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Home My WebLink About17517-Z ~O~-M NO. I 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~ 017517 Z Permission is hereby granted to: County Tax Map No, 1000 Section ,...~ ....... Block ..... .0....,~. ....... Lot No ..... .~.....~, .......... pursuant to application dated ...... .(~..~~.....-~'~., ............. 19,~..~., and approved by the Building Inspector. Fee $.,._..'~....: ........... Building Inspector Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMFNT TOWN HALL $OUTHOLD, N,Y. 11971 TEL.: 765-1802 BOARD OF HEALTH ............ 3 SETS OF PLANS ............ SURVEY ........ .~ ........... CHECK ~/:. ~%-.P .............. ~" SEPTIC FORM ................ Approved .O.~..~..:kl., 19.~.~. Permit No..). ?.~!?.~. · qr/]/ Disapproved a/c .................... . ............... ~ NOTIFY CALL ..................... BLDG. DEFT. (Building Inspector) ~ APPLIC~IION FOR BUILDIN '~ ' 1.7 ':/ ...... ' INSTRUCTIONS a. TNs application must be completely filled in by ~pew, ter or in sets of plans, accurate plot plan to scaD. Fee according to schedule.--~-- · . .... ~ ~ .~ ..... b. Plot pl= showing locanon of lot and of bmldmgs on prem,ses, rel~gn~w~o ~o,mng premmes or pubno streets and g~vmg a detmled description of layout of proper~ must b~ld}~wnt,., on. t~e d~agram which ~s pan of t~s app,- or areas, 'c~on. o. Th~ work covered by tNs apphcatmn may not be commenced bef~ ~ssua~c~ of Building Pem~t. d. Upon approval of th~s apphcatmn, the Bmldmg Inspector will msu~0~dmg Pe~t to the appHc~t. Suoh pe~it ' shah be kept on th~ premises available for ~spection throu~out the work. ~. No buildNg shall be occupied or used in whol~ or in part for any~oi~hatever until a Cemificate of Occup~ey shall hav~ been granted by ~e BullriNg Inspector. APPLICATION IS HEREBY MADE to the BuildNg Depmment for th~ issuance of a B~lding Pe~it pursuant to the Building Zone Ordnance of the Town of Southold, Suffolk County, N~w York, ~d other applicabl~ Laws, OrdN~ces or Regulations, for the construction of bufldNgs, a~ditions or alterations, or for removal or demolition, as hereN desc~bed. The applicant agrees to comply with all applicable laws, ordinances, bufld~g code, housing code, and regulations, and to admit authored Nspectom on premises and ~ bulldog for necessa~ inspections. (S~gnature ot apphcant, or name, if a corporanon) (Mailing address of applicant) State whether applicant'js owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. 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 .................... Locationoflandonwhichproposedworkwillbedone. ..Z~..~..~. . ..~.J.'.'~.~... ff.~..~./L, ff.¢. ............. ............... .... .. ......... ...... ...... ............. House Number Street Hatnlet County Tax Map No. 1000 Sectiou ..... ')_5 .......... Block ..~. ............. Lot...~.~. ............. Subdivision ..................................... Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premises and intended use and. occupancy of proposed construction: a. Existing use and occupancy ...S'"~f'~.~.?....- .T.O...~.~ /?~/'/'t/) O~'.~ - b. Intended use and occupancy ..................................................... 3. Nature of work (check which applicable): New Building ..... ' ..... Addition .......... Alteration ......... Repair .............. Removal .............. Demolition .............. Other Work .............. ~ (Description) 4. Estimate'd Cost ....................... ~ .............. Fee . .].~.'...-"~'/ ............................ (to be paid on filing this application) 5. If dwelling, number of dsvelling 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 use .................... 7. Dimensions of existing, structures, if any: Front ............... Rear .............. Depth .............. Height ............... Number of Stories ........................................................ Dimensions of same structure with alterations or additions: Front ................. Rear .................. Depth ...................... lteight ...................... Number of Stories ...................... 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height ............... Nmnber of Stories ........................................................ 9. Size of lot: Front ...................... Rear ...................... Depth ...................... 10. Date of Purchase ............................. Name of Former Owner ............................. 1 1. 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 within 300 feet of a tidal wetland? *YES .... NO .... *If yes, Southold Town Trustees Permit may be required. PLOT DIAGRAM * Locate dearly 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 coruer lot. ~ ~,. APPROVED AS NOTED BULLDOG DEPARTMENT AT ~-1~2 9 AM ~ 4 PM FOR THE ~NG INSPECTIONS. ~UNDA~ ~0 REQUIRED ~ ~NCR~E ~,- ~~NMUST STATE OF NE~V YORK, COUNTY OF .~-,~. (.z~.... ~ S.~ {~iii~ ~iI__ ilil~liili~ i1~111~ ~ ............ /~4~e/~ ~' ~¢~ ...... . . [_ _2~22 ................. bem~ duly sworn, deposes and says that he is th~ applicant (Name of individuai signing contract) above named. He is the ............................................. ~ ................... (Contractor, agent, corporate officer, etc.) ' ' ' .... ~' ',::~'i } ~ '~ ........ of said owner or owners, ~d is duly authorized to perform or have oerfomod tho e . - ........... o~u wurK a~u m ~e ted file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work w~l be performed in the manner set forth in the application filed therewith. Sworn to before me this ........ .............. ......... '7- N~ ~bli~, Sli~ ~ ~ Y~ ~'t (Signature of applic~t)