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Home My WebLink About17693-Z FO~I,M NO. ~ TOWN OF $OUTNOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT CrHIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 017693 Z Permission is hereby granted to: .~.,~......~..,~ .............................................. .~....~....~....~. .................................... __ .,,,,,..~.~~-;~...r.,..~.,. ....... ,o.~.~..~....~.....~./.... ...... .~. ........................................ County Tax Map No. 1000 Section ..../'./......~.... pursuant to application dated ..../...~.~ ................................. , 19.~...,~., and approved by the Building Inspectar. Fee $.~...~.. Rev. 6/30/80 FORM NO. 1 TOWN OF S,OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 E.,an, ....,9 BOARD OF HEALTH ............ 3 SETS O,~ PLANS CHEcKS RVEY. X .5 '''.. '.'.. SEPTIC FORM ................ NOTIFY CALL MAIL TO: ,sapproved a,c ..................................... El APPLICATION FOR BUILDING PERMIT BLDG. DE .P.,_T,. TOWN INSTRUCTIONS a, Tkis application must be completely filled in by Wpewriter or in ink and submitted to the Building Inspector, ',k;ith 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 street~ or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of th/s appli cat/on. c. The work covered by tls 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 permil shall be kept on the premises available for inspection throu?ghout the work. e. No building shall be occupied or used in whole or in part for a~y purpose whate~t~ll~t of Occupanc3 shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a BuiJ~g Permit purs.u~ to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York/a~P -'-~ '~' ,- -_~,~, 9~ces or Regulations, for the construction of buildings, additions or alterations, or for r~p'V~l~r'l~i~o~lk~l~l's~l~ ~cribed. The applicant agrees to comply with all applicable taws, ordinances, building c/~'e', ~,~ffs'~~N~orso,~and to admit authorized inspectors on premises and in building for necessary inspection/~'till~l~lW ~ r . /~ //~~,,um,,~. "'(h~o~ '~;e';'~i~; ~~'ho%')' · ' .6.. '"" State whether applicant is owner, lessee, agent, architect, engineer, general co}{t~ac~_, e~Octu~~r ~O~.~.uilder. ............................................... ; ....... f ~,At '~'~'~' '' r :..r, , . 4 ...... '.. .... Name of owner o£premises ........................................................... (as on thc 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 ...................... I. Location of land on wi]ich proposed work will be done...~./.~ .~.~.-~'..(~..~'?.".~'..~.~..~.4.. ,,~.../'~,~c,,~"' House Number ~ St reetx, Hamlet County Tax Map No. I000 Section .... ,'/./~. · ....... Blgck -/.~- ......... . Lot./7.* t..u~. ......... Subdivision ',','~//q...~?.//,~.,~.~.~...fl../~./~. ,/~'./'~/.a.~ Eiled Map No..~.~...7.~. ....... Lot. Afl'. ' (Name) ¥ ........... State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ..................................................................... b. Intended use and occupancy ~-.~.4u-~. .~./~.~' · · . .~..~..a~....~../~..,~..~/.. ................................ 3. Nature of work (check which applicable): New Building ..... '.....~ffddition .......... Alteration ....... Repair .............. Removal .............. Demolition-- ............... Other Work ..... (Description) 4. Estimated Cost ...................................... 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.,nature and extent of each type of use ..................... 7. Dimensions of existing structures, if any: Front... ~['~ ........ Rear . .~J~. .......... Depth . .~..~. .......... Height . ~.~. .......... Number of Stories . ~ ..................................................... Dimensions,~lq~lure with alterations or additions: Front ................. Rear .................. Depth ....k~. 'J ?..*...~J"~.. ....... Iteight ...................... Number of Stories .... . ..... 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height ............... I~lumber of Stories ............. '~; ......................... '/2.~ .......J ' 9. Sizeoflot: Front "37~'':' ............. Rear..../."~..~w: .............. Depth 2..~..~-. .... 10. Dateofeurchase .././..~/.,J~.r.~iF.~;~. ............... NameofForrnerOwner~t~C,'~.~.~/~,~..o~..,f-'/Z...~,,~..,~.. 11. Zone or use district in which premises are situated. ,4~ff'e~. ................................................ --/ 12. Does proposed construction violate any zoning law, ordinance or regulation: ~1/.'' ........................... 13. Will lot be regraded ~...(.,~l~"'r'C.g/.,'~..ff',.~ ............... Will excess fill be removed from premises: . Yes ~No2 14. Name of Owner of premises ' .,..('~..~...;;~-ff~...~ ........Address ~.~/.,,ff~.~(.~..,~f~f~mne No. Name of Architect ........................... Address ................... Phone No ................ Name of Contractor ................ .. ......... Address ................... Phone No ..... . NO.: ,~f'.~.... 15.Is this property located within3OO feet of a tidal wetland? *If yes, $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 9r description according to deed, and show street names and indicate whether interior or coruer lot. } ~/~ .......... -.~. / Sworn to before me this Notary Public ...... .~?. ~ .............. County (Signature of applicant) 4. FINAL - BE C~ ~ ~0. ALL ~~ STA~ CO~ / CODES. ~ OR STATE OF NEW YORK, COUNIY OF ........ ............... ~4..~ :. ............. being duly sworn, deposes ~a says that he is the applicant (Na~ of i~ividual signing contract) above named. it, th, ............ ................................................................ (Contractor, agent, corporate officer, etc.) of said owner or owners, ~d is duly authorized to perform or have perfo~ed the said work and to m~e 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 wdl be perfomed in the m~ner set forth in the application filed therewith.