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Home My WebLink About19264-Z FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL ~OUTHOLD, N.Y. 11971 TEL.: 765-1802 :,pproveS ..~.~., 1,~?. Pc=it No..1..~.0.~. ~ .~ Disapproved ale .................................. ...//'"~. .L. (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS BOARD OF HEALTH ...~ . . 'f,L'~'' '-' ' 3 SETS OI~,LANSi ~ !~ , ' .... CHECK / '~ SEPTIC FORM ~.,.~.(~_~.'. ...... NOTIFY C^LL ....... 5./. e.~ .~. ...... a. Ttds application must be completely filled in by Wpewriter or in ink and submitted to the Building Inspector, with 3 ,;ets 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. 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 4mil 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 ~t~ail 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 ~Iuilding 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. F1;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 necessary?r~spections./~,.~. ~.Z~.4-; .~...~q:/~)-;"~-~,' '* ~ ~'~.~.l,.(,'¢,J ............. __~, (Sign, ature of' applicant; or. name, if a cor~porauon),/_ ~ ...... ~-" i~'~hill ;~;e'~ ~',~bbii~;;/)' ' ' c ..... :' ~;tate whether applicant is ,owner, le, Fsee, agent, architect, engineer, general contractor, electrician, plumber or builder. ......................... ....................... ?/,.. ........ ,). 7. ;;~./ ........ . ..... ; .... : ....... (as on the tax roll or latest deed) !:' ,;~plicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No .......................... Plumber's License No .... /8/.~.. :'./? ........ Electrician's License No... ~..9..~...~. ........... Other Trade's License No. '"'---- J q~(~ Locatio,ofland on which proposeS work will be done ............... · ...... .~..,~.O,/~~g .... · ....................... llouse Number Street tSHamlet C9' ............ County Tax Map No. 1000 Section ....~..~ ........ Block ....0.~2."--'~.O.O. ..... Lot..~..O./<:.O. O Subd,v,~on.. L3~.,~4~,.,..~.: .............. ~,Icd ~,.~p ~o.. 8.?.g.~ .... ,.ot~~. '.' /... (Name) State existing use and occupancy of premises and intended nsc and occupancy of proposed construction: a. Existing use and occupancy .... 5....___ __ ,t~'''---~" .... ;'~ ........ . .....i'.; '""'~ ..... . .................... b' Intended u~e and occupancy .... /...,~..L.~..'..~..~..~./~. ~}~.~//f,~-- r/ 31 - - ................. 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work ............... (Description) 4. Estimate'd Cost.. ~...~...~'. ~.~.,.app..~--...~.. ~. ~.~-$~-~.a~..00... Fee ...................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units . .-~ .q. ......... Number of dwelling units on each floor ~ If garage, number of cars ...:..' .................................................................. 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use .~ ................ 7. Dimensions of existing structures, if any: Front ...... '- .': ...... Rear ....... ----. ...... Depth Height ....... .-5'. ......Number of Stories .... ~ .................................................. Dimensions of sa~me structure with alterations or additions: Front ...... ~ ........ Rear . ~ ............. ~D.epth .. .... L ................ Height ......... .-':' -,. ;, ....... Number of Stories ....~'~. ~ , ' 8. taxmenmons pt entire new construction: Front ~ .5.: O' n~ 'X <"-:'o ,., ' '.',' ' '.4 >-' "~"- ....... ~H. mght ............... Nu.m__b~r of Stories / '~_~ ''' '/ "~.5. ................ taeptn .,.,q :~.. gL ....... · ' .... ~ ...... r'?-, ...................... ~..:~.. :.., .... 9. S~zeoflot:Front~-0~....7.~..-.O ...... Rear ~ )'~---0 Depth /2-~-~" I0. DateofPurchase 0//3 t / ](2 .... ~'a f''- ' .... ;' ..... '~"? ;!lJ'.:.:~$; .......... ~ , · ..... 7 ...../. .............. ,~me pi eormer owner IAarV4..q~' t ' ~-.~ I1. ~one or use restrict in which premises are situated...~,/./~. ................. 6/~i'i. i ....~ i i .~..~.~. i i ........ 12. Does proposed construction violate aa~ zoning law, ordinance or regulation: ~ .................. 13. ~}I1 lot ,be~regrad? . .~..~/q~l~/~{.~ ?~;' ¥ ,: .~... Will exc~s~l_l be, rem~4v, ed from premises: ~,- Y~ei'' '(z N~o 14. mm ~ o° [ u. w,ne..r ° ~ P~etm ~e.~,"~'~41/, ~:t~ ~'' ~'~t4' Address .,.~-~-I.~ ~.~.4~. Phone No. ~...4.~;~..~([ ,Na '~rcnne ct ('~41/'~r'~t~ C34~ · '/~- · .,. · · Add ress,~a4-_./;~t.~..~. · ~.t~. Phone No of Cont. racto ' e Address Phone Nol i&."373 1 15.Is this property located within 300 feet of a tidal ~etland? *YES .... NO.~'.~. · If yes, Southold 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. STATF_,OF NEW YORK,~ , e e cousVY OF .... ~.c,.-b.¢.o! C. °'~ ~ ~/ ~~ ~;~---- ff ./ ' ~' :r&~~~' aO~X~:~ being duly s,vom, deposes and says that he is the applicant (Name of individual signing contract) .......... above named. ..... .... .......... ' ......................... (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 the work will be perfo~ed in tlie m~ner set forth in the application filed therewith. Sworn to before me this " ~ ~ 4~ ............................. ~ ~ ~~ (Signature o~ ,O0'g/ Att ,,Og ,~0 o9~ N 3A1~2 ~2731_4~VC130