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Home My WebLink About17234-Z I~OB~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 017234 Z Permission is hereby granted to~ /2 ~.~...~... ......... ~~... ..~ ........... ' .~...~zz....-J~.~ ........... ' ' ...... :'"2':77 ...... _: ......... ~ ..... . . o.,.. ...... ....... a remi, e ' ~-'~'t pr 'ss ocated at ....... ~[>,....C~, ............. ~/~ ....... ~~ ............................................... County Tox Map No. 1000 Section .... ~.~..2 ......... Block ............. .~...... Lot No. ~ pursuant to application dated ............ . .~..,/../,, .......................... , 19..~'Z~'~ and approved by the Building Inspector. Fee Rev. 6~30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 NOTIFY - TEL.: 765-1802 CALL ~5~ MAIL Examined · -~--~-, - ......... , 19~.t. , Approved.. ?~./..~. ......... ' 9 .~?~.. ee nnit No. /~.~..~..~. ~/ Disapproved a/c ................................... · . ............................ / ~;Building Inspect;;; ........ APPLICATION FOR BUILDING PERMIT INSTRUCTIONS BOARD OF HEALTH ............ 3 SETS OF PLANS ............ SURVEY ..................... CHECK ...................... SEPTIC FORM ................ TO: a. This application must be completely filled in by Wpewriter orin 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 apph- cation. c. The work covered by tiffs 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 ~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 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 Southold, Suffolk County, New York, and other apphcable Laws, Ordinances or Regulations, for the construction of buLldings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building coge, housing code, and regulations, and to admit author/zed inspectors on premises and in building for necessary inspections. ..... ///<': ............. (Sigr~ature of applicant, or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, en~neer, general contractor, electrician, plumber or builder. .............. ......................................................................... Name of owner of premises ....~../f.//.~./~....,~.~...a(..~..t.¢.$../.'C.. ' . ....... (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 ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done .............. ' ................................ }louse Num her : Streek. Hmnlet County Tax Map No. 1000 Section // ~ \ ~' #~Y~"'~' >,:..~_~.j .................. mp k .... - Z' ' '~' Lot ................... Subdivision ~-~/.~E /~'/20 Eilcd Map No ............... Lot (Name) ~,' 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy .......................................................... ~. .......... · ntended use and occupancy .................................... ; .... ;.. ¢ .............. 3. Nature of work (check which applicable): New Building ' Addition ........... 'alteration ......... Repair .............. Removal .............. Demolition . .~.-:...:~: .......... Other Work .............. (Description) 4. Estimatc'd Cost.. ,~.etO.~ ........................... 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 naturs: and extent of each tyg.e.oj?use ............... ..,... Dimensions of same structure with alterations or additions: Front ................. Rear .................. Depth ...................... Heiv. ht~ ...................... Number of Stories ...................... 8. Dimensions o~er~i,~'_e new construction: Front ............... Rear ............... Depth ............... Height ............... Number of Stories ........................................................ 9. Size of lot: Front ...................... Rear ...................... Depth ...................... 10. Date of Purchase ............................. Name of Former Owner ............................. 1 I. Zone or use district in which premises are situated ..................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ............................ Will excess fill be removed from premises: Yes No 14. Name of Owner of premises .................... Address ................... Phone No ................ Name of Architect ........................... Address ................... Phone No ................ Name of Contractor .......................... Address ................... Phone No ...... ~ .... ·.. 15.Is this property located wlthln300 feet of a tidal wetland.* ~YE~i...~... ~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. ' ~TA1 OF NEWYO K, ~5: (Name of individual signing cent[act) :bove named. being duly~ thnlhe is the applicant is the ......................................................................................... (Contractor, agent, corporate officer, crc.) said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this ~plication: that all statements contained in this application are true to the best of his knowledge and belief; and that the Ork will be performed in the m~ncr set forth in the application filed therewith. .yom to before me thi~