The URL can be used to link to this page

Home My WebLink About17775-Z FOSM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ J 17 7 7 5 Z DateG/~.........d•.`.:...~ 19...1. Permission is hereby granted to: ~ /~~i//V~i~r'ItiLI.C ~i2~~ y 7'G N/~/ , ra .............,~f~....~................................. .........r..............l~....................................................... ct premises located at !l..f./..tl y~......o.`,~........................................... ,,~.i........ G%%~......~ .................................................................LL.............................................................................................. Caunty Tax Map No. 1000 Section ...J~...~7......... Block ........f Lot No.....~.. pursuant to application dated ...........rt..~..~J 19.~..~~, and approved by the Building Inspector. Fee $...~..~.-,.ri..:.U Building Inspector Rev. 6/30/80 a.. E~ ~~t _ BOARD OF HEALTH - 3 SETS OF PLANS FORMN0.1 SURVEY ,JAN Z 3189 TOWN OF SOUTHOLD CHECK . +,,,'r,, BUILDING DEPARTMENT SEPTIC FORP1 . ~-x~.---- ; TOWN HALL SOUTHOLD, N.Y. 11971 NOTIFY T _r.' TEL.: 7651802 CALL y~ PIAIL T0: Exantincd 19 U . Approved I~.Y1.~crmit No..i• • . Disapproved a/c ~ (Building Inspector) APPLICATION FOR BUILDING PERMIT ` ~ Date .~!...~:3........., 15~ INSTRUCTIONS a. Tlus application must be completely filled in by tgpewriter or in ink and submitted to the Building Inspector, with 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 [o adjoining premises or public stree or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this app. 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 perm shall be kept an the premises available for inspection throw}tout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupant 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 th Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances c Re=ulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein describec The applicant a~rces to comply with all applicable laws, ordinances, building code, housing code, and regulations, and t admit authorized inspectors on premises and in building for necessary/i,!n,,~LPections. (Stgni applicant, or name, if a corporatton) • (Mailing address of applicant) State whether applicant is ow//1ner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of Premises r r-~.. S . . (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title aF corporate officer) Builder's License No. . Plumber's License No. . Electrician's License No. . Otfter Trade's License No . . I. Location oC land on which proposed work will be done . . . • House Number Streets Hamlet ~ , County Tax ~.\fap No. 1000 SeCilO? Blyck Lot ~ Subdivision Filed !\tap No. Lo[ . (Name) ~ State esisting use and occupancy of premises and intendcd\se and getup ncy of posed construction: a. Existing use and occupancy ~'~.i~~~~•'"• • • • • • . . b. Intended use and occupancy •..~Q(~•.••,•_•_•••••,• 3, Nature of work (check which applicable): New Building Addition / • • • . • • • Alteration . Repair Removal Demolition Other IVork . S~ ~ (Description) 4. Estimated Cost Fee . . (to be paid on filing this application) 5. If dwelling, number oC dwelling units Nttmbcr of dwelling units on each Cloor . Ifgatagc.numbcrofcars 6. If business, commercial or mixed occupancy, specify nature and extent of cash type of use . 7. Dimensions of existing structures, if any: Front . Rear Dcp[h . Hci~ht Number of Stories . • Dimensions of same structure with alterations or additions: Front Rear . Depth Iicigh[ Number oC Stories . Dimensions o[ entire new constntction: Front Rear Depth . Height ...............NumbcrofStorics..............:......................................... 9. Size of lot: Front Rear...................... Depth 10. Date of Purchase .............................Name of Former Owner . 11. Zone or use district in ~vhiclt premises are situated . 12. Does proposed construction violate any zoning law, ordinance or regulation : . 13. Hill lot be regraded 1yi11 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............:.. . IS.Is this property located within X00 feeC of a tidal vetlaod? *yES....NO.... *If yes, Southold Town Trustees Permit may be required. PLOT DIAGRAM Locate clearly and distinctl}• all buildings, whether existing or proposed, and. indicate all set-back dimensions from property fines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF 1E~V 1"ORK, S.S COU\T1' OF . • . being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. I]cistlte (Contractor, agcnC,corporatc officer, etc.) oC said owner or owners, and is duly authorized [o perform on.+havc performed [he 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 •.vork will be performed in [he manner set forth in the application lllcd therewith. Swom to brforc me this ...........a day of.... 19.~~ Xotar}• Public, ....~:~~5-~7•'.-~. !I ~.~-..tL~~...... County , .~i . HEtENKDEVOE ~ (Signarnre of applicant) NOTARY PUBOC, State of Nee Yak No. 4707878, Suffolk County q Term Expires March 30,19