HomeMy WebLinkAbout18649-ZTOWN OF SOUTHOLO
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
18649
N~
Permission is hereby granted to: /. ~ ~ / _..¢
...../..~¢......~~.¢./~... ........................
...... .......
.... ~¢¢.~¢ ...... ~%.....~..¢~-~; ....................................................................
,, ,,~,,, ~.,~ ,, .~.~ ....... ~¢~...~¢, .....................................................................
................................................ ~~ ...................................................................................
pursuant to application dated .... ././...~../../~.. .................................. , 1~ and approved by the
Building Inspector.
Fee
Rev. 6/30/80
$.79
19.
1
I- $T'¥
~.¢~. :162.~6
~6 F~ U. TO
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1802
E.,an, in~d. '/'//~ .......... 19 .'~..
,,pproved. ......... ,
Disapproved a/c .....................................
APPLICATIO~ FOR BUILDING PERMIT
BOARD OF HEALTH ............
3 SETS OF PLANS ............
SURVEY .....................
CHECK ......................
SEPTIC FORM ................
CALL ....
MAIL TO:
BLDG. OEPT
'FOWN OF
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Build ng Inspector, with B
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~-'v'mo" a detailed description of layout of property must be drawn on the diagram which is part of this appli-
cation.
o. 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 inspect/on throughout the work.
¢. No buildLng shall be occupied or used in whole or in part for a0y 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 Sou}hold, Suffolk County, New York, and other applicable Laws, Ordinances or
Reo_ulations, for the construction of buildings, ad. dj}ions or alterations, or for removal or demolition, as herein described.
Th~ applicant agre.~.~aS~t~i[ll appticabie laws, ordinances, building code, housing code, and regulations, and to
admit authorized irlg~[M~'b~ ¥ffe'fnises~ ~..., J ~,and~in building for necessary inspections.~..~_ ~ _L ~ !
........... Y~ ...... -~-. (Signature of applicant, or name, if a corporauon)
(Ma}lin= address of applicant)
State wide}her ap.p!ic~n~ ' "
i~"'~)wner l~,e a~ent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises... .. ..--..---.,-.--.'--...''t.. ......................... '. ............
(as on the 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..0..'~...~..~..~. .............
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
1. Location of land on which proposed work will be done ....... ' ......... '. .......................... .~.~ ....
,5..'m h.z.c...' ....
· 1.0 ............................. ...' ............. o..,q .......
}louse Number Street, Hamlet
County Tax Map No. 1000 Section .O..~. ,~. J.O. ·'O ..... BlOck .~. ~.: .O..O. ...... Lot .O..'~.~..~..~..O..(~...
Subdivision ..................................... Eiled Map No ............... Lot ...............
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy 0 .1~.[" ......~tt...I.(~/.,.
3. Nature of Work (check which applicable): New Building ..... ' ..... ~Add~Jicn .......... Alteration . ~ .....
Repair .............. g~moval .............. Demolition . ..~ ........... Other Work ......
4. Estimate'd Cost .. . .O..o..o. ............... Fee ....................................
(to be paid on filing this application)
$. It' dwelling, number of dwelling units ............... Number of dwelling units on each floor .........
lfgara,,e.~ number of cars ......................................................................
6. If business. Commercial or mixed occupancy, specify nature and extent of each type of use ...................
7. Dimensions of es~s.ti~g structures, if any: Front ............ Rear Depth
Height ........ ,.:; ....... Number of Stories ................................
Dime 6rS rn~ it ith It additi F ......................
nsions a ructurew a erationsor ons: rent ..... ..... .. ..... Rear ...... ..... .....
Depth ............ tleight ...................... Number of Stories .................
8. atire new construction: Front ............... Rear ............... Depth .............
......... ; ...... Number of Stories .............. ; ..................
9. Sizeoflot: Front .I.q~.o. ' ..... Rear I.O. ep.,.t .~.. Depth .,.I.{o.O. .....
10. DateofPurchase ~o~~r ~3
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
14. Name of' Owner of premises Address ................... Phone No ......
Name of Architect ........................... Address ................... Phone No ...............
Name of Contractor ................... Address ................... Phone No.. ~,...; ...... '..
15ols this property located withln300 feet of a tidal wetland.* ~YES .... NO ....
~If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions frorr
property lines. Give Street and block number or description according to deed, and show street names and indicate whethe:
interior or comer lot.
FOLLOWING INSPECllON$:
1. FOUNDATION TWO REQUIRED
FOR IN~URED CONCR~.i~
2. ROUGH - FRAMING & PLUMSING
3. INSUt. ATION
4. FINAL CONSTRUCTION MUST
BE COMPLETE FOR C,O.
ALL CONSTRUCTION SHALL MEET
THE REQUIREMENTS OF THE N,Y.
STATE CONSTRUCTION & ENERGY
CODES. NOT RESPONSIB[~ FOR
DESIGN OR CONSTRUCTION ERRORS
STATE OF NEW YORK,
COUNTY OF ....... S.S
(Name of individual signing contract)
above named.
being duly sworn, deposes and says that he is the applicant
Itc is tile
(Contractor, agent, Corporate officer, etc.) ...............' ' '
of said owner or owners, and is duly author/zed to pc,florin or have performed tile 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 wi/l be performed in the manner set forth in tile application ~lcd therewith.
Sworn to before mc this
F,q)TARY PU~IC, State M New Y0d~
Ne. 4707878, S4Jffoik Counl~o,
T~m F. xpires March 30, l~-2M
(Signature of applicant)