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Home My WebLink About19238-Z FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1803 BOARD OF HEALTH ............ 3 SETS OF PLANS · 4~ -,,- ~,- .... SURVEY ,,,a~,*-.~ !' ,~-. ~ . .~..- .... CHECK SEPTIC FORbl ................ Exaxnincd...~.~(°,19.~.O Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT NOTIFY z/'~ tv CALL . . .c./.././..-'./..o.,~ .~2 ...... MAIL TO: %0~N OF ~OU', ~~. ..... INSTRUCTIONS a. Tiffs application must be completely filled in by Wpewriter or in ink and submitted to the Building Inspector, with 3 :;ets 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 ,hall be kept on the premises available for inspection throug_hout the work· e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy ,hall have b~en granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the 2uilding Zone Ordinance of the Town of S0uthold, Suffolk County, New York, and other applicable Laws, Ordinances or Reculations, for the construction of buildings, additions or alterations, or for ~:¢moval or demolition, as herein described. Fhe applicant agrees to comply with all applicable laws, ordinances, building code, housin~ code, and regulations, and to admit authorized inspectors on premises and in building for necessary, inspections ,~.4, 4..~'~.;: ./d:- 4, ~ ,. ;.~..~( ............. .._4, (Sign,attire of applicant, or name, if a corporation) / joo':o ~.(%~.,:~q. ,~. &.&7;~.~d ~1.:¢//93: g:ate whether applicant is..=own.er, le.~see, agent, architect, engineer, general contractor, electrician, plumber or builder. :.; :', :/:.. - x(5 , ,. ............................... (as on the tax roll or latest deed) i:' applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ........................... . . .If ........ lumber s License No .... " ~*ctr~cian's License No... Z ?. ~.~ ........... Other Trade's License No. :T..-.-. ............... · ~ ~_L ,---~.; ,,') ~ Location of land on which proposed work wiil be done...>:~':~.74. ".C~...~.~~f _Z~ff ....... ~z~>. ~. x.:... ~ ......................... ~~:f~.~.. ~ ~ ........ Cou ~O nty Tax Map No. 1000Section ................. : Block ...O.~,.O.~ ..... Lot..~~.~.. ~ . /~ (Name) .............. S~ate existing use and occupancy of pxemises and intended use and occupancy of proposed construction: ~ a. Existing use and occupancy .... ~.'~..~ .... ; · =. ............... . ............................... b' Intended use and occupancy . --o~ --... ,":;,::,.." ..~ 0 ~o~ ~ 3. Nature of x(;ork'(check which applicable): New Building .......... Addition Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work ............... 4. Estimate'd Cost . o (Description) · .... .-./,./'-?.a :STvoo ..... Fee ...................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units . .,~ .~. ......... Number of dwelling units on each floor If garage, number of cars . ...: ~ .................................................................. 6. If business, commercial or m~xed occupancy, specify nature and extent of each type of use 7. Dimensions of existing structures, if any: Front ........ '---x. ...... Rear ....... ----. ...... Depth ' Height ~ Number of Stories Dimensions of same structure with alterations or additions: Front ........ -7. ........ Rear . v :'. .............. Depth ........ .'.. ............ Height ......... '~ · .~. :, ........ Number of Stories ....--~--.... ,. , 8. Dimensions of entire new construction' Front ~ ~ O' r~r '"g q----"o ~, ., '.4 ~.' ~ ........ · · · '-- ................ ,-, · ........... oeptn . ,.,q '.~. 7 ......... Height ............... Nu,nb~er of Stories . . ./. :~.~. ....../.. . ./. ..... 9. Sizeoflot' Frontfi~,,,2~O~. 75.'~.-0 Rear /)--~-"~/- ')'<-' O .... ~-''[,'')i:-¥t':'~:'P"2L'tj .... ........ . ........... "~" ~l- · t,.~ .~ ......... lJepu oq-w.¢~--~ 10. Date of Purchase ...d..././f..3..I./. :~0 ............. Nan{~ of Former Owner 7.~.o~/ t~i~5~;?;;fa ......... 11. one or use restrict ~n which premises are situated · .ff'!./-~. ............. ~.. .......................... 12..D..o..es. proposed constructio,.n viol,.ate up, zoning law, ordinance or regulation: ~ ....................... 13. Will lot be regraded . ,.../gS-a~, [5(~./gL.~!fl ./~ ........... Will exce~s ill.1 be, remoyed from premises: Ye 14. Name of Owner of p,,re,mise<~'~:~.~-gd'. ~.~5'2/tg~ttJ... Address ,,t,~f.-~t.C~../,~ 4.r~.~. Phone No 25'7' ~..~1/ Name of Architect (.5/-~1/~)'.-~,a~;4/~ . Addre~* t,~., x,'.., ,,/,-,/'b)~J~-' ' ,,~ ,, · ~.} k.',;2." '-,'~;ift ' ' - '"~'q ' a fiji 1~5' · 'z' · '/?ff · 'l ..... ~,~.o.-r_.l m:~,4, r.~,.'-:., t.r ..~... rnone ~'~o.. ze..q., ot 7. Y./... Name of Contractor ~d~.4-.~.~z~.~. 5~,~.g ('.~/,/J Address '~,~.~7~/~-~t ..... '/'"" ................ . .,,. ,,-.- .... rnone p~o..m ,~./../.~...~,.. 15.Is this property located ~ithin 300 feet of a tidal ~;etland? *YES .... lqO.~'.~. · If yes, $outhold 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 comer lot. 5T,\TE. OF NEW YORK..,_ _ S S .... . · , / · 'fr~4~. f~f~Z~J~ being duly sworn, deposes and says that he is the applicant ' (Name of individual signi~'c;;~a~i~ .......... above named. ..... .... .......... ' .............................. (Contractor, agent, corporate officer, etc.) ' ' ' of said owner or owners, ~d is duly authorized to perform or have performed the said work and to m~e and file this 2pplication: that all statements contained N this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set fortli in the application filed therewith. Sworn to before me this ~ 47~ ................................. ~fl~ ~ ~ (Signature of applic~t) ,~g'69~ ,O0'gZ /H ,,0§ ,lO ,9~ N