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Home My WebLink About19243-Z FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1802 3 SETS O,F PLA~;iL~'..'; ........ sURVEY ./~;;V'~.. 1°.. ,~.;, .~. ...... SEPTIC FORM . J. j ............ Approved .. . .~.(a., 19~.O. Permit No..L .]..~.~.,~.~' Disapproved a/c ..................................... ................................ (Building Inspector) APPLICATION FOR BUILDING PERMIT NOT~P~ '~(7 CALL . . .~.... :'. ..... 7 ...... MAIL TO: ~o~~ INSTRUCTIONS a. This applic~'tion must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 ~cts 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. ¢. Thc 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 3uilding Zone Ordinance of the Town of S0uthotd, Suffolk County, New York, and other applicable Laws, Ordinances or Re.2ulations, for the construction of buildings, additions or alterations, or for ~:emoval or demolition, as herein described. l'h2 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 necessargTnspections. ? ~ ¢ / /z~,~,.~:/c.'~..~. ~,.,:,.~.~: ............. ,~ (Si~ ture O~ anolicant, or name, if a corporanon) t ,- t-, (Mailing address of applicant) '~ ' qtate whether applicant is~owner, le,~see, agent, architect, engineer, general contractor, electrician, plumber or builder. · .,,.,.~/.Z~-..~..-. r,.~.c~.~:~ ................................................................ , /,~ , ,, ~, ~.., ~ ~.~;- .~_ . ? .g .;ameofownerofpremises .':'.".~.~-,~'./D:'-C.'~--,.~.-:'. ..... 5/~'-~'/~..--~-~--r'-~:c'~:/iC,/-''0- :'[.~.- ........... (as on the tax roll or latest deed) I:' ;:;qqicant is a corporation, signature of duiy authorized officer. (Name and title of corporate officer) Builder's License No. ~ Plumber's License No .... /(. ~/..~. · 7 ./".' ........ Electrician's License No... I .9. ,~...~. ........... Other Trade's License No. :..-f'~. · · ............... ..,, 13(..).,~ ~ Location of land ~on which proposed work will be done....'~..?~...L~..~..~.'-L-(..'~.../.~'/'..-4<.~4-.~/t~..~.~.'~.~ .... · ....................... z ............... House Number Street bHatnlet County Tax MapNo. 1000Section ................. : Block ...D.~.t.O~ ..... Lot..D ~,.~o,.... ~_~.¢,.,.g~, ~.. ............... ~,~d ~,~, ~o..8.¢dd ..... ~ot~~~.. State existing use and occupancy of~jemises and intended use and occupancy of proposed construction: a. Existing use and occupancy ..... ~ ....~~~ .... ; .~ ....... ~,- ..... .; :...... ~ ..... . ........ . ............ .... ......... ...... 3. Nature of work (check which applicable): New Building .......... l/' Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work ............... (Description) (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 ..... .--7-. .......Depth.: ............. Height ....... ~ ...... Number of Stories .... .~. .................................................. Dimensions of same structure with alterations or additions: Front ...... ~ ........ Rear . ~ .............. Depth ...................... eight ......... .---;., .......... Number of Stones .......... t ? .?.wY?5. ' ..... 12. Does proposed constructio~n, ,~_ ._vi°late a,n~ zoning law, ordinance or regulation: ~. ...................... ~,~:~, lot be regraded No) 15.Is this property located within 300 feet of a tidal ~etland? *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. fiTAT 'F..OF NEW YORK.~ ~ _ S S } COUI~T,Y/,,/ _ ~.,o,OF .... -.%.0'.+.4")o1.~.. ' ,q , ; · :;/'f,/. ~7~.. ~..x_-A~,~/. F'~.c,~.d.~'..~.. .......... being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) ?.bore named. ,lc 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 ?.pplication; 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 flied therewith. ~ Sworn to before me this .~ .......... [ .............. day.or .... ~.../.~./Id ........ , 19 .~.O .No ' ' / · ~/ ~ ~ ~ o~ N~, Y~ ................................... No. 4755734 ~I~1 In ~ ~ (Signature of applicant)