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Home My WebLink About19235-Z FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1802 Disapproved a/c ................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS 'BOARD OF HEALTH .. ~ ...... 3 SETS OF PLANS% 1~ ~ , '2/-'~ '"~ ~' ~ 'il" ',~' ' CHZCK .,.. ~ t ~ SEPTIC FORM ...... ] ' CALL ..................... MAIL TO: /00 ~o~~ 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 properW must be drawn on the diagram which is part of this appli- cation. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issued a Building Permit 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 S~uthold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for ~emoval 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 necessarg?qspections: ~ ., ~ j r: .......... ..~4, (S~on, ature ot apphcant, or name, ~f a corporanon) I · U/ ..... /v ........................ .... tr~ ....... ~" (Mailing address of applicant) ~ , State whether applicant is~owner, l~.ssee, agent, architect, engineer, general contractor, electrician, plumb~'r or builder. ;/i .. ;, .-';., i'",') ......... : .............................. Na..o, ow.,,o,.=,., .: . ........... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No .......................... , ........ lumber s License No... Electrician's License No... I (~ ~'~ Other Trade's License No. /Y. :-:-: ............... o" . 18 1. Location ofland on which proposed work will be done. . , ~~ _~ -, ...... ~ ~ .~ ~. ," 'Z'~'-'~ .... ' ....... House Number Street ;~,nle;- .... ~ .............. CountyTax Map No. I000 Section ....... ~ ....... : Block ...D.~.O~ ..... Lot..~Z~.~ Subdivision.. ~_~6~.~,(. Filed Map No..8.?~f ...... /_ (Name) ........ Lot~~.. a. Existing use and occupancy .... ~ (2' ~ .... ; ' ~ ....... 7.' .... l'. ..... ~~, ': ..... . ........ · ............ ~ ~} [/ ~~ 3. Nature of work (check which applicable): New Building .......... Addition ........... \iteration .......... Repair .............. Removal .............. Demolition .............. Other Work ............... - ~. ~ (Description) 4. Estimate'd Cost.. ~...~..J(. ~.?.,.aoo ............. ~-~ ~ .~'--$~--,a~. oo Fee (to be paid on filing this application) 5. If dwelling, number of dwelling units . .-~ .q. ......... Number of dwelling units on each floor If garage, number of cars ... ~ .................................................................. 6. If business, commercial or mixed occupancy, specify nature and extent of each ty_ff.pe of use '5 ................ 7. Dimensions of existing structures, if any: Front ..... .~. ·: ...... Rear .............. Depth . .7... .......... Height ....... ~ ...... Number of Stories .... ~ .. Dhnensions of sa~me structure with alterations or additions: Front ...... ..'77. ........ Rear .: .': ........... ~D.epth .. ....~. ................ Height ......... .--r..,. ;, ........ Number of Stories ....--~. ~ , '' 8. ~a~mensmns otentire new construction Front _-~ S~- ~/' ~-~ "g <"-:'o ,-, ' ' ;' ' '.4 5:-' 9." ....... .................................. taepm . ,ak ~. 7 ? ........ Height ............... Number of Stories / ~'~ ! /. · 9. Size of lot' Front/?~,'-o~ 7 ~.'~.- 0 '¢,:: '~'-~)~'~ 2d ' ti,3~- '~ ............ .' ';~ ' '3' ' ' :~ '~ '~ '~-: * .... ..... · ' ....... ~ ....... r, ear ~_,~.-~ri~ /~- Deptt3 644/~-~ .... 10. Date of Purchase d//3 !/ ;h9 ''~, /'~_' .... ,2, ..... /} ~ , ~/~'z.;~='~ ......... ..... ' '. .... .7' ..../-.. -', ........... ....~ame ot vormer uwner ./~t'~t-'~.< i~. ~one or use di, stnct ~n which premises are situated . . .~-,/./~. ................. 04.. i~. i .............. z. ooes proposea constructio~n violate anv,.zoning law, ordinance or regulation: ~(./,~-0.. ....................... 13. Will lot be regraded . ,,.~ ./~g,~j?} )/~; .......... Will exce,3s fill be, remo,ed from premises: . Ye ./ No' 14. NN~a~__e _o~f ?w.n.e~r o~.mi~sef~07.~/.~.2,0_~,.~.~t,j.. Address ,,~.4Z~:f~./~ .~f. Phone No 25-/' .~.~1/ N,U,e o[ _~rcnnect .(~(%~,j;~C,~,,y3 (~.z. '//-' '~'-' Address~,l...~,~t.,~.._.07-f.~.tJ~f.. Phone No..~.a~.~7. a q ~ ' 15 Isam~IisC°nt;aoCt?effr~(t/~ '4cfi~'~'' !~.~/~{.~.-~.~4.¥,~... ·Address ~-.t~/;"~.. ~24~.~... Phone No. -~- Y.7. J ~? - P p y tocatea w~thin 300 feet of a tidal {/etland? *YES .... NO.~'.~. · If yes, Southold Town Trustees Permit may be required. ... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. //~ ; Z! I t l 3rs& ' /-[ STA OF ' S S ·/(-~' '~g'~'ff~ '~' '/7']~?")v42/ being duly sworn, deposes and says that he is the applicant · ( amp of individual signing cont;a'c'ti .......... above named. ' ..... .... .......... · ............................... l/e is the (Contractor, agent, corporate officer, etc.) ' ' of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his 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 ......... ........ .... ......... ...... ~'t ..~,.a w.v.-.~,~.. ~ .'~....4.,~.x. ~ .... Courtly / / / ~o, 4755734 ........................... I1~1t~ In $uS~t ~ (Signature of applicant)