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Home My WebLink About26060-Z FORI{ NO. I TOIdN OF SouT[IOLD BUILDING DEPAETHENT TOI4lq HALL SOUTHOLD, N.Y. 1197! TEL-- 765-1802 Disapproved a/c (Building Insl~ector) .... BOARD OF HEALTE 3 SETS OF PLANS ............... SURVEY ............... CHECK SEPTiC%~ .................... NOTIFY: CALL I~AIL TO: IL, f!! oct ;i/' AFFLICATION FOR BUILU,N ~_ "~- Date ................ 19 INSTRUCTIONS ..... a. ~i, '~li~ti~.~ ~letely fi11~ in ~ ~iter or in i~ ~ ~itt~ to ~ ~dldi~ Ins~tor 3 ~ts of pl~, ~ate plot plm to ~le. F~ ~m~i~ to b. Plot plm ~ l~tim of lot ~ of ~il~i~ m ~, relatim~ip to ~joini~ pr~s or ~lic ~i~ ~limtim. c. ~ ~ mr~ ~ ~i~ a~li~tim ~ ~t ~ ~m~ ~fore isle of ~ildi~ Pemit. d. ~ ~1 of ~i~ ~limtim, ~ kildi~ In~etor ~dll i~ a ~ilding Pemit to the ~licant. ~mit ~11 ~ ~pt m ~ ~ ~il~le for in--tim that ~ ~mrk. e. ~ ~il~i~ ~11 ~ ~i~ or ~ in ~le or in ~ for ~ ~ ~at~er ~til a ~rtificate of ~I~ IS ~ ~ to t~ ~ilai~ ~nt for ~ i~e of a ~ilding Pe~t ~r~t to the ~lati~, for ~ ~tim of ~ildi~, ~iti~ or alterati~, or for ~al or ~litim, ~ ~rein ~latims, ~ to ~it m~ri~ i~tors m ~ ~ in ~ilding for ~es~ in~tims. ~si~ of ~n~, & ~, i~'i'~o"~i~: .... ~ tmn) (~ili~ ~ress of ~li~) ............. State ~r ~l?mt is ~r, les~, ~nt, ~itmt, ~gi~r, ~ral ~tractor, el~tricim, pl~r or ~ilder ........ ~ ~ ........... ~ o, ~ o~ ~-,~ .... ~.~zr~...d~... ~X~. ~4~ ............. ¢~ ~ ~ ~= ~1 ~ ~~) -'r .............................................. ...... ~/~~. ~(~f officer. (~ ~ ~i~ o~d~,~ of~i;;~ ................... Builders License NO .......................... Phmnbers Liaellse ~ .... X~..ff./...~. .......... Electricians License No....//ff~ }~ Ot_Imr Trade's License No ..................... I. I~cation of land on ~,tlich proposed ,~ork ~eill be da~e. .z~~.~ ~ , _, ., ...................................... . ..................... · ' · ............. L4.4. t'/f..Z. c~ T~ ~. ,,0 ~i~ ..~e,../. ............. ./. ........ ~t ..... ~......Y.~ ............................... Filed ~ No. (~) ............... ,or ..~..xZ:.Y.L.. State ~isting use and occupancy of pr-,-~ses and intended use and occupancy of proposed construction: a. Existing use ~r~ occupancy ................................ 3. N. at.re of ~ork (d~..k ~Jidt applicable): ~ Building .......... Addition .......... Alteration .......... Repair ............ l~.~tal ............. l~ml itiofl ............ Other Nork .................................. ,(1)escrl ption) 6. Estimated Cost ......................... fee .............................................. (to be paid on filing this application) 5. If ds~elling, r~ber of d~elling units ............ tls~ber of d~elling units on each floor ................ If garage, tuber of cars ...................................... 6. If I~siness, c~.~reial or mixed occupancy, specify nature and extent of ead~ type of use ...................... 7. Dimensions of existing structures, if any: Front ................ Rear ............... Depth ................. Beight ......................... lx~t~er of Stories ...................... Dir0ensions of sam structure ~ith alterations or additions: Front ............... Rear ............... Depth .................... Belght .................... beer of Stories ................ 8. Di,~nsions of entire new construction: Front .//~. ........... Pear ../[.~. ......... Dep~ .. fl.-.~. ....... Ileight ...... ~.~. ................ Number of Stories ....... /. ............ 9. Size of lot: Front .................... Rear .................... Depth .................... 10. I~ate of Purchase ..................... Nane of Fortmr O~n~r ........................................ I 1. Zoee or use district in ~hich premises are situated ...... ~l~.~'.~. ....................................... 12. Does proposed construction violate any zoning 1~, ordinance or regulation: ............ ',;;'~' ......... 13. Will lot be regreded .................... ~ill e~eess fill be removed from premises: YES l~ Rate of Ardfiteet ~/'~//~/~/(~'...4~...~.ff./. ................. Mdress A'~///.~....'~.~....~..~..~..'~..~..~.~./~...~'Phone NO ............ 15. Is this pcoperty ~ithin 300 feet of a tidal wetland? * ~S .......... NO .......... PLOT DTAGRAH I~cate clearly ~ distinctly ail buildings, ~nether existing or proposed, and indicate all set-back dimensions property lines. Give street and block n,~her or description according to deed, and sho~ street nares m~d indicate M~ether interior or corner lot. .~FA'IE ~F bi~ OOUN IY (~ ....................... .......................................................... being duly swon~, deposes and says that he is tie applicm~t (Nm~ of individual signing contract) Ile is the (Contractor, agent, corporate officer, etc.) of said owner or owners, a~d is duly autborlzed to perform or have perforr~d tim said w~rk m~l to make and file this applicatio]; that all statorents contained in this application are true to the best of his Imowledge and belief~ and that the w~rk will be perfonrr~d in tim mam~r set forth in the application filed therewith. ,%~rn to before r~e this ....... .~. ff~.. ....... Notary Publi~--/.~" .~...~..~..'.~ g..v.."..-~... ELIZABETH A STATHI8 NOTARY PUBUC, State of NewYo~ No. 01ST6008173, Suffolk COUIltY Tm'm Ex~Ires June 8.~ -