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Home My WebLink About19355-Z FOItM NO, ~1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. ¥. BUILDING PER~IT (THIS PERA41T MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) NM ~5~ Z .......... .......... :: ....... :.: ......... County Tox Mop No. 1000 Section ...~.~.~ ....... Bilk ........... ~ ........ Lot No...~..~ ....... Building Insp~tor. Building Inspector Rev. 6/30/80 SLDG. DEPT/--- ~ OF SOUTH LD FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1802 Exanfined ................. 19... Approved ~.. ~.- .~...., 19~2. Permit No./. ¢. ,-~.~"..~ Disapproved~c ..................................... BOARD OF HEALTH ............ 3 SETS OF PLANS ............ SURVEY ..................... CHECK ...................... SEPTIC FORM ................ NOTIFY: CALL ..................... 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 Ihspector, 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 street: or areas, and giving a detailed description of layout of property must be drawn on the diagram which is par~ 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 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 at3y 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 Bttilding 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, ad~ditions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary~inspections.,t ~,0~1'~ .~..Co/'~ (Signature ot applicant, or name, if a corporation) (Mailing address of applicant) 4 t t~.3' State wh~ther applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ........................... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Na e and title of corporate rice Builder's License No .... ~ ~/ Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done; llouse Number Street, Ha myer County Tax Map No. 1000 Section .... [~ ........ : BlOck .. ]. .............. Lot. ~ Subdivision ..................................... Eilcd Map No ............... Lot ........ (Name) 2. S~te · ' ' use and occupancy of proposed construction: ex~sting use and occupancy of premises and intended A. Existing use and occupancy. ~ .~ B. Intended use and occupancy. ~~'~' 3 N f k( h k hi h ppli bi ) N ildi Additi ARe rio · atureo wor cec w c a ca e : ew ~u ng .......... on .......... Fa n ...... ,** o · . Repair .............. moval ............ Demolition .... Swimra -..k~ · Tennis Court '';--7 ..... Accessory Building .......... Fence ....... Other Work; .... ~. 'J' "'* re · f " .. 4. £stimatedCost. .... --1'~"~''~'"' ...................... e ....... .....-................ (to be paid on filing this application) $. If dwelling, number of dwciling units ............... Number of dwelling units on each floor ............... If garage, number o f cars ....................................................................... 6. If business, commercial or mixed occupancy, specify nature and extent o£each type of use .................... ?. Dimensions o£e×isting structures, if any: Front.., ............ Rear ............... Depth .............. Hei2ht ............... 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 .............................. 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 .... No.. 14 Name of Owner of premises Address Phone No ........ Name of Architect ........................... Address ................... 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 may be required. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all se~back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or comer lot. STATE OF NEW YORK, S.S COUNTY OF ................. ................................................. being duly sxvom, 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 pe,rform or have performed the said work and to make and file this application; that all statements contaioed 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 applicatiou filed therewith. Sworn to before me this ........... ~f .........dayof .....~ ..... 19 Notary Public ...... ~-~r~.. ~ ~../~..'..~/~.... County ................. ,,._ ,_ 707878, Suf~'k. _Cguldy .~ ,.-. I:xpires Mm'ch 30, l~ (Signature of applicant 7