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Home My WebLink About21358-Z FORM NO. 1 TOWN OF SOUTHOLD · I3UILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined /.W//~. 3 · -~- .............. 19 ,~....~3 Approved ~ ~:~.. '~ '" · ....19 ~..,~Permit No. ~a~...~.~....~...~.. ~ Disapproved a/c ' . ........ + . .JJ~ildingz:~'spector) . ' APPliCATION FOR BUILDING PI:RMIT INSTRUCTIONS BOA'RD OF HEALTH 3 SETS OF PLA~S SURVEY CllECK SEPTIC FORH ~:OT I P¥ ~ HA I L TO: a. Tiffs 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 orJareas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli. cahon. ? c. The work covered by this application may not be commenced before issuanc ' · · d. Upon approval of this application, the Building Ins,,ector w": .... ~ ...... e o~f Bull. drag .Permlt. ' ..... ,urn a r~uumng cermet 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 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, build/ng code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary- JOspections, - . ..... :.;., C., ... ' (Signature of applicant, or name, if a corporation) ............ ........... .......... .' (Mailing address of/applicant) _ State whether ~,nt is owner, lessee, agent, architect, engineer, general ~electrician, plumber or buiide;j ............ · ......~.~r...:. ' - . Name of owner of premises .... .C .~.O,r'.~.~ ~X.~..b.3:... f~?....~. 0-. k .% !. l.~ ............................... ' ' (as on the tax roll or latest deed) If applica, pt is a i:orporation,.signatur..%of duly authorized officer. ..... .. .:. . .......... {.~e and title of corporate officer) ..... Builder's License No ..... ~.~27~. ........ · ......... Humber's License No. Electrician's License No ................. ...... Other Trade's License No. 1. Locatiqn of land on which proposed work will be'done. ... ~ l.qg.' .... &)o. ~!. ~ .< . .O. c~. . . : ...................... .O. ,:,.~:,t.'"' }louse Number Street , Hamlet County Tax Map No. 1000 Section .............. Block ................. Lot Subdivision ................... ............... '(~q'a;,;~) ................ Filed Map No ............... Lot ............... State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Ex,s,,n.. use and occupancy ...... ! , b. Intended use and oqcupanc, ...... 51a.~.[~....~7.~,/~ . 10~oC /5C,~" ............... :'': .......... Nature of work (check which apPlicable): New Building. Addition · Alteration Repa/r .............. Removal ......... Demolition . . ..... · · · · '.'. - ·; ..... Other Work 4. Estimated Cost '/3-~.'..~.Q i.'..' ...... ' ........ ~' ...... ' ...... .......... . .' (Desc~:ption) Fee 5. If dwelling, number of dwell/n- units ~)/d (to be paid on filing this applicati~. If garage, number of cars _,¢'j' · g/~-' ..... Number of dwelling units on each floor 6. If business, commercial or'~;:-'-'-' ....... t.~,. ¥,,O:. .............................. · ............... 7 Dimension ofexistin,, st~u';';t~'~ occupancy, specify r/a. Lure and extent of each t.~ne of us _ ' 14,,;,,~, ,~ ~ ~ f ,, ,if any: Front .... .q]-O ,, c/ '--, e, ...,,L-cl..~.,~ ..... "' ;~y'o"~ .~_-..~,,4 ...... Nmnber of Stories D ~ ......... l~ear .. I.'..Z:..C) Depth ...~.~ ~ (5 ..... ~tmensions of same structure with alterations or''~ d' .. De th ' -C'b s' Front o p .... .............. .eight. ................. ....... o..~fimensmns o.f entre new construction' Frm;t' ' ''''~ ' i~?t3 ....... '.. Number of Stones.. ,~.. · ~ , .... . Name of Architect .... ' ................. ss ... ...... ~.. ph,,,o ~. - Name of Contract,-- '/~'~'2):' 'Z' '6'7 .......... Address .... ,~ ,. · .......... '... ' · ~'~ y~, So~hoZd ~o ~ ......... ~e~Zand: .~. PJq _&r.~£..... · vzn ..... ~es rerm:l.c may be requiret~'""r' No ......... .... _ PLOT DIAGRAM Locate clearly and distinctly all buildings, whethe~ existing or proposed, and. indicate all s'et-back dimensions fro! property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. ;TATE OF NEW YORK, :OUNTY OF~ .~, ~ S.S . ......... =//." ; . · (Name of individual signing contract) being duly sworn, deposes and says that he is the applicant bore named. !e is the , ' (~ o h.'"Tt~ L-~" ~ t-- ' ' ' said owner or owners and ~s -- (Contractor, agent, corporate officer, etc.) ....... ' duly authorized to perform or have performed the said work and to ~plication; that all statements contained in this application are true to the best ofh~s kno , make and file this ork will be performed in the manner set forth in .... :! ' ' wled e · . vorn to before me this me app~manon filed therewith, g and behef, and that the .... / ,. ...... :.; ......... day of ........ .......... ,. ,,...-~ . ;~, .~?(A//5~-~Ount .... · ~ ';W/~''- HELENE O HORNE Notary Public, State of New York · ' ' ' ~ c .................... · No. 4951364 C Oua!~f,ed in Suffo!k CounW ~::~.,:, t gnature of ap lican omrmss~on Expires I~,lm! 25L '~ ()Z~--~'- P t) ~¢~P OM' Da f~ :