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Home My WebLink About19353-Z FORM NO. it 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) ..z..~m....~.~..~..~4 ...~..~..~.~.....7~ ............................ ...... ~._.~.,.~.../....7,~....~....z ....... ., .............. ., ....... .~ ........ at premises located at ..... .~,_..~....,~_..._~-*..~.......--~.....~~, .~._,~..,~...~.._~.._...~~ Building Inspector. Building Inspoctor Rev. 6/30/80 FORM NO. 1 TQWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL,: 765-180:3 Exanffncd ................. 19... Disapproved a/c" ' . ............................. BOARD OF HEALTH ............ 3 SETS OF PLANS ............ SURVEY ..................... CHECK .................... .. SEPTIC FORbl ........... ''.. NOTIFY ~ Z~ 7 CALL-- .. S .3'. 7.7..:k MAIL TO: (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. Tiffs application must be completely filled in by typewriter 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 to adjoining premises or public streetz or areas, and giving a detailed descr/ption of layout of property must be drawn on the diagram which is part of this apph- 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 appl/cant. 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 agy 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 thc 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 {'emoval or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, b>~i=~ding code, housing code, and regulations, and to admit author/zed hlspectors on premises, and in building for necessarvJfisp~ctions, x --, · , z .................. · (Mailfng address of applicant) State wh~ther applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises . .'V?..g.~ .~.."&~..~....'...~ .~.d.~. .A~..~.. ~ ........................ (as on the tax'roll or latest deed) ' '. ...... ..... ....... ( amc and tiiit~;,6fcorporate officer) ' Builder's License No...~..'7.2 Plumber's License No ......................... Electrician's License No ....................... Other Tradc's License No ...................... 1. Location of land on which proposed work will be done; IIouse Number Street/ Hamlet ....... ! ............... County Tax Map 0 ~.-~...~.., ' No. 1000 S~ction Block Lot Subdivision.. ................................... Eiled Map No ............... Lot ............... (Name) State existing use and occupancy of premises and intended usc and occupancy of proposed construction: 3.. Exist. ing use and occupanc~ ................................ B. Intended use and occupancy ..... es.(.he./~.~,~.... ~/4../~7. ....... 3. Nature of work (check which applicable): New Building ......... Additio .~---~'. · · --- · · - Altcration ........, ~,i. Repair .............. R~moval .............. Demolition" ... ~ ...... S~imrnino"° ~$~ ~l~ Tennis Court ......... Accessory Building .......... Fence ....... Other Work; ....... 4. Estimated Cost ..... ~.]..t~..~.. ?.O..~....~. ................ Fee ....... ~....~.,~ ~ ........ :.*'iff., '[' (to be pa d on filing this application}~ 5. If dwelling, number of dwelling units ............... Nnmber of dwelling units on each floor ................. If garage, number of cars ....................................................................... . 6. If business, commercial or mixed occupancy, specify natu!'e and extent of each type of use ...................... 7. Dimensions of existing structures, il' any: Front ......... ...... Rear . ... .... ; ...... Depth ................ Height ............... Number of Stories ........................................................ Dimensions of same structure with alterations or additions: Front ................. Rear ............... Depth ...................... Height ...................... Number of Stories ....................... 8. Dimensions of entire new construction: Front ............... Rear ............... Depth .............. Height ............... Number of Stories ............ ,..: ............................. ' ............. 9. Size of lot: Front ...................... Rear ...................... Depth ....................... 10. Date of Purchase ............................. Name of Former Owner .............................. l 1. Zone or use district in xvhich 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 .... No.. 14. Name of Owner of premises ................ ' ....Address ................... Phone No ................. Name of Architect ........................... Address ................... Phone No ................. Name of Contractor ................. i ........ Address ................... Phone No ............ ; .... 15.Is this property located within 300 feet of a tidal wetland? ~YES .... NO .... · If yes, Southold Town Trustees Permit may be required. PLOT DIAGRAM Locate clea~ly 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, COUNTY OF ......... ........ S,S ................................................. being duly sxvorn, deposes and says that he is the applicant (Name of individual signing contract) above named. I-h: 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 thi~ application: that all statements contained in this application are true to the best of his knowledge and belief; and that th{ Work will be performed in the manner set forth in the application filed therewith. Sworn to before me this · , ............... ~.~ .... day of..~ .......... 19 ~~ ~ ~ NOta. P~blic ........ ~--~.~. Co~ty ~N~ ~ · ~ ~ ~ ........................ ~4~8~L ~ (Signature of applic~t