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Home My WebLink About25669-Z FORH NO. TOi~N OF SOUTHOLD BUILDING DEPARTHF. NT TOI~N HALL SOUTHOLD. N.Y. ! 197 I TEL: 765- 1802 ' ~ BLDG. DEPT. ~-~d....H: t.?. ......... Disd~,o~d alt .................................. ........................................... INSTRUCTIONS BOARD OF HEALTH ............... 3 SETS OF PLANS ............... SURVEY ........................ CHECK ......................... SEPTIC FORt4 ................... NOTIFY: CALL .................. HAIL TO: .................... a. Ibis ~uplicatico ,,mt be completely filled in by type~iter or in ink and su~itted to the Building Inspector 3 sets of p]~, accurate plot plan to scale. Fee according to schedule. b. Plot plea sho~in~ locatico of lot and of buildings on p~emises, relatio~hip to adjoining premises or public streets or areas, ~ givin~ a de~ailed description of layout of property ~n,~t be dr~ on the dia~r~n daiah is part of this ~licatico. c. The ~rk co~ered by this application my not be c~,,,-~d before issuance of lhildin~ Pemit. d. UIm ~"~al of this ~licati~, the lhildin~ ln.~ector ~rill issue a Buildin~ Pemit to the applicant. Such pemit shall be kept on the praises available for inspection throut~out the ~ork. e. lto buildin~ shall be _oc~ied or used in ~/~ole or in part for any purpose ~d~atever until a Certificate of APPLICATIC~ IS 11~_~¥ ~ to the Buildit~ Depa~n~t for the issuance of a Buildin~ Permit p,rmiatlt to the m,!ldin~ Zone Ordinm~ce of the To~n of ~uthold, ~uffolk County, ~ Yonk, and other applicable La~s, Ordinances or p~Eulaticos, for the const-mctim of buildi~3s, ~iditions or alterations, or for r~al or d~lition, as herein d~.~cribed. The applicant a~rees to r~s~l, y with all applicable la~s, ordinances, huildin~ code, housin~ code, and re~ulaticos, and to ~tnlt authorized inspectors m premises and in. ' ' ' ' - ............... (Signature of at~licant, or nane, if a corporation) ..... r. .... Q, hiling a~rlre~ of ~t~elic-~t) State ~nether ~pplicant i,~ mr, le~t, ar~i~ff~ ineer, general contractor, electrician, phafl~er or .................................... .~ ......... ~ ............ .......................................................... ~ of o~er of pr~i ~e~ (a~ on the ra.~ roi1 or late,~t deed) If a~licant i~ a corlx~mtico, ,ig~am of duly authorl fficer. (N~e ~d title of corporate officer) Buildera License 1~ .......................... Pl,~hers Li~ No .......................... Electricim-~ Lio-~e No ...................... 0ther Tt~4~'s License No ..................... ~ ~'¢0 ~ /~ ~'¢/) "C;}¢'t '~' I. Location of la~d on ~hich proposed ~rk ~rill be dote /~ ~'/~'(4 ,. ~ Hcsise l~her Street Itel et ~ ~ ~. ,~ ~,. ...... ~.~ ....,,~ ........ a ...... ~, ~:.z ......... aivisim ...................................... Fil~ ~ ~ ................ l~c ............... (~) 2. a ~sti / ~ ~~ ~ ~__..__~_____.__~a ................................... ~. ~ ~ ~ ~ ...................................... .. ...................... ~. ~ziture or ~orX ~c~ ~ applicable): Na~ ~ildi~ .......... ~iti~ .......... ~terati~ .......... ~ir ............ 4. Estb~t~ ~st ... ~ ............ f~ .............................................. (to ~ ~id ~ fili~ thi8 ~li~ti~) 5. If &~lli~, ~r of ~lIi~ onits ........... ~r of ~lling ~its ~ e~ fi~r ................ If ~r~e, ~r of ~rs 6. If ~i~ss, ~',~'..~rcial or ~ ~, ~i~ ~e ~ ~tent of e~ ~ of ~ ...................... ~. Di~nsi~s of ~sti~ st~s, if ~: ~t ................ ~ar ............... ~pth ................. l~i~t ......................... ~r of Stories ...................... Di~i~ of ~ at~e ~th alterati~ or ~iti~8: ~t ............... ~ar ............... ~pth .................... ~i~t .................... ~r of Stories ............... 8. Di~i~ of entire ~ ~t~ti~: ~t ................ ~ar ............... ~ .............. }~i~t ......................... ~r of Stories ..................... 9. Si~ of lot: ~t .................... ~ .................... ~pfl~ .................... 10. ~te of ~dm~ ..................... ~ of Four ~r ........................................ I I. ~ or ~ district in ~i~ p~i~s a~ si~t~ ............................. or . ............ .......... 13. ~ill lot ~ ~ of ~tr~tor .......... ~ .................... .... ~ress ...................... ........ ~ ~ .............. 15. Is ~is p~ ~in ~ f~t of a till ~tl~? * ~ .......... ~ .......... PLOT DIAGRAH I~cate clearly and distinctly ail buildings, ~nether existing or proposed, and indicate ail set-back dimensions rio- property lines. Give street and block ~amber or description according to deed, and sho~ street nares and indicate ~ahether interior or corner lot. ,~rA'IE OF ~!..'~/ Y~, (l~re of individual signit~ contract) above I~ i~ tl,~ ....... ;...~.~.},,.~...; ............................................................ ~tr~tor, ~nt, co.rate officer, etc.) " o~ ~id ~r or ~rs, ~ is ~ly ~t~ri~ to ~rfom or h~ ~r[o~ tim ~id ~ ~ to m~ ~ file this a~llcatio~; that ~ ~ ~ill ~ ~r[o~ in tl~ m~r ~t forth in ~e a~ii~ti~ fil~ ~. (Signature of Applicant)