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Home My WebLink About24118-Z BLDG. DEPT. TOWN OF SOU 7: Di m~rr~l a/c .................................. FORM NO. I TOWN OF' SOU'FllOI,D BU] I.DIN(~ DEPARTMENT TOWN II^L1. SOIITI1OI,D, N.Y. 11971 TEl.: 765-1802 BOARI9 OF IIEAI,Tll ............... 3 SETS DF PLANS ............... SURVEY ........................ CIIECK ......................... SEPTI. C FORH .................... APPI.I[CATION FOR BIIILDING PERMIT I NS'FRI ff;'r I ()NS a. 'lld.q appllcatlcta ~mt I~ conOtetely fillc~l in 1~ t~.mlter or in ink m~l ~l~[tt~ to fl~ ~filding Ins~ctor with 3 ~ts oF plus, ~o~rate plot pl~ to ~ale. F~ acconllng to h. Plot plan ~it~ lmatim of lot ~ of I~dldi~, ~ ~i~*, relati~shlp to ~joinlng ~ises or ~d~lic struts or areas, ~t givi~ a ~tail~ ~scripti~ of l~nt this 'a~l lentil. c. lhe ~rk c~r~ by thi~ a~l. icati~ ~ ~t 1~ cu~,,~l I~fore issue of ~dtdi~ Pemit. d. U~ alqn~ai of OHs a~licati~, tim ~ildlng ln~l~ctor ~*ill is~m a ~ildi~ Pemlt to the ~llcant. ~h ~mit shall I~ kept ~ tim ~i~s ~ailable for ins~ctim thr~J~t the ~rk. e. ~ ladldi~ ~mll l~ ~o~pi~! or u~ in ~mle or in D~rt for a~ ~ ~mt~r ~tll a C~rtlficate of ~m~m'y ~ml I h~ l~n gr~t~l 1~ tim hlildi~ lns~tor. A~,IC~TI~ lS I~,~l~ ?~ to tl~ ~ilding l~art~nt for the is~e of a ~ilding Pemlt p~mnt to the h~ildi~ 7~ ~lim~e of tim 'r~ of ~tl~ld, ~ffolk C~n~ty, ~Ddati~m, for tim ~stnmti~ of ~dldi~s, ~kllti~m or alteratims, or for r~al or d~l ition, as I~rein ~scril~l. llm a~lic~t a~s to cu,~ly with all a~llcable reD~latim~, ~] to ~it ~tlmri~ in~tors ~ ~im, ~1 in ladldlng for ~ces~ ins~cti~s. (gMli~ ~klress of ~llc~t) ~ ..... StaLe M~tber applicant is omar? less<~e, agent, architect, engi~r, ge~ral cmEr¢~l;q[~r~t~r¢~im~,plt~r or I~lihlor. .................................................................... , .,:'?~: ~,~'l-~E'/f~'~u ~ ~r ~=fzU ~' '~ ......... (as m ................................. the t~ mi I or latest ,~!) f ~ ;~ Ii ':" rq l ll'l:'rf,i~?f*t:C~',~ :f ~i"~ ~ "~, '~; ......... If appl leant is a~.corporation, .~g~tu/;e~Of (h~ly mdlorlr~t officer. .... ................ ( ~ ,~d titl~ of cor~ra~flcer) P~dlders 1,icen.q~ No .......................... l?lt~nlmrs I.icens~ No .......................... Electricians I,icens~ ~ ...................... Otl~r Tra~l~s l.lcens~ No ..................... :' U'~fE CONSTRUCflO~ ~ ~PF~GH ¢~ CONgl-RUt;IION ERROP.,~:: ,~ T~ ~ ~. ~ ~ ~0 ............... ~,~ .....:..... ..... ~ .......... .... .... .... ..... (~) a. ~xisti,,g u~ aml ~},~ ............ ~q.~.~ ................................................ /. I~q~iir ............ I{~nr~)vfl I ............. ~.~ llt~i hliill~ .......... ion .......... Al terat ion .......... I)oit)l itio. ............ Olher (I}e~c.r i pt i~O (Io I)e paid (~l fill.i,~ this alq)licfll:ion) If: (k~ell i-I~, nn~d~er of dwelli~qA u[~ils ............ ri.i~er elf {k~llinl~ t.;il~ {s~ each fhx)r ................ 1~ ~"[at~¢, ,*.d~r (,i: ~m'. ........ ~.~ ...................... Ik:i~ .................. ~ ...... ~.d~r o1~ ~toti.~ ...................... I~pih ....................I~i~[ ................. ~ ~s,i~r o~ Storie. ............... ,~i~,,; ........ /.~.~ ...........-,,~, ,,~ ~.,i~, ..... / .............. II. Y~.~ o, u~ di.~ icc in ~id~ pt~.i~..~e s~t~t~l ............. "~~ ........................................... 12. Ik~. prol~l c~x~.~n.:ti~ violat~ m~y ~.Hn~ 1~. mdi,~.:~ ~)r r.[~ul.~i~.l: ........ ~ ........... '"- ""=" -~ ~-~, -~ ,~-,,,~... ~~.. ~/~F~. ~u,~..~ .......................... ~ //F~ ¢~~.~. -, .............. ZT~-~ ~,,. ,.: ~.~,.~:t ..~~..~.~ ....... ~,.=... :~?~...~ .......... ,,=,..~ ............... 15. I~ thi~ I),'~qx~ity within ERX) ~ I1,' YES, ~lllllJ i) 'l[lfi I'i.OT I) I^GIIAH IZX:ille (:learly aJKI (listit~ctly all I~Hl(liiq~s, ~liethel exisl it~g or prol~)~M, alii il.licate all ~t-I~k iliultilsions fEtUS i)rol~iiy lilts. Give sti~mt a,~l I)l(x:k ~td~r or {~s(:ripti(.s flcco[diiig I:o (k~l, m~l ~]c~ street lust.s a~l i[~li(:ate t~telJ~l iiJlecior OF COllar lot. PROVIDE ]/,, HR. FIRE RATED SEPARATION TO PART. 717.3 (f) (l) OF N.Y. STATE BUILDING CODE. ,~;IA'll,: (N; ~':t~ YOILK, (x~JmY ix,' .. </z,~/-/'/~Z~/ SS UNDERWRITERS CERIIFICATE REQUIRED PLUMB£R CERTIFICATION ON LEAD CONTENT BEFORE CERTIFICATE OF OCCUPANCY SOLDER USED IN WATER SUPPLY SYSTEM CANNOT EXCEED 2/10 OF I% LEAD. ((k)lll latter) al~elll:) (:erlx;raie officer, elc. ) ;llqd J(:atioii; lilal, all stalc~,eat~ (:(~llflit~(I iii Illis ;q)l)lii:at iolJ ;.e Itt~ lo Ihe I~sl: of hi~ kix~lc~Ji~e ~itxl I~Hiei; ;J,.l thnl the ~)lk will I~ i~rroiu~J Je tile II~IIIIEI- Set: [orlh iii the al)ldi(:al, ion fil~l II~rc~ith. ~o I~fl)r(~ Ill~ this .. ~.~ ........ ,,,y ,,~ ..~ ~ ..... ~..2. ~.. HELENE O. HORNE Notary Public, State of New York No. 4951364 Qualified in Suffolk CotJnty ~ ) ( 1 Commission Exi:,il'~,Js I',,qa¥ :.2, I 9