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Home My WebLink About19244-Z FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1805~ Examincd....~.,~..~.~.,19~..0. Approved ...~..~...~., 19 .~.0. Permit No..l.~..~t:~.t~. Disapproved a/c .................................. ~. ................................ ..... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS 'BOARD OF HgAI~TH ..j .......... 3 SETS ~OF ,PL,Xr!S ?(>,.~.. ........ SURVF~¥ ~9~. ·., ;, ~+2d.".'..,, .~ ....... SEPTIC FORM .... ~.~ .......... NOTIFY //~ ~ ~.~ c~tt ..~.~.~7.z.~.C~ ...... MAIL TO: /~. ~ ,~~~ ~ a. This applicJtion must be completely filled in by Wpewriter 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. e. 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 pe,mit 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 S0uthold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for 3emoval or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to adm, it authorized inspectors on premises and in building for necessary/ ,Tnspecti°ns-. ,./..,(.j. ,~c~_ rT.. f~ .,.~.">.t, ............. ........... _4, (Sign,ature of applicant, or name, if a corporauon) / ' (Ma' in= ad ress of applicant) , State whether applicant is owner, lessee, agent, architect, engineer, general contractor electrician, plumber or builder . . . :: .-. : ......... .................................................... / , (,- ...)_ Name of owner of premises .~:.~./i~,~'~f~.~-~'. ~- Z.,,~. ~...~..'./¥ .... .~'.'~-/~:~-.~.g-r'. ~.~:'~.0. (~. ........... (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 .......................... Plumber's License No .... /8/.~.. i'./~ ........ Electrician's License No... I ?. -~..-~- ........... Other Trade's License No. i · .-f'~. · · ............... Location of land on which proposed work ,rill be done .... ~',~.~...(~. ~.2.~.. 0 · ....................... ...... ' .... [louse Nu~m ber Street vHmnlet iQ' ....... · ......................... Subdivision .. t..g..~.O.-~. .............. Filed Map No. 1~ (Name) /..~ ' State existil~g use and occupancy of,psemises and intended use and occnpancy of proposed construction: a. Existing use and occupancy .... ~ .... ~ .... ; '~ ....... i" i'' "'fi./~.';/'} ~ff.Z~'" :'~ ..... ' ........ ' ............ .... ..... ...... .......... b- Intended use and occupancy ' · ' ' '"' '~"~' ": ~ob~,. t3 ' 3. Nature of work (check which applicable): New Building ........ Addition Alteration Repair .......... .............. Removal .............. Demolition .............. Other Work · / '-- -- Fee 4. Estimate'd Cost . ~...~..~'. ~'..~,.~.oA .~...~.. './. ~.~ ~,,.~p~. ~o (Description) '~ 7 (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 ... :' .x-. ................................................................. 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 ....... ----. ...... Depth Hei,,ht ....... ~ ............... f~ulnoer ol btones .... Dimensions of sa~me structure with alterations or additions: Front ................. Rear . ~ .............. Depth ...................... Height ......... .-w..~ .......... Number of Stories.. ~ ..... >'....f ...... 8. Dimensions of entire new construction: Front ..."~ .~-'.:.0 '.' .... Rear . . '.~ ,.~.-~o. ......De th _H.e~ght ............... Number of Stories . . ./ ~ t P ' '~ ............ 9. Size of lot: Front//.~,'-o.. 7 ~.'~.- 0 Re' '"-'~X J Z,; ' li2--~'g.; .............. ;4 · · '.' · · :~ -.~ :~ ./- · * .... 10. Date of Purchase ---'cY' ~'fii~ '/)' ¢~ ...... ar . .~,~r'.q~-. _/~ .-./.4. ....... D~eptt) ~-.~..~f. ~ .'-?. ..... 7 ......... ._, .: '.' · '.'.?; .... /- ............ : .?~ame of Former Owner ./J.~-cq-c./. 11. ,-,,~uc m uae Ulatnct xn wmcn premises are situated..Z"//.2 (~_'_ _ ~ .......... 12. Does proposed constructio/t violate anx~ zoning law, ordinance or regulation' 13. ~' '''~ ,~--; ~t~t"~'~',: ...... .-~.--Wlllexc~sfill.be. removed from remises: y (N~ Will lot be re*faded ...,~ ~ · ' ........................ 14. ,N, arne of Owner ofp~r%mise~t./~..~L~,./~.i~e3t~t/.'. Address .~t~.f...-~t.C~zff. ¥']/2-/ m,P~o ~,~ ~7c-/. ~/! c~ame of Architect (.'~(.~.~t/~g/.~{' ~ ~xLJ_ -~ 0 './ '~ ' ;'.,~' .r. .....,,,,,. ~v. &~ :. ~-:t. '....'-~--.. Name of Contract^'~q~,J~¥f]-'~ ~'~1 '/)/~,~7''' auuress,~.~./y~,t..~.._.0~, .7~,~,.,/f/.. Phone No..'].,~.~. o~ ~ ~.f/. ur 4,.,wm-.~ .--w~. ~... :~/M4.c.-.t .o~.t/,2 Address ~i~.~ ~/~.. ~.~. Phone N~ .~. '~"* '~;'~"~'~'' ' ....... · ...... v....~.~: . .~.,~. ,~. ~,~ . . 15.Is this prope~t? located ~ithin 300 [eet o[ a tidal 6etland? *¥R$ .... NO.I,~'.~. · If yes, Southold Town Trustees Permit may be required. PLOT DIAG R2MM 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. ~h/) 0 '0 Et- STATE_OF NEW YORK ' S S CO.U T OF .... lC · / ' ~'~"2~-L'~ "~'"7"?' '~q?'(Name being duly sxvorn, deposes and says that he isthe applicant above named, of individual signing contract) .......... .eisthe ..... .... .......... ' ............................. (Contractor, agent, corporate officer, etc.) .... of said owner or owners, ~d is duly authorized to perform or have performed the said xvork 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 ~he work will be perfomed in the m~ner set forth in the application filed therewith. Sworn to before me this N~ 4t~ ............................. ~fl~ ~ ~ ~ (Signature of appiic~t)