HomeMy WebLinkAbout25703-Z ~ORHNO. I
TO$~I OF SOUl,OLD
BUILDIBG DKPARTHENT
SOUTilOLD, N.Y. 11971
TEL: 765-1802
BOARD OF HEALTH ...............
SURVEY ........................
SEPTIC FORH ...................
NOTIFY:
CALL ..................
HAIL TO: ....................
TgW~,' QF S~UTHOLD
a. This ~plicaticn -,mt be'c~.~letely, filled in by typewriter or in ink and su~itted to the Building Inspector
3 sets of pl~n~, _~c~wa~ plot plan to l~-~le. Fee accordinE to schedule.
b. Plot plan sho~ locatim of lot and of buildings ~a pr~gses, relationship to adjoining praises or public
s~reets or areas, ~d givinE a detailed description of last of p,~e,~ mast be d~-~n on the diagrm vhich is part of
~his application.
c. ~he ~ co~ered by this application my not be oa,~e~-d before issuance of Building Pemit.
d. U~,~a ~'oeal of thia ,wlication, h~e Building v~ector w111 issue a lhilding Pemit to the applicant. Such
pemit shall be kept ~ ~!~ premises available for inspection througbeut the ~ork.
e. lto building shall be _oco~?ied or used in ~/~ole or in part for ~ny ~ ~/aatever until a Certificate of
Or~ncy shall have been ~m,~ed by the Building T~pector.
/a~J[CATIiIt IS '~i ~ to the Building ~t for the issuance of a Building Pemit pursuant to the
lhilding Zone Ordbmnce of the To~n of Southold, Suffolk CounVy, New York, and other ~pplic~hle T~s, Ordin~ces or
Regulations, for the const-mcti~ of building~, srlditioas or alteratioas, or for ~..~al or ~,,.-,lition, as herein
described. ~he ~plie~a,t a~rees to ~.,-..ly vith all ~lie~hle l~-s, ordinances, building code, housing code, and
regulations, and to ~i~ ~orized inspectors o~ p,~,,:ses and in building for necessary inspections.
....... ...... ..... ............ ......
(Signature of applicant, or haW:, if a corporation)
(i~ailing ~dvess of ~lic~mt)
lessee,~, architect, engineer,' get--fa1 contractor, electrician, phx~ber or build~
State
applicant
is
o, mer,
~ o~ --, o~ ~,~-- ...~..~!~..;...~e~.....zi.e..~/.e~.. ~.~/. .................................................
(as an the tax roll or latest
If applic~t is a _co!lx~2tion, signature of duly ~thorized officer.
.... ...................
tlqa~ and titl~ ~f c~,~iare officer)
Electrici~ License I~ ......................
Other ~'s Lic~-,se No .....................
I. ~ti~ of 1~ ~ ~ p,~ ~ ~11 ~ ~ ...........................................................
3. ~ture of ~ork (d~e_k ~tlid~ applicable): ~ ~ildi~ .... ~iti~ .......... ~terati~ ..........
~ir ............ ~l ............. ~liti~ ..... O~r
~ ~ ~' ~ (~ripti~)
4. Esti~t~ ~st
(to ~ ~id ~ filing this a~li~ti~)
5. If ~lli~, ~r of ~111~ ~its .... ~ ...... ~r of ~lli~ ~its ~ e~ ~r ..... ~ ..........
6. If ~i~ss, ~rclal or ~ ~, ~i~ ~e ~ ~tent of e~ ~ of ~ ......................
7. Di~nsims of ~sti~ stems, if ~: ~mt ................ ~ ............... ~pfl~ .................
l~i~t ......................... ,.~r of Stories ......................
Di~i~ of ~ st~ ~th alterati~ or ~iti~: ~t ............... ~ar ...............
~pth .................... ~i~t .................... ~r of Stories ...............
8. Di~i~ of entire ~ ~t~tim: ~t . ~j~ ....... ~ar ...Z/~ ~p~ ...~..~ ......
}~i~t ...... J.~. ................ ~r of Stories ..... ~'. ..............
9. Si~ of lot: ~t .................... ~ .................... ~pO~ ....................
lO. ~te of ~d~a~ ..................... ~ of Four ~r
II. ~ or ~ district in ~i~ p~i~s a~ si~t~
~2. ~s ~o~ ~t~tim violate ~ ~i~ 1~, o~i~ ~ ~latim: ........................
13. ~ilI lot ~ ~ .................... gill ~ fill ~
14.
............................. ~
PLOT DIAGRAH
I~cate clearly and distinctly all buildings, ~he~her existing or proposed, and indicate all set-back dimensions
property lines, give street and block r,,~r or description according to d~c~, and ~ street nm~_s and indicate
~aether interior or corner lot.
YFA3E OF ~!.~ YOlk,
,~q
UOJR P/ OF .......................
.... ....
(l'~k~re ~~ .................... ~i~ duly ~m, ~s ~ ~ys ~t ~ is ~ a~li~t
of iMivi~l si~ing cmtr~t)
(~tr~tor, ~nt, m~rate of H~r, etc.)
~f ~id ~r or ~rs, ~ is ~ly m~ri~ to ~rfom or ~ ~r[o~ fl~ ~id ~& ~ to ~ ~ file this
a~llcatlu,; ~at all stat~nts cmtai~ in ~is a~licatim are t~ to ~ ~st of his ~1~ ~ ~lief~ a~
tlmt ~ ~ rill ~ ~rfo~ in tl~ ~r ~t forth in ~e a~li~tim fil~ ~.
NOTAR~ A ~I'A~
( '~nacure o~ Apulia() "'