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Home My WebLink About17561-Z II'OR,M NO. Il 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) NE 17561 Z et premises ,ocatecJ at .....~..~..~.~...~'~,~'.~.~.~.~~..~Z.. ........................... County Tax Mop No 1000 Sect on .....~....~.. ..... Block .............. ~. Lot No ...... ...~...~ .... pursuant to application dated ....... ~..~./~/..~.. .............................. 19..~.~, and approved by the Building Inspector. Fee $.../.'~.~ Rev, 6/30/80 '[OWN OF FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 ~.,ammed ./..0.~.~./ ....... ,19 .g.~ / Approved ~..~..~· .... ':. , 19~mennit No 17~ / ~ ¢ctor) ' APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH ............ 3 SETS OF PLANS ............ SURVEY ..................... CHECK ...................... SEPTIC FORM ................ NOTIFY ~^LL .q.~.~ 9.~..~. .... ' ....... MAIL TO: Date ................. , . INSTRUCTIONS a. This application must be completely filled in by Wpewriter orin ink and submitted to the Building Inspector, with sets of plans, accurate plot plan to scale. Fee according to schedule. b. Hot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public street or areas, and giving a deta/led description of lhyout of properW must be drawn on the diagram which is part of this 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 permi shall 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 Occupanc': 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 Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances o: Regulations, for the construction of buildings, a..d, ditions or alterations, or for removal or demolition, as herein described The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and tc admit authorized inspectors~Q~on premises and in building for necessary inspections. ,~ ~ _ ~ ~.I ~ ---- ~'r~,o (Signature of ap~ac~a~t; or name, if a corporanon') ' ' 'q[ ,~--~. ~Aq~ 0~0.1.~ ~i~:,4 ............... :"'x' ............... "'~- -~ .... ~twrr ROt ~,-,~. Ol M~ e ~;a:~ t. ;~, (Mading address of app~cant) [1~'~{ · State wheth~it~c.j~}~q, owne~.egent, architect, engineer, general contractor, electrician, plumber or builder. Name IKs ~ ... . ........... of ow~ Sg~o~,~s:. ~; ~ .mr. ............ .... .~..~..-r.....~...K~..~. .............. 0 3 ,,i ' '.,~ ~ ':';' ' (as on the tax roll or latest deed) If applicant is aktb~'pom}J~, ~t~at~r~e.o~.~}y ~uthonzed officer. ........ ;(,'~-;5 ' 'i £~'t:}~/~.l~.'.~.'~W ' ~0t~' ;.2 ' '~ ......... u~ arrte an~enrre'~g!2C~orpg~t~omcer) Builder's License No ..... .~..0..b~. ............... PI tuber s Lmense No ........................ · . . ~ ,a~- Electric an s License N ~ Other Trade's License No .... .~.0..~.~. ............ 1 Location of land on which proposed work will be done ' .-77.¥??. .~0,.e ..~.y.~:.v~ '.'-g..a cod&ali House Number Street Hamlet County Tax Map No. I000 Scctiou ~O"~ Block .O.~ Lot O~. Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed constrtiction: .............. ....... ...................... ............. b. 3. Nature of work (check which applicable): New Building . '... Additionk . . ,.~/,k~:rfitio, n . ....... Repot .............. Removal .............. r ;; g it on '6; 'er ' ............ (Description) 4. Estimate'd Cost ....... ~.~.W. tt.i..~ ....................... Fee (to be paid on filing this application) 5. If dwelling, number of dwelling units ............... Nuxnber of dwelling units on each floor ........ ....... If garage, hum her o f cars ....................................................................... 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use .................... 7. Dimensions ofexistin~ 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. Din~ensions of entire new construction: Front ............... Rear ............... Depth .............. Heiglit ............... Nmnber of Stories ....................................................... 9. Size of lot: Front ...................... Rear ...................... Depth ..................... I0. Date of Purchase ............................. Name of Former Owner ............................ I 1. Zone or use district in which premises are situated .................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ............................... 13. Will tot be regraded .,. JkIQ. ','D: ................... Will excess fill be removed fro2m premises: Yes 14. Name of Owner of premises . l~.'l[l..~..~.~..~.~. ..... Address ...~...~Olq .'~e,¥.'t~..~hone No. '~2 .~.~9 .... Name of Architect .... Iq o~.F_ . Address ... Phone No ......... Name of Contractor ....... /'2t.?~.~ .............. Address ....... wetland? ~¥1~S .... lqO.l~.. 15.Is this property located within 300 feet: oil a t~J.~l~l ....... Phon~No ........... . ~If 5, es, $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 whethe: interior or corner lot. FOLLOWING INSPECTIOI~: 1. FOUNDATION - TWO REQUffiED FOR POURED CONCtlETE 2. ROUGH. FRAMING · Iq. UMBING 3. INSULATION 4. FINAL C~NSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENT¢~ OF THE N.Y, STATE CONSTRUCTION · ENERGY CODES. NOT RES~le~"SlBLE FOR DESIGN OR C. ONSTRUCTION ERRORS STATE ,O,F NEW YQRK . COUNT'~ ~ .... .~..,~.o.'~.~,.. ',,' . S.S .... 2 .................... (Name of individual signing contract) above named. being duly sworn, deposes and says that he is the applicant tie is the ......... ~..~..Q.~..g .... (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or bate 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 the work will be performed in the m~ner set forth in the application filed therewith. Sworn to before mc ~lis. ............. ...... ...,,.. _J ,< ..% .5