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Home My WebLink About20927-Z FO~M NO. B TOWN 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) No-N°. 20927Z .... · ~ ....... ~....~...~...~.~ ...................................... Coun~ Tox Map No. 7000 Sect,on ...... ~ ............. B,~,~ .... ~.. ............ Lot No ...... ( ................ pursuant to application dated ......... ~ ......... ./..~... ........ , 19..~.,~nd approved by the Building Inspector. Rev. 6/30/80 FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOED, N.Y. 11971 TEL.: 765-1802 Examined ................. 19... Disapproved a/c ..................................... BOARD OF HEAI.~ll ......... 3 SETS OF ?LANS .......... SURVEY ................... CIIECK .................... SEFTIC FOR,~I .............. CALL ................... FLAIL TO: (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by Wpewriter or in ink and submitted to the Building Inspector, with 3 2ts 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 th/s 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 pazt for any purpose whatever until a Certificate of Occupancy imll have been granted by th~ Building Inspector. - ' APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the ;uilding Zone Ordinance cf the Tcwn of Sc, uthold, Suffolk County, New York, ~nd other applicabl.~ Laws, Ordinances or '.egulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. 'he applicant agrees to comply with aB applicable laws, ordinances, building code, housing code, and regulations, and to dmit authorized inspectors on premises and in building for necessary inspections. -- (Signatu'fe of applicant, or name, if a corporation) .... ........... : ..... (Mailino address of applic2int) ;tare whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder2 ~ame of owner of premises ..~ .~~....~ .......................................... (as on the twA roll or latest deed) f applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... ...................... ........................... ltouse Number Street Hamlet County Tax Map No. I000 Section ....... ~ ........ Block ..... ~ ..........Lot ... ~ .............. Subdivision ..................................... Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~ ~OU~~ ~~ ~ b. Intended use and occupancy.,, . , , . .................... . , ,. ., ,, 3. Nature of work (check which applicable): .Ne~t Building .......... .~ition .......... Alteration .......... Repair ............ Removal ... ~ .... Demolition .' ............ Other Work ............... - (Description) 4. Estimated Cost ..... Fee ......... /. · · ./- .~..1. ~.. - -~- · ............. (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 occupancy, specify nature and extent of each type of use ..................... 7. Dimensions of existing structures, if any: Front . . . :~.'z~./. . . ~ . . . 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 .......... Depth ... ?..~. ............... 9. Size of lot: Front .... ~. f .......... : :.'I~;~; i iiiii$i-~i'ii ......................... / ............. 10. Date of Purchase ..... ~ ...................... Name of Former Owner ...~ ......................... 11. Zone or use district in which premises are situated ..................................................... 12. Does proposed construction violate ~ny 5oni~ng law,.ordinance or regulation: ~..(9. ....... ' .................... 13. Will lot be regraded ... t~ ~..,...~'./.'.~.~ $¥.c c.k_(. ~/2, .c~.,.. Will excess fill be removed from premises: Yes 14. Name of Owner of premises .L~g~-~-~.~Address ................... Phone No..,~.'~']/. ~..~g.:~ Name of Architect ~.tt2~./~. ~..~.~(E,//L/C~L ..... Address 1~.O..~ig4.)'. Y'.Z~ ,~]7,.. Phone No..':~..~.~.. ·/. Name of Contractor .......................... Address .................. Phone No ................ 15. Is this property within 300 feet of a tidal wetland9· *Yes..~... No ......... · If yes, Southold Town Trustees Perrni_t may be required. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether ~xisting 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 coruer 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) bore named. 'e is the ......................................................................................... (Contractor, agent, corporate officer, etc.) f said owner or owners, and is duly authorized to perform or have performed 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 ork will be performed in the manner set forth in the application filed therewith. .yom to before me this ....................... day of ...................... 19... otary Public, . ................................ County (Signature of applicant)