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Home My WebLink About17221-z FOR~ NO. O 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) 017221 Z County Tax Map No. J000 Section ............. ....~.~... Block ........... ~.. Lot No ............. ~ .... · ~../&~ ....................................... , 194~.~..., and approved by the pursuant to application dated Building Inspector. Fee $..~ ./~"/~/~... Rev. 6/30/80 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT SEPTIC TOWN HALL SOUTHOLD, N.Y. 11971 .~.~./.~. TEL.: 765-1803 CALL _~ ~.~ MAIL Examined .......... , 19. O~'.. Approved. · · .7././.~5.-'7 ......, 19~Pennit No. / Z.~..~?../.~ Disapproved a/c ..................................... APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH ...... 3 SETS OF PLANS ....... SURVEY .......... CHECK .......... FORM ............. : TO: JtJL - 6 t988 Date... 9 .~..(¢'. ........ 19~.~' INSTRUCTIONS a. This 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. · ....... ~ \ c. The work covered by this application may nOt:be-¢ommence,~ before issuance of Building Permit. d. Upon approval of this application, the BuJdihg Inspector will issued a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout fhe Work. e. No building shall be occupied or used in whole or in part fbr.any 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 applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. .......... (Signature-o_Capplicant, or namE, if a corporation) .p..o. ¢.0. ~. ~.~.~....~. ~.k,,~.l.J ~.~ %. t .~.0.t... (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. .~.*.,>e~-t-.e,. {...~.o ~.'~C~T~ fi'. .................. , ............................................. Name of owner of premises ............ .~. r., .... ~., c. k~, (:'. J....~01::3,.~..S ........................ (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) - ' ALL CONTRACTOR'S MUST BE SUFFOLK COUI~TY LICENSED Builder s License No .......................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ..... 5-i~.~.... }.'rb. ).a%O,O ) 1. Location of land on which proposed work will be done .................................................. ....... 5':0. ........... ,,..0¢.,. ....... o .Id ........ House Number Street Hamlet County Tax Map No. 1000 Section ..... ~. (::? ........ Block ... ~"7. ............ Lot... ¢~...~"T. .......... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: occupancy O ~o~, ~.. ~. ~ [~. ~.I.-~/e_~..o.J~..go.o 6 e..,~. ............................ a. Existing use and b. Intended use and occupancy .~.. ~.5 ~, ~ .,~..5 .I .~$. Ix>. Ct. [~.. ¢~.c,-6.D ............................. .A. ddi 3. Nature ofwork(checkwhlchapplleable): New Building :...... , . t .......... Alteration . .... Repmr ..............;, Removal ............ .. Demohhon} ..... ~ . Other Work. ,~ ..... " ~ "~ ': '' /' ?' (Description) 4. Estimated Cost .......... ? ................ Fee ........ .~. · (to beI paid on filing this application) 5. If dwelling, number of dwelling units .. ........ umber of dwelhng units 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 .................. 7. Dimensions of existing structures, if any: Front ............... Rear ...... i ....... Depth .............. Height Number of Stdries ' Dimensions'of same structure with alterations or additions: Front ...... ' Rear ....... Depth Height! Number of Stories Dimensions of entire new construction: Fiont .......... . ..... Rear ....... j ....... Depth ............. Height Number of Stdries .' fl Fro ' ~' '~ 9. Size o ot: nt ............. ,...' ...... Rear ...................... i Depth .................... 10. Date of Purchase ................... Name of Former Owner 1 1. Zone or use district in which premises are ~ituated ........................ i ........................... 12. Does proposed construction violate any zo. ninglaw, ordinance or regulation: ...l~N).ca ...................... 13. Will lot be regraded ................. : ........... Will excess fill be remove~d from premises:' ' Yes No 14. Name of Owner of premises ........... ~ ......... Address ............... ~ ....Phone No ................ Name of Architect ! Address Ph~n~ Name of Contractor'e~o~..~.r.,.r:-. ~.'~.~c,,_~.~t.y.<'rm,~'5. Address ~::3ogl:~'"~-: 15. Is this property locatei~°within 3'O~feet of ~ tidal wetland? *Y~s ~. No '. .... ' ..... *If yes, So~thold Town Trustees Pe'rrait may be required. [ PLOT DIAGRAM Locate clearly and distinctly all buildings; whether existing or proposed, and. in~dicate all set-back dimensions from property lines. Give street and block number o~ description according to deed, and show street names and indicate whether interior or corner lot. : i STATE OF NEW YORK, COUNTY OF ........... . ...... S.S .... · .............................................. being duly sworn, depqses and says that he is the applicant (Name of individual signing contradt) .. above ~named. He is the "~ ; (Contractor/agent, corporate officer; etc.! ~ of said owner or Owners, and is duly authonz9d to perform or have performed the smd~vork and to make and file this application; that all statements contained in this application are true to the best 6fhiS knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith.? Sworn to before me this I 19.~.~. · ~.~. ~/.. ,~Yf~-~..... County ~ Notary Public ..... ..~....~,~...'~..,. ' . ..i.~...~..,.~ ~t't~ ~. ~ ~.~ ~ kl (Signature of applicant) ~,OtARY PUB/Ill, No, 4707878 Surf0/ , to,,,, £'~ires ~tCh 3