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Home My WebLink About19543-Z I~O~M NO. ,s 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) Rev. 6/30/80 FORM NO. 1 TOWN OF souTHOLD BUILDING DEPARTMENT TOWN HALL ~OUTHOLD.,. N.Y. 1-!-9'71- TEL.: 765-1~0~ Examined .... 19 Disapproved a/c ..................................... BOARD OF HEALTH ......... 3 SETS OF PLANS .......... SURVEY ................... CIIECK .................... SEPTIC FORH .............. CALL ................... MAIL TO: (Building Inspector) '~ APPLICATION FOR BUILDING PERMIT INSTRUCTIONS .,. a. 'rids application must be completely filled in by typewriter or in ink and submitted to the Building Ixapaator, sets of p!n.~, ~r,,rat¢ plot plan to scale. Fe~ according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public stre~ or areas, and giving a detailed description of layout of property must be drawn on the diagram which is pan of th.is apl~ cation. c. The work covered by tkis 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 peru shall be kept on the premises available for inspection throughout the work. ¢. No building shall be occupied or used in whole or in part for a!~y 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 Building Zone Ordinance of the Town of Soutlzold, Suffolk County, New York, and other applicable Laws, Ordinances Reeulations, for the construction of buildings, additions or alterations, or for ~:emoval or demolition, as herein describe~ Th~ applicant agrees to comply with all applicable laws, ordinances, building code, housin~ code, and regulations, and (Signatur,' of hpplicant, or name, if a corporation) (M~iling address of applicant) State wh~ther applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of o~vner of premises .... (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- ......................... . Plum bet's License No ......................... Electrician's License No ....................... Other Tradc's License No Location of land on which proposed work will be done, House Number Street ' Hamlet County rax Map No. lOOOSecfion ) }..'~ ....... : Block .. .l... Lot ~. ...... " Subdivision Eilcd Map No . . Lot ............... (Name) ~.~ Stzte existing usc and occupancy of prcmises and intended usc and occupancy of proposed construction'. A. Existing usc and occupancy .......................... . e~ 'i . ~. . ...... B. Intended use and occupancy ............................................... 3. Nature of work (check which, applicable): New Building .......... .Ad~te~ Repair .............. R~moval .............. Demolition .~ .... Tennis Court ......... Accessory Building .......... Fence 4. Est,matedCost...). . . ............ ... .. . ..... .. 5. If dwelling, number of dwelling units ............... Number of dwelling units on each floor ............... If garage, hum be r o f cars ....................................................................... 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ................... 7. Dmensionsofexisting. structures, if any'. Front..~.~.C%. '"ca{5~'lY'-~'Rear. .........-.---.- Depth ..... -. · i .... 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 .............. Hcieht .............. N~..~r. 9 f Stories .............. ; .~ ......... .... ;." :~ ..... -b'~'/5 ~ .......... 9..Si~e oflot: F~ont ... i... ~ ............. --~- P,o~: ...... .~ .~ ............ ~,ep~n ..................... 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 ...... .~.m--r,.~..' ............... Will excess fill be removed flrom pre. mi~: --,-, )'c:&: .,~: 14. Name of Owner of premises ...~'.&.~. ~..¢?. ~. ~. ¢.'~.... Addre= . 9¢..%.[.u. i ~.~.C.-...~: .x/a. Phone No..'>..~f5 F.~. tv.. Name of Architect ................ 3 .......... Address .......... Phone No ............... Name of Contractor....J...~ ./~?. ~...~..~. q)9~..~.~,-,-W..vxq-~ddress. ~. ~'~. ~. ~.~..~/.~( · Phon~No. · .?-J, 9-~--- I.~.I~ t_lmi~ property located within'J00 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, mad. indicate all set-back dimen:ior.; :: property lines. Give street and block number or description according to deed, and show street names and indicate interior or comer lot. STATE OF NEW YORK, COUNTY oF ................. ................................................. being drily sworn, deposes mad says that he is the (Name of individual signing contract) above named. H~ is the ........................................... : ....................... ; .................... (Contractor, agent, corporate officer, etc.) of said owner or owners, mad is duly authorized to perform or have performed the said work and to make and file th application: that all statements contained in this application are true to the best of his knowledge and belief; mad that work wUl be perforated in the m~ner set forth in tim application filed therexvith. Sworn to before me ................... day of ...... ~ ....... 19 .~