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Home My WebLink About17749-Z FO~e NO. D TO~N OF $OUTI']OLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) NO- 0177~9 Z County Tox Mop No. ]000 Section ...~..,~... ............ Block ......... ~.. ........ Lot No ..... ~..'...~. .......... pursuont to applicotion doted ................................................ , 19..~...~.., ond approved by the Building Inspector. Fee $...~...~ Rev. 6/30/80 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1902 Approved ., 19,4~). Permit No...,~..~.~. Disapproved a/c ..................................... BOARD OF 3 SETS SURVEY CHECK SEPTIC NOTIFY CALL MAIL HEALTH ...... OF PLANS ....... FORM ............. : Date ................... 19... INSTRUCTIONS a. Tins application 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 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 permit 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 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 applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, buildinz code, ho)/sin~g,,ff-~fde, and regulations, and to admit authorized inspectors on premises and in building for necessary ins~ (Sigff~ture 0ffalSl~ant, or name, if a corporatio.n)~ ,.~ ....... (Mailing address of applicant) applican~ lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. State whether .................... ....................................................... Name of owner of premises...~.~..o..~..~..~. ~'~c'> F ~%-~~ (as on the tax rollt/, latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) ALL COI~TRACTOR'S HUST BE SUFFOLK COUI~TY LICEI~SED Builder's License No ..... C> ./4J.,~.~./(~ .......... Plmnber's License No ....... ~/.~.~... ........ Electr'cian s License No. .. ~.~¢. ~ ...... Other Trade's License No ..... ~%~.~ ...... 1. Location ofland on which proposed work will be done: . ~'~ /~/~ ' Street ' Hamlet ........ County Tax Map No. ,000Section ...~.¢... ........ Block .... ~ ............ Lot...¢.~ .......... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and o cc up a~y~. ~. ~ ~¢ ff ~/~. ~ .... /... ~~ ~ .................... b. Intended use and occup anc~fl~~Z .~.~~.~ ..... /. ~..~... ~ ........... 3. Nature of work (check which applicable): New Building ..... ' ..... A~tion .......... Alteration ~. ......... Repair .............. Removal .............. Demolition ...~ ......... Ott~&V~. .............. q, ,~r¥ .... 4. Estimated Cost .... ~.....~-. ............................ Fee ...~..O.,....~. ...................... " '"'(Tf'~T~aid 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 nat.~xe and extent of e~ch type of use ..................... 7. Dimensions of extisting structures, if any Front i~).q .... Rear ,~& .......... Depth Height . /~ Number of Stories .~'.~...- ''"iiiiiiiiiii Dimensions'of same structure with alterations or additions: Front Rear Depth ...................... Height ...................... Number of Stories ....................... - 8. Dimensions of entire new construction: Front -- - Rear ~ ........... Depth ...~r. ............ Height ............... Number o~9~ Stories .............. ' .......................................... 9. Size of lot' Front ] ~] ~L ~./q.. t~ 2 Rear De~th 10. Date of Purchase ... ]~9,,~/.~ .~. ............... Name of Former Own~er .~.~.~..'.~'>.t~.,~.~ .q~,~-/'. ....... 11. Zone or use district in w'~i~h/premises are situated... ~.../. ~. ~/.T../. ~.C......(? ........................... 12. Does proposed construction violate any zoning law, ordinance or regulation: .../L.J.(D ........................ 13. Will lot be regraded ..... 2L/. ~ .................. Will excess fill be removed from premises: Yes No 14. Name of Owner of premises ....~. ............... Address .................... Phone No..~-'?~'.. ............ Name of Architect ....... :-...~ ................ Address ...7.. i ............ 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 maybe required. { PLO~ D~AGRA~ 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, S.S COUNTY OF ................. ................................................. being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. He is the (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 the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this ............. '~. .......... day of ..... Notary Public .... ~....~. '....~..~. '..~/d'~ ..... County N0,1',AR¥ PUnt!C, State of Ne~ ¥0d~ / //~ (Signature of applicant) r~o, 47078?8, Suffolk ~0unt~ Term £x0/res M&~eh ]0, 1~ ~ /