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Home My WebLink About17155-zTOWN 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) 0~7~55 Z Do,e ...~ .?'.~ ..................................... .¥~,. _~...~...~.:~ .......... ./,~/.? .......... ....... .............. County Tox Mop No. 1000 Section ......... ~/. ....... Block ........... ~ ...... Lot No ........... .~..~..... pursuant to c~ppJicotion doted ................ ~./~. ......................... , 19..~..,~and approved by the Building Inspector. Fee $ ......... Rev. 6/30/80 Examined f(~..~.,~ ........ 19 .~..~ Disapproved a/c ..................................... FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N,Y. 11971 TEL.: 765-1802 BOARD OF HEALTH ............ 3 SETS OF PLANS ............ SURVEY ..................... CHECK ...................... SEPTIC FORM ................ NOTIFY CALL ..................... ~MAIL TO: (Build, lng I~ector) APPLICATION FOR BUILDING PERMIT 'APPJtOVEDASIIOITO/ Date .... ........... a. ~/~E~V~C~Iy filled in by typewriter or in ink and submitted to the Building Inspector, with3 sets ofl~l~t~.~o%~ _e.~r~ee according to schedule. b. ~l~'li~i~'I/i~~nd of buildings on premises relationship to adjoining premises or public streets hr area'g, ~'~~of lhyout of property must be drawn on the diagram which is part of this appli~ c. _~T~ptli,Oi~eren oy tffd~'h"lb~li~hti'on may not be commenced before issuance of Building Permit. ' - '-~'F6¥'8~ ' ' ' d.4.'E~'~V~l?pro ~t~l~~~he Building Inspector will issued a Building Permit to the applicant. Such permit shall be l~lttt~l~i~.i~t~p~ffblblb"~Tlnspection throughout the work. e. g~-~-~e~sed in whole or in part for any purpose whatever until a Certificate of Occupancy At~~~[~IJ~o the Building Department for the issuance of a Building Permit pursuant to the Buildi~_~,e~J~~~Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regul~,'Y~'e~¥q~3hg~f~fi~ings, additions or alterations, or for removal or demolition, as hereLn described. The applicant agrees to comply with all applicable laws, ordinances, building.code, housine~code, and regulations, and to admit auth?rized inspectors on premises and in building for necessary~p~, s. (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, en~neer, general contractor, electrician, plumber or builder. Nameof0wnerofpremise, ./~..'~).~.y.....,.,.~.. ,'~./.~ '.~ ..,.~..~. ................................. (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/and on which proposed work will be done ...... ' ' . ............................. . . /. ................. t. l,g., . . . .& House Number Street Hamlet County Tax Map No. 1000 Section ...~./. ........... Block ...~ ............. Lot .... ' ............. S.bd s on.&t. ........ ,ed.ap No ............... ot. .... ' ........ (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy . . .~ .~. .q~ .... ~ .... . .......... b. Intended use and occupancy . · i ...... . . Locate clearly and distinctly all buih property lines. Give street and block numb interior or comer lot. 3. Nature of work (check which applicable): New Building ..... ' ..... Addition g~.~..~..'~.. Alteration Repair Removal .......... ............................ Demolition Other~9i~ 4 Estimate'd Cost .~...~..l~.. i (Descript.ion) ' (to be aid on filing this application): $. If dwelling, number of dwelling un ts ............... Number of dwelling units on each floor.. If garage, number of cars ....... I .......... ' ............. 6. buan ss. c merclal or mixed o cupanc¥, specify nature and extent of each type of use .............. font.. . , ....... 7. ~aimensmns o~ existing structures, if any: F ear . t .... ..... ,,..' .... : ......... ::,..........R epth ............... igh Numbe of Stories .......... Dimensions of same structure with hlterations or additions: Front ..................... D -~ ' ................. Rear . · mensions ofe. q,0tire new co s c ........... Height .... .~..t. ...... Nmuberiof Stories ' i i '-;4 ,,-vw ...... -.~.. laeptn .;r ............ 9. Size of lot' Fron~ ~ · 10. Date o£Purchase~.~..~r.~ [ .. · ....... ,~I~epth .. v' '.~'' .,..~ ......... 1 1. 6one or use district in which premises are situated 12. oes proposed construction violate ~Iny zoning law, ordinance or regulation: ,~).J~ffi~[~,~ 13. Will lot be regraded ../,9~.(~.~ ..... i ............... Will excess fill be removed fr cruise · If yes, Southold Town Trhstees Permit may be rea i;~--"~(}~J'~3~la~f31~q~{~'' [nils, whether existing or proposedottp, g~tilgffiatlel~okl~[~d~i~ns frown ;r or description according to deed, and show street namet~'fi~d~dil%e whether t STATE OF NEW YORK, S.S COUNTY OF ................. .~.~.~ >/.O..,~.~...~.: . .'7~..~ ~ .~.*.~...0 ...... .1~,: eing duly sworn, deposes and (Name of individual signing contra~ct) above named. says that he is the applicant He is the. . ........... , ........ (Cent po ffi ) r ractor, agent, cor rateo cer, etc. of said Owner m' owners, and is duly authorized to perform o~ have performed the said work and to make and file tliis application; that all statements contained in this application are true to tbe best ofliis knowledge and belief; and that the Work will be performed in tlie manner set forth in the application filed therewith. Sworn to before rne this (Signature of applicant)