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Home My WebLink About19265-Z FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Approved ~-.~.., 1979. Pennit No. Disapproved a/c ................................ ......~. ...... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS · BOARD O,F HEALTH SURVE-?" .-.j / /~' ' ' NOTIFY CALL ...e.'?.? ...... MAIL TO: io0. XO 4_~.d~dfl. x;! ~OW~-b[ ~OUi ~u~ Date Y/ ...... 19 ¢~. a. Tiffs applic.4tion 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 th.is appli- cation. c. 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 permit droll 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 iltJilding Zone Ordinance of the Town of S0uthold, Suffolk County, New York, and other applicable Laws. Ordinances or Re,zulations. for the construction of buildings, additions or alterations, or for ~:emoval 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 necessarg~. ,spections _.~, (S~gn, ature ot applicant, or name, if a coi'~o'r~tldn')'/' /'or,-3o ~(.£'.~,~.z~q_ 'fY .... [,'./' ....................... .... 'rk. ...... ' ' (Mailing address of applicant) ,o , itf(li !~~~!i!i!!! ~~i~i i~iTi'i in~ii')geneQ~.'i°iiiiiiTr'~'l.'iitii~iii' ii;b~''r or builder. (as on the tax roll or latest deed) ~:' ::;,plicant is a corporation, signature of duly authorized officer. (Name and titie o~ corporate officer) Builder's License No. '" Plumber's License No .... /8/.~.. T./'.''/ ........ Electrician's License No... I ~ .~...~. ........... Otller trade's License No. ' ...... Location of ,and on which proposed work ~~~~ '., ........ ~ .... . ..... :.~ ~,..~-~,~~ ................................ l{Ouse Number e~ .... ' ' [~e' ', ....... ~ ............... County Tax Map No. 1000 ~ection .... 9 , , mo~k .... O. ~,.o.q ..... Lot..Da g~ ~.0 , [~ (Name) " ' ................ State existing use and occupancy a. Existing use an ~ , ~ .' ........ . .............................. d occupancy ............................. ~1 [~ , ~,,,....,~~~ ................ 3. Nature of work (check ~vhich applicable): New Building .......... Addition Alteration Repair .......... .............. Removal .............. Demolition .............. Other Work ............... (Description) 4. Estimate'd Cost.. ~...~..~/. ~..?.a.o.o. ~..~.. ~./y. 3-3'7~,v~..0.o.. Fee ...................................... (to be paid on filing this application) 5. If d~velling, number of dwelling units . .,~ .~. Number of dwelling units on each floor...-"A~.... 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 ....... .--.W. ...... Number of Stories .... Dimensions ofsam__e structure with alterations or additions: Front .... ..--=. · Rear .... . .. D.epth .. ..................... Height N : ': L' ' . ................ 8. ' .......... v .......... umoer or Stones....--:7-. .... . >' .,..., ...... D,mens~ons of entire new construction: Front ...-~ .5-..-.0 7.... Rear .. '.~ ~.<~.-;o De · r = O ' He,ght ............... Numbgr of Stories .. / -~'" t ......... pth .,~ .> ........... 9. Size of lot- Front/Z~-O.. 7 to~..- 0 R'e' '"~',a'; Z~ ' t:;2-'-"<'.:, ...............; .... .... ET ....... . ........ ar t,q'~. /3 - '~ De t ~.'~ ~ '7 "2 ;-'b .... 10. Date of Purchase //'3 I/ ¢t9 '',, '~fi'._' .......... . P:~ ,~:=~'~...-~ ...... Y ....... ~- · · INam '.t2 ~ - ' ....... .... /'. ........ :. e o~ l~'ormer Owner . ~t4*/ ~ .... I 1. Zone or use district in which premises are situa /:'/D ~./~ · · _,o-¢d4~, ........... ,, ted .... , ............. 12. ooes proposed construction violate an~zonin, l~w ~--,: ..... : ...... c/._ ........................... 13. Will lot be re-rade' //,_~ ,,~/~, /~ ..... ,~mm,mce or regumnon: ~ ...................... .... ° ~ .... ~/~'~0 7~ ;' ' '.": ';''' Will excs ~I be. remoyed rom premmes Ye. 14. eaameo~uwnerozpremises~./d0?.~.~.~/t~,~l~,v.,/ --~ ~-r= ,~-~-~>~-[ ' :~ · · us~ ..t~.,t.. auuress ~/.-ttttk~ 4 ~ c-.-'. · [ ' Name of Architect ~.~/~./t4.~c~Q.q~a-c..k ,,, (5 ..,..-.54.:~1. ~.... Phone No. ~,.q './..~. Name of Contracto2-P/),3v.c~-}a-Q~ ' ~,'.3 ~4t~ './?,,q',~ 7' ' ' .aa, a, resso~'a~,z'-/~r4~t'~-~'07~;~',~''' Phone No..'~.*.~"T.. 8.~. fi.C/... - , ............ ~-~4-,-.. ,..,~..~.~ . . . ^aaress O~.tct~(it~4'..7/.~.~... Phone No..q~/.~../.? .5-'.,~, .. IS.Is this property located within 300 feet of a tidal {~etland? *YES .... NO.I~.}. · 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. STATE OF NEW YORK~ cou. r-'y OF ........................ being duly sworn, deposes and says that he is the applicant ' '" (Name of individual signing contract) above named. " ,,eis,he ..... .... .......... ' ................................. (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 application: that all statements contained in this application are true to the best of his knowledge and belief; and that ~he work will be performed in the manner set forth in the application filed therewith. Sworn to before me this .1. [ . .-~..~, ........ day.of .... ~...t.~. ....... ,19 ~' ry bile, . · ..... County [.,/ No. 47..~/34 ........................... Oaafl~ la 8u~o~ 0our~ (Signature of applicant) i ,IH ~09 ,10 .9l N ~ ~7 731_,-/ ~/ V 0_,-7 0