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Home My WebLink About19240-Z FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 BOARD OF HEALTH ............ 3 SETS OF\PLANS ..... ~.' I~' ' ' Examined.--~~ .~-.~-., 19 °).°. ..\pprovedd~ fl[[. 7x.J~,~. ~,[~-, 19 99. Permit No. ?'~' .~. '~.~.q. '.0..~-. Disapproved a/c ....................... . .............. ................................ ..... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. Tlfis 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 tiffs 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 iluilding 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 removal or demolition, as herein described. i'l~e applicant agrees to comply with all applicable laws, ordinances, building code, housin~ code, and regulations, and to .:dmit authorized inspectors on premises and in building for necessaryTnspections. .~4, (Sign, ature o~ applicant, or name, if a corporanon) 5tare ghether applicant is owner, le,~see, agent, architect, engineer, general contractor, electrician, plumber or builder· · . -~ // . (as on the tax roll or latest deed) h' aF. plicant is a corporation, signature of duly authorized officer· (Name and title of corporate officer) Builder's License No .......................... Plumber's License No .... /8/¢ ."../~. ........ , ~ Electricians License No... I .9..~...,.~. ........... ,..,,, · Other Trade's License No .... · .......... I ,.~.,~,5 ~~ ~ Location of land on gl,ich proposed work gill be done .... ~~~.. ~'~'~5~-/~~. ....................... .......... ilouse Number Street ~Hamlet ~ .... County Tax Map No. 1000 Section ..... ~0 ........ : Block ....0.~,.0.~ ..... Lot..O~/5 ~P.. ' bdivmion.. ~.~ t.g.f~ ............... Filed Map No. t~ (Name) State existing use and occupancy of ~$emises and intended use and occupancy of proposed constrnction: // 3. Nature of work (check which applicable): New Building .......... Addition Alteration Repair .................... .............. Removal .............. Demolition .............. Other Work ............... · /r./Y (Description) 4. Estimate'dCost ..~..~.J(..~'..?.a.o.o..---Z~...~.. .~-57~./~' oo Fee I . , .~ (to be paid on filing this application) 5. f dwelhno, number of dwelling units . .,,~ .q. ......... Number of dwelling units on each floor. · .'7'ZW..... ~ ....... If garage, number of cars ...:..' .................................................................. 6. If business, commercial or mixed occupancy, specify naZe and extent of each ty.~.pe of use . ~ ................ 7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth. ,77.: ....... Height ....... ~ ...... Num bet o ! Stories .... Dimensions of sa~me structure with alterations or additions: Front ...... ..--'7. ........Rear . .-:n. .............. Depth ................. ..... Height ......... .-':., .......... Number of Stories....--:w'.... ,. , - 8. Dimensions of entire new construction. Front '~ .5.: a ~ Rear '.~ ~.~-~-.-'o De-th ¥' 4'--' ~ ........ 10. 11. 12. 13. ~4. I Name of Contractor'S. ~? ~ ,354~ ~,,,),)" ' ' ' , .... ~..-~'~"','.'-.~-~.' ....Address th~.~z(X.~/.~.~...PhoneNo .~.~.~. 15.Is this property located within 300 feet of a tidal {~etland? *¥1~$ .... lq0.1~.~. ~If yes, $outhold To~n 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 inte~or or comer lot. e b c.q..z. STATEOF NEW YORK- ~ , ~ ~ I,i .... ~ ...... ~ : lbove named(Name of individual signing co~3~c~5 .......... being duly sworn, deposes and says that he is the applicant tie i, the ..... ~ff~7 & .... .~e ~< ~30. ~ .......... ' ................................. (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 application: that all statements contained ~ this application are true to the best of his knowledge and belief; and that work will be perforated in the m=ner set forth in the application filed therewith. Sworn to bel~re me this ' ~ 47~ .......................... ~fl~ h ~~ (Signature o~ applie~t)