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Home My WebLink About17172-zTOWN O~ $O~THOLD BUILDING DIEPAR. TM~=HT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 017172 Z o, ~,,es ,~,,~ o, ................... ~~.....~.~..¢ ..... ................. ~.~.a...~........~~...z~:~ ............ ~ ........................... L ..... pursuont to opplicotion doted ...~ .......... ~...~ .......... , 19.~ oho opprov~ by the Building Inspector, ~ Rev. ,5/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N,Y. 11971 TEL.: 765-1802 Disa~l~-c;ved a/c ..................... (Building Inspector) APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH ............ 3 SETS OF PLANS ............ SURVEY ..................... CHECK ...................... SEPTIC FORM ................ NOTIFY CALL ..................... MAlL TO: Date ................... ... INSTRUCTIONS a. Tlfis 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. e. The work covered by this application may not be commenced before issuance of Building Permit. fl. 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 agy 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, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applica6'le laws, ordinances, building code, h~ausing code, and regulations, and to admit authorized inspectors on premises and in building for necessary ir~pections. /// · ., ..... (Si~0qture ot applicant, or name, ]f'a'c'o~'~o'rJrlc~n) ' , ..... -(Mailin~ address of applicant) · State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. (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.No ...... .x~.. I. Location of land on which proposed work will be done.. ' . ' ................... tlouse umb~r~ 'q' ..... " Street\ ' ' Halnlet .... ............ County Tax Map No. I000 Section ...... __.._._... B_?ck .. Lot ...... 7,.,...,:.~ .... Subdivision ..................................... Eiled Map No. ~, · ............. Lot ........ (Name) ~ ....... 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. ~.'istmg u~e and occupancy..'¢~.~. ~~.~.....~.....¢._~..~4. :~. .................... k ( h l~pli ) · 3. Nature of wot check whic a cable: New Building .......... Addition .......... Alteration ......... Repair .............. Rcm0vaI .............. Demolition .............. Othcr Work ............ _.~ ,. i (Description) t4u c ~..-'~.. , 4. Estima ost.. " .... ~ .........................Fee.~.. ..-- --. ................ (to be paid on filing this application) $ Ii'dwelling number of dwelling hnits · ' · .............. Number of dwelling units on each floor If garage number of cars ' If' business, COmmercial or mixed occupa"p"p"p"p"p~specif,, nat rc · . . . ! ., u ~,.~tunt Ol caen type oK use ......... D,mensmns of exmtmg structures if aay: Dimensions of same structure with alt;~att~'onne~ g;a'~'ront . ' ...... Dn.nensmns of entire new Constructio~t'; i;; .L'[;;;;; ;~ number of Stones ..................... Ee'ght ............... Number o~..' '..' ] .'.' ~ .... .., s~ea~ .............. Depth ............. Size of lot: Front .... i ..... ~ ............. ~ ................... . Date of P h ~ ........ '~. ..,.,,.. .!..... · ........ Does proposed construction violate any zoning law, ordinance ................... Narne of Owner .... ~1 excess fill be removed from prem~i Yes ' ' of premises ...... · ..Address ' Nmme of Architect .... ~ ................... Phone No ................ ...... , ................ Address Phone No.... N~wne of Contractor ' .............................. ......... ~ ................ Address ................... Phone No ............. '... 15.L~ this property locaeed ~£thin.~O0 feet of a tidal ~etland? ~YES .... NO .... ~If yes, Southold TownI Trustees Permit may be required. i PLOT DIAG RAM Locate clearly and distinctly all ~uildings, whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and block ~umber or description according to deed, and show street names and indicate whether interior or COmer lot. 9. I0. 11. 12. 13. 14. STATE (DF NEW YORK. CO UNTXF'~OF-:~.~' ..... -.. ....... .......... ( ......... a ....... i" i ...... '6 ........ above named.Name of in ividualsi nin contrac being deposes and says that he is the applicant lie is the (Contractor, agent, corporate officer, etc.) of said Owner or owners, and is duly t tbonzed to pe,rform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the Work will be performed in the m~ner sqt forth in the application filed therewith. Sworn to before me this [ . ............... % .~ ...... day of..;, . ............ ' HREN K. DE ~E ~A~ PUBLIC, ~ate of ~w Y~i ' ' ' ' ............. , ~. 470787~, Suffolk Coun~m~ (Signature of appHc~t) ~ T~m ~rm M~rch 30,1~ -