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Home My WebLink About19246-Z FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 ,-'.xa,nincd 'i .~.~. '~' '~'" 19~.o. Approved .'~ ~., 19~.O. Permit No..I.~ ~.~. ~..21Z~ Disapproved a/c ............................ ........~. ............................... · ..... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS BOARD OF HEAl'TH ' 3 SETS O,F,.PLANS .,.~. ....... S U RV E Y~,~.-W'~ ~3.,.%' ............ C.ECK ..... '.~: .'. ;,".~' ',~,> ..... SE~,T~C FORM .... ~T~:.W ........ CALL ....... 7./..0.']..cT. ...... MAlL TO: a. Tiffs 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 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 o£ 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 Buildin§ Zone Ordinance of the Town of S0uthold, Suffolk County, New York, and other applicable Laws, Ordinances or P. em'lations, 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, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary?n, spections. , ., ~ j / i ,,'/ .,/ ~., ./ z , e". dO., , . : ( ............. ._.~. (Sign. amre of applicant, or name, if a corporanon) / · 0 .... 'd/ ....................... ' .... 0:' ...... ' (Mailing address of applicant) , 5;tare whether applicant is ,owner, le~ssee, agent, architect, engineer, general contractor, electrician, plumber or builder. .... ??. : .: ....... , meofownerofpremises" ~i~.~,-,~e' :~':2. ~'(~_ '~;.'"''i'.~..-~5~-22;-'-'~'~"5'57~''' ........... ......................... ~.. K :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/~. T./'? ........ Electrician's License No... I .9..~..f ........... Other Trade's License No. FT..'.', ............... lO.qq ('I.~^ , l:,.,{]Ct_ Location of land on which proposed work will be done.' .-77'7..7..~.-~~. · · .~../~..~.~~..~:.14-~-.~.~p-~-~~ .~.... · ...................... Ilouse Number Street OHamlet 6/ ............ County Tax Ma)bNo. I~000 STc~io;;..~[ P .......... ] Block .... O. ~. ,.£,).O. ..... Lot..~..O./, CO ' Subdivision...~.~R~.~./.~CP..~'.~7.~.~. ............ Filed Map No..S ?~'~' Lo'~~ ' ' . /,_ (Name) .............. ' ' ' State existing use and occupancy of~jemises and intended use and occupancy of proposed construction: / 2 3. Nature of work (check which applicable): New Building .......... ~'/' Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work ............... (Description) 4. Estimate'd Cost .. ~...~..J('. 7...?.,.aPP..~. ...... o ',,~'~.v~. oo 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 nsc . ~ ................ 7. Dimensions of existing structures, if any: Front ...... ~ ...... Rear ..... ~ ....... Depth. :Z--... .......... Height ....... ~ ...... Number of Stories .... .7'7. .................................................. Dimensions of same structure with alterations or additions: Front ...... ~ ........ Rear . ~ .............. Depth ........ .".. ............ Height ......... x'.., .......... Number of Stories ....---~. ........... , ....... 8. Dimensions of entire new construction: Front ...~ .~..-.O ~'.... Rear . . '.~ .,~.-~o. ...... Depth .,.22, .'~.-7 .O.' ....... Height ............... Number of Stories .../. :~... ! . .,:. ........................... ./.., .... 9. Sizeoflot:Front~,~...7.~.~.2.0j ....... Rear~.~iT~---.O.. .. Dept[l 10. Date of Purchase ...Q.f./(.'3...I./. '~0 ............ Nam[ of Fo'r~er 6~v~ler'. ~ .-~'. ,~~ Il. Zone or use district in which premises are situated...~/.~. ................. C~_' .................. iii ..... 1 2. Does proposed constructiofi violate a,n~zoning law, ordinance or regulation: ~ ....................... 13. Will lot be regraded . ~.-~a:Z,~,..t~/.~fn .......... :... Will exc~s fill be, remoyed from premises: Yes f No) 14. Name of Owner of premiseff [./0'/..~t.//~_ c/ff~,.Z/lg~t/ Address ~,,~f.--t~faAzf~..~'/~ Phone No · / ,, Y')'.'77 ' ' '' Address~.x~l-./C/..t.4~..07-/..~./-~...(~ " ' ' ' '/'f' ' /'' :' .... ' ....... Name of Architect ~.~4t/~,~C;,~¢ .<~-~. ~.../?~..~... Phone No..7..4.~... b/.~'. ~/.~.. Name of Contractog' ?~&//4-., .t~. ~.. ~,/24~-~ ~.... Address ~."~'~ ~./'J~.~... Phone No. -~. Y.7./.~ ~--~'~- - · 15.Is this property located within 2300 feet of a tidal ~:etland? *YgS .... NO3,¥}. · 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 corner lot. ~/'~ 0 (~ ST..\T -E.OF NEW YORK,, ~ _ S S cou r V OF .... · / ' >'f~~.a/~ ~~~ .......... being duly sworn, deposes ~d says that he is the applicant (Name of individual signing contract) above named. · l lc is the ..... ~~ .... ~ ~ ........ (Contractor, agent, corporate officer, etc.) of said owner or owners, ~d is duly authorized to perform or have perfo~ed 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 ~he work w~ll be performed in the m~ner set forth in the application filed therewith. Sworn to before me this .......... ,., ........... ~ ~ ~. ~,~ ~ Y~ ................................... ~fl~ ~ ffi ~ (Signature of applic~t}