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Home My WebLink About21272-Z FO~M NO, 11 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) N~N? 21272Z Permission is hereby granted to: _ ~.~ .......... ~.~./...~.:.~ ...... ,..x~.~.~x ........ .......... ........ ........................................................ t p 'S S ocated at .....~... .................. ~..~.,~ff ........... ~.~(.~ ....................................... [ ..... County Tax Map No. 1000 Section ...... ~:;,..~.. ........ Block ........ ./... ......... Lot No. pursuant to application dated ............. ...~..~..~.. ........................ , 19...~...~, and approved by the Building Inspector. Fee $./..~... ....... Rev. 6/30/80 - . BOARD OF HEALTH ......... : FORM NO. 1 ,3 SETS OF PLA,'~S .......... TOWN OF SOUTHOLD SURVEY ................... ~,99,~4 BUILDING DEPARTMENT CIIECK ..................... M/~R j 8 '~ TOWN HALL SEPTIC FORH .............. SOUTHOLD, N.Y. 11971 TEL.: 765-180:3 Approved i ............ I9... Permit No. , Disapproved a/c ..................................... (Burl, ding I pl~,~to[) APPLICATION FOR BUILDING PERMIT t:O?I FY = CALL ................... MAIL TO: Date ................... 19,.. INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, 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 streets or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- c etlon. 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 any 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 ~uilding Penlait ~ursuant 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, additions 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 reg.ulations, and to admit authorized inspectors on premises and in building for necessary inspections. (Signature of applicant, or name, if a corporation) (Mailing address of applicant) State whether 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. (Name and title of corporate officer) Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... l. Location of land on which proposed work will be done .... .~. ~.'~. ,'~ ............................. House Number Street Hamlet County Tax Mapho. 100OSection ...~..~.. .......... 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 ......................................... ,.~- - .... ,r' '.~, ................ b. Intended use and occupancy ................................................... ,,/, :.~ ............ 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration ....... ~ . . Repair ...... ,)f. ..... Removal .............. Demolition .. ~ ......... Other Work ............... · (Description) 4. Estimated Cost ......... ~'~. ~?'4~. ............... Fee ...................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ............... Number o f dwelling units on each floor ................ . If garage, number of cars ........................................................................ 6. If business, commercial or m~xed occupancy, specify nature.and extent of~ach type of use ...... 7. Dimensions of existing stractures, if any: Front..../d'~ ....... Rear ....~ ...... Depth ii ~..~i i 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 ............... Height ............... Number of Stories ........................................................ 9. Size of lot: Front ......... , ......... ~.. Rear ...................... Depth ...................... 10. Date of Purchase ............................. Name of Former Owner ............................. 11. Zone or use district in which premises are situated ....................... j ./ ............... ~ ....... 12. Does proposed construction violate any zoning law, ordinance or regulation: ..... ~.~ ................... ~ 13. Will lot be regraded ....... : .................... Will excess fill be removed from premises: Yes c- mm~ 14. Name of Owner of premises .................... Address ................... Phone No ............ :... Name of Architect ........................... Address ................... Phone No ................ Name of Contractor .......................... Address ................... Pho~,No ................ I~ this property within 300 feet of a tidal wetland? *Yes ...... .. NoR ...... *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 description according to deed, and show street names and indicate whether interior or comer lot. 15. · AP RO 'ED AS NOTED · FEE: BY, N~I~ BUILDING DEPART~N$ AT 765-180~ 9 AM ~ 4 PM FOR ~E ~LLO~NG tNS~CT~NS: 1. FOUNOATION - ~0 REQUIRED FOR POURED CONCRETE 2. ROUGH. FRAMING & PLUM~N~ 3. INSU~ION ~ 4, FINAL - CONSTRU~ION MUST 8E COMPL~E FOR C,O, ALL CON.RUCTION SHA~ ME~ THE REQ~REME~S OF THE N,~ STATE CONSTRU~ON & ENERGY CODES. N~ RES~NSIBLE FOR DESIGN OR ~NS~UC~ON ERRORS STATE OF NE~?Y'O~I~,~//...~ ~ COUNTY/O~..-~.~. L .~ .~_~.~ ...... ~. ~~... ~.. ~, ~ .~ ~f ...... being duly sworn, deposes ad says that he is the applicant (Name o~ndividual signing contract) above named. He is the ~ ~ ~ (Contractor, agent, corporate ?fficer, etc.) of said owner or owners, ~d is duly authorized to perfom or have perfomed the said work and to m~e ~d file ~is application; that ~1 statements contained ~ this application are true to the best of his ~owledge and belief; and that the work will be perfomed in the m~ner set forth ~ the application filed therewith. Sw°mt°bef°remeT~ ~ ff~ ~ / ~ dayof ~ /~t~t~ , County · · F ~11 Sta~N ...... ~'''~ ........ - ......