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Home My WebLink About20634-Z I~OR~ NO. · TO~'N OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. ¥. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N°N? at premises located at ..........~...¢....~.....'..~.....~.. ...... ~L1~¢9/ '"' .~"~i"'"ii'"i'i"i ........... County Tax Mop No. 1000 Section .... /.~.~..,. Bilk ..... ~,~ .... Lot No ...... pumuant to application dat~ ......... ~~ .......... /~.~, 19.~nd appr~ by the Building Insp~tor. Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined ................ , 19... ~.0 ~' ~/--~--- ,\pproved . .r.I/[,,~.-~, 19~,,,,~Permit No. ~-..<~..~. 7~4 -/ .~ Disapproved a/c . .~. .................................. BOARD OF H£ALTH ......... 3 SETS OF PLANS .......... SURVEY ................... ClIECK .................... SE~Tt-C FORH .............. NOTI FY: CALL ................... flAIL 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 3 ~ts 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 ~r areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- ation. c. The work covered by this application may not be cbmmenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permit hall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in pa~t for any purpose whatever until a Certificate of Occupancy hall 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 ~uilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or ~,egulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. ;rate whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. 4amc of owner of premises .. ~. t~.~..'~. ~..5..~t.' ..... ~ $'.~...~ ..................................... ..... (as on the tw/; roll or latest deed) f applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ........... ~.~'~SP~ '/'_4,..~F Plumber's License No ........ ~(/. ?. -~'~..~./.?/· . . . Electr'cJa,n s License No ............. ~. ........ Other Trade's License No ...................... Location o f land on ~c~.ropose~work will be d'(me ..... ~.~T~ ..... ~ ............ ' ......... . 3...7Y.. ........... .................................. ..................... llouse Number Street Hamlet Map No. 1000 Section .... ttt~.~. ........ Block .... ~)..2._ ......... Lot .... ~. ~/2~./...; .... County Tax Subdivision ..................................... Filed Map No ............... Lot ............... (Name) . ' State existing use and occupancy of premises and intcnded use and occupancy of proposed construction: a. Existing use and occupancy ....... ~ .: .................. ' .................................. b. Intended use and occupancy ........ ~...~.~...~,'. ......... ~ .~ ................... 3. Nature of work (check which applicable): New Budding .......... Addition .......... Alteration .......... Repair .............. Removal .............. Demolition ...~. ........ Other Work ............... (Description) (to be paid on filing this application) 5. If dwelling, number of dwelling units ............... Number of dwelling units on each floor ................ · If garage, number of cars ........................................................................ 6. If business, commercial or mixed occnpsncy, specify nature and extent of each type of use ..................... 7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............... Height ............... Num her 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 ...................... I0. Date of Purchase ............................. Name of Former Owner ............................. 11. 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 ................ t5. Is this property 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 set-back dimensions from property lines. Give street and block number or descriptioh according to deed, and show street names and indicate whether interior or corner lot. TATE OF NEW YORK, S.S OUNTY OF ................. .......... ,~ ..................................... being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) >ore named. e is the ......................................................................................... (Contractor, agent, corporate officer, etc.) ' said owner or owners, and is duly authorized to perform or have perfor~ned the said work and to make and file this plication; that all statements contained in this application are true to the best of his knowledge and belief; and that the ~rk will be performed in the manner set forth in the application filed therewith. ~orn to before me this ., County