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Home My WebLink About19239-Z FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined · . -~~- -~- .~.., 199.Q Approved · . O.(o., 1990. Permit No..J.~l~.~..] .~.. Disapproved a/c .................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS BOARD OF HEALTH ............ 3 SETS OK PLAN~.,~...~-~ ....... ~ ', '" f '( /-~ ,) SURVEY .~ ..... f ! fb..¢~. -' ....... CHECK .......... ~ ~:./.'. ....... SEPTIC FORM ... ~.. :'.~ .... NOTIFY ~/'~ CAL~ ..................... MAIL TO: 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 property 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 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 -hall 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 guilding Zone Ordinance of the Town of S0uthold, 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. I'he applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to .;dmit authorized inspectors on premises and in building for necessar~,m~spections. ~ ,., ;~4./. ,~.<~,..~-../&',,.~-~,. ............. 4Z?(~./?Sien, ature of applicant, or name, if a corporanon) · c~ .... q;/'~." i:,~'~;li:,;~ '~;e'~'~ 'o'~';p'pii'cTn;)'''e ..... :' :tare whether applicant is mvner, le~ssee, agent, architect, engineer, general contractor, electrician, plumber or builder. ......................... ,: ........ ~, ..... .:~ ....................... ............... ... (as on the tax roll or latest deed) h' ::pplicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No. ~ P,umber'sLiccnse No .... /81.~. .:'./~ ........ Electrician's License No... L ,~, ,~,-f ........... Other Trade's License No. : .-'7. :: ............... do. .... ..... ........... ............... >' ............... 1_ (Name) State existing use and occupancy of pjemisesand intended use and occupancy of proposed construction: a- Existing use and occupancYb. Intended use and occupancy .... 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration .......... Rep.air .............. Removal .............. Demolition .............. Other Work ............... (Description) 4. Estimate'd Cost .. ~...~..~. 7.~..,.o. op. .~. .....~ o 'JT~.a~. . . .°° . 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 mixed occupancy, specify nature and extent of each type of use .... ~ ................ 7. Dimensions of existing structures, if any: Front ...... ~ ...... Rear ..... .-:--r-. ....... Depth.:. 7. .......... Height ....... .":-7. ...... Number of Stories .... .77. .................................................. Dimensions of same structure with alterations or additions: Front ...... ~ ........ Rear . ~ .............. Depth ....... %'.. ............ Height ..... .-w.. Number of Stories 8. Dunens~ons of entire new construction: Front .'~ .5.: O Rear ~ .;~.- o Depth ,.~ ,5 - r/ Height .............. Number ot Stones . ./. :~. .. i ,<. / 9. Size of lot: Front/~,2Orc...7.5..- O~ ..... Rear..f~b~,.. 7,5 .'7.0 ....... Denth {.)-(W'~'r~~ ~ '~ .~ O ' : !! - ~ ~U ' -:-,~,~ .......... I0. ~Date of Purch,~e........(/.3...t./.. [(2... ¥...: .....;,N,4me of Former Owner . ,fl.q~-~t .*/. l_,O~ff .......... 1 !. z:one or use msmct ~n wmcn premises are s~ruatert..Z"I ./.4 ................. 6/. ........................... 12. Does proposed constructio2n viol.ate any zoning law, ordinance or regulation: ~. ....................... 13. Will lot be regraded . ,.Flga:U~.~/.~t.~ .,~ ....... ~... Will exce~s fill be, remoyed from premises:. Y_e~ /' No) 14. Name of Owner ofpremisesr_,~j0?.'904q'~./u~Xlg~.Rqx{/ Address t,~.-t~aJ~-~.~-~LL-'/ Phone No 25-/. ~..7/! Name of Architect ~.ff~,.0,/~J~cg,a ~_D~/~.~...,fl, i.,. i i Address~0[.~-'/CftC[ .~. i~ .~.' i i Phone No' ?/5.',~'~.'" o~'~ {,':~ ' ' Name of ContractorT[,)0r~-. ~(...((~tS[.e.. {~'.,5~.g,4.... Address ~-aa/~'~'j7/.~.~... Phone No. -'~. Y.7-. IS.Is this property located within 300 feet of a tidal ~etland? *YES .... *If yes, Southold Town Trustees Permit may be required. PLOT DIAGR~ 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. ~tq~'~tr~<- ST..\TF..OF NEW YORK,~ _ S S fi COUSTy/~/ ~ ~.n~OF .... ~.u.-{--.C. ol.ld-.... ' .n .--' ..5:/~,/....C~. ~. t,~'~ .~..~..~?.?...~.. .......... being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) .lbove named. ..... .... .......... ' .................... (c°n Ortract , agent, corporate officer, etc.) ............. af 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 ~he work will be performed in the manner set forth in the application flied therewith. Sworn to before me this ~ ......... .......... .... ......... 19 .~.0 "°taryPublic, ,',,~ ~..~ .... County ~/ ) .,./? /f~ ,? / No. 47~'7~ OJ,l~ In Sutk~ 0~ (Signature of applicant) ,O0'gZ A4 ,,Og ,lO ,,gl N I '!