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Home My WebLink About17715-z FOBM NO. · TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT Cf'HIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N9 blTY15 Z County Tax Mop No 1000 Section ..... .~..~ . . Block pursuant to apphcatlan doted ...... /.~./.~ .... Building Inspector ·., 19 ~.~., and approved by the Rev 6/30/80 Examined /~ ."2--~-.... Approved /~. ~ Dmapproved a/c ,19 / · 19 J . Permtt No BOARD OF HEALTH ...... 3 SETS OF PLANS ....... FORM NO, I SURVEY .......... TOWN OF SOUIHOkD CHECK .......... BUILDING DEPARTMENT SEPTIC FORM ............. : TOWN HALL HOTIFY ~.~OUTHOLD, N.Y 11971 ~.4 .~.~c~ ~7d' TEL.. 765-1803 CALL ............ MAIL TO. · ~ tn= Inspector) APPLICATIO~BUI LDING PERMIT INSTRUCTIONS a. Tlus apphcatton must be completely filled in by typewriter or in ink and submitted to the Budding Inspector, wtth sets of plans, accurate plot plan to scale. Fee according to schedule b. Plot plan showing locatton of lot and of buddings on premises, relatmnshtp to adjolmng premises or pubhc stree 'or areas, and g~vmg a detailed description of layout of property must be drawn on the dmgmm whtch m part of this app catmn. 6~2~ ~t'cli~l~e~~tl°n may not be commenced before msuance of Building Permit ' ili~t}6fi 711~TdlT~tT~, the Bmld~ng Inspector wxll issued a Building Pe~[t to the apphcant Such pe~ sh~~~~r mspectmn throu~out the work .~;~~~c~r used ~n whole or ~n p~t for any purpose whatever untda Ce~fficate of Occup~ shaE~v~~~~nspector ~X~Iq~BY MADE to the Building Dep~ment for the msuance of a Braiding Pemxt punuant to tl Buddxfi~9$e Or~fi~~f 8outhold, Suffolk County, New York, and other apphcable ~ws, Ordxn~ces, Re~l~fi~[~he co~tmchon of bmldmgs, addmons or alterations, or for removal or demohtmn, as hereto describe, Th~a~ ~~~1 apphcable laws, ordinances, building code, housing code, and regulanons, and adm:t ~$~~.3~mz~gs and m bmldmg for necessa~ inspections ~ ~ ¢ ~ ~ (Signature Capphcant, o e, corporation) ..... ~ ~ .... (Mmhng address of apphc~t) State whe~er app~a~ ~er, lessee, agent, ~ch~tect, engineer, general contractor, electrician, plumber or bulld~ N~e of owner of prem,ses . . ~f4~ fi (as on the tax roll or latest deed) If apphcant ~s a corporation, mgnature of duly authorized (Name and title of corporate officer) ALL CONTRACTOR'S MUST BE SUFFOLK COUNTY LICENSED Builder's License No . ~'7~. Plumber's License No Electrician's License No .. Other Trade s Ltcense No Location of land on which proposed work will be done House Number Street County Tax Map No 1000 Sectton .7~ .......... Block Hamlet ....... ot. ........ Subdlv]mon Filed Map No Lot . (Name) State exmtmg use and occupancy of premises and intended use and occupancy of proposed construchon and occupancy (~.. io e.. ~ b~, c~,<, ~4,~C' ~ ............................ Exlstlng use a b. lntended use and occupancy Clo.se~. ,.~.. ~,~,c..l~,..5.-,~r' c~ 3. Nature of work (check which applicable) New Budding Addition ........ Alteranon ...... Repar ....... Removal ......... Demolition .......... Other Work. 3 I (Descnpllon) 4. £stlmated Cost ...... ............. Fee .... 9. ................. " (to be paid on fihng th~s apphcahon) 5. If dwelling, number of dwelhng units ...... Number of dwelling units on each floor .......... If garage, number of cars ................................................... 6. If bus~ness, commercial or mixed occupancy, specLfy nature and extent of each type of use ............. 7. Dunensmns of existing structures, if any. Front ...... Rear .......... Depth ......... Height ..... Number of Stones .......... :, ............... D~mensmns of same structure with alterations or additions Front ......... Rear .............. Depth ............ Height ......... Number of Stones .................. - 8. DnnenslonS of entire new construction' Front ......... Rear ............ Depth ......... Height .......... Number of Stones ......................................... 9. Size of lot Front ........ Rear ............... Depth .................. 10. Date of Purchase ................ Name of Former Owner 11 Zone or use district in which premises are situated .................................. 12 Does proposed construction ¥1olate any zoning law, ordinance or regulatmn .. . ~. ~ .................. 13. W~II lot be regraded .............. Will excess fill b.e removed from premises. ~Yes Nc ' 14. NameofOwnerofpremlses . ..~o~,.e_ .Address . ~,~[~.~7/-. ,.PhoneNo.~g.~.:..3.~,, Name of Arclntect ............. Address ..... , ..... Phone No ......... Name of Contractor's: ~ ~ e i~. ~ ~r,~e~..~Xet,~.~d dress P. 0 )~o~.3r~& ~xM~hone No. ~ 15. Is this property located-~zthin 300"feet of a tidal wetland? *Yes ..... No ~/ .... *If yes, Southold To*m Trustees Permit maybe required. PLOT DIAGRAM Locate clearly and distinctly all bufldmgs, whether existing or proposed, and indicate all set-back d~rnens~ons from property hnes Give street and block number or description accordmg to deed, and show street names and indicate whethe, interior or corner lot t I STATE OF NEW YORK, COUNTY OF.. . i SS being duly sworn, deposes and says that he is the apphcanl (Name of individual signing contract) above named (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 apphcation, that all statements contmned m this apphcation are true to the best of his knowledge and belief, and that the work wdl be performed in the manner set forth m the application filed therewith. Sworn to before me this ........... ~.0. dayof .... b .e,~-~.. .......... 197.7 Notary Public ....... ~.. i~.-~' .~..~.. County(, NIX~TB~: S~,~:~77 ~ ' (S,gnature of applicant: Term Expires MalCh ~}, 19