ~ ..... b. Intended use and occupancy ..................... ~ ~ ;~* ~. . ....... 7. Dimensions of existing structures, if any: Front ......... ~. .... Rear .............. Depth ......... Height ............... Number of Stories ........................................... Dimensions of same structure with alterations or additions: Front ................. Rear ..... Depth ................... i. ·, Height ...................... Number of Stories ......... 8. Dimensions of entire new construction: Front ............... Rear ............... Depth .. Height ............... Number of Storie~ ............................................ 9. Size of lot: Front .......... i ............ Rear ................ ' ...... Depth ......... 10. Date of Purchase .......... ! ................... Name of Former Owner ................ 11. 3. Nature of work (check which applicable): New Building ..... ' ..... Addition ..... ; .... Alteration 4 E timate'd Co F ~ '" 5. If dwelling, number of dwellin¢ units ~ u ' · ' ............... N tuber of dwelhng umts on each floor ................ If garage, number of cars .... I ................................................................... 6. If business, commercial or mixed occupancy specify nature and extent of each type of use .................... Zone or use district in which p~emises are situated ........... 12. Does proposed construction vxolate" any zomng' law, ordinance or regulation: 13. Will lot be regraded ........ ! .................... Will excess fill be removed from premises: Yes No 14. Name of Owner of premises . .[ .................. Address ........... Phone No.. .~.~.~.2~.,g .~.~.. Name of Architect ' ' Address Phone No Name of Contractor Address Phone No 15.Is this property located within 300 feet of a tidal vetland? *YES .... 1~IO .... · If yes, Southold Tow~n Trustees .Permit may be required. ... i PLOT DIAGRAM Locate clearly and distinctly aill buildings, whether existing or proposed, and. indicate ail set-back dimensions from : number or description according to deed, and show street names and indicate whether property lines. Give street and blocl interior or corner lot. STATE OF NEW ¥~)RK(7,C2 rl~ COUNTY OF...--~ ~ .~.c~. (~... S.S .......... ~ .................. being duly sworn, deposes and says that he is the applicant (Name of individual sighing contract) above named. ., He is the (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 cont¢ined in this application are true to the best of his knowledge and belief; and that the work will be performed in the manndr set forth in the application filed therewith. Sworn to before me this ~ ..... . .......... ...... Notary Public, ...[~r~(.~...~.."~..~. County ~o Ilu~. ~lf~dln 8uffolk~xlfit~ W/r/ (Signature of applicant) mml~wn