HomeMy WebLinkAbout21343-ZTOWN 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)
No_N°. 2134~Z
Permission is hereby granted to:
....... ...............
~ ~,~i~ ~ed ,~ ....~~...~~~~ ............................................
County Tax Map No. 1000 Section ...... ../...~....~.. ....... Block.............~"......... Lot No ...... ..~..../... ..........
pursuant to application doted ..... . .,~/'..~.._.~:T... .................................. , 19..?.~.., and approved by the
Building Inspector.
Fee
Rev. 6/30/80
Disapproved a/c ................................ 2 . .: .
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765*18013
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
· INSTRUCTIONS
BOARD OF HEALTIt .........
3 gETg OF PLANS ..........
SURVEY ...................
ClIECK ............
. .....
HAIL TO:
a. This apPlication must bc 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 sfi'eets
or areas, and giving a detailed description of layout of property must be drawn on thc diagram which is part of this appli-
cation.
c: The work covered by this application may not be commenced before issuance of Building Permit.
d.~ Upon approval of this application, thc Building Inspector will issued a Building Permit to thc applicant. Such permit
shall be kept on the premises available for inspection throughout the work.
c. 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 thc Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regolations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
Thc 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 inspec~ g. -~,f?./.~---__. ,
//?:-:. . ............... : ................. i ....... '....
~- ~ 2~-~ d/ ~'J-.~~'' (Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, generai 'contractor, electrician, plumber or builder.
Name of owner of premises ... ~.~.44 .~. .. ~ ...................................
(as on tlr/tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
Plumber's License No .........................
Electrician's License No .......................
-Other Trade's License No ......................
1. Location of land on which proposed work will be ·done. /~. ~ ............. ~. ....... :'. '. ..............
.... .................. ........... .........
House Number . Street Hamlet
Cotmty Tax Map No. 1000 Section . ~. :{~. ~. .......... Block ~ ' Lot ~../
Subdivision .................................... '. Filed Map No ............... Lot ................
(Name)
2: State existing use and occupancy of~e~mises and intended use and occupancy of proposed construction:
a. ' o e and occupancy ...~.:..' ....... ....~. ................................................. ..
Intended use and occupancy /~ ~/ ~ ..~.,~... "
3. Nature of work (check which applicable): New Building ......... Addition .......... Alteration ...........
Repair .............. Removal .............. Demolition ~'...: ......... Other Work '~
~ .... ! (Dcscription~
4. Estimated Cost.. Fee..//.~' .~.. ..........................
(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 .... ~ .......... Rear .............. Depth .............
Height ............... Number of Stories ........................................................
Dimensions of shine structure with alterations or additions: Front ................. Rear ..................
D pth ' Hight N be f St ri
8. Dimensions of entire new construction: Front ............... Rear ............... Depth ...............
Height ............... Number of Stories ....................... ~ ............................
9, Size of lot: Fro'hr ......... ~ ........ ' ., Rear ...................... Depth ......................
I0. Date of Purchase ............................. Name of Former Owner .............................
1 I, Zone or use district in which premises are situated ....... ....... .................................. .....
12. Does proposed construction violate any zoning law, ordinance or regulation: ...........................
ddress ................... Phone No.' '~
Name of Architect .................. / '~ Address ................... Phone No. ~,.?..~q/31~.
Name of Contractor i/~, ~.',~?( i l.~.-/-,/. $?/q~&q .... Address .............. ' ...... Phone No.
15.' Ip this property within 300 feet of a tidal wetland? *Yes ........ No .........
*If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from
property Hnes. Give street and block number or description according to deed, and show street names and indicate whbther
interior or corner lot.
APPJil)$ED AS NOTED .' /
NOTIFY BUILDING DEPART~lfl-~ AT
765-1802 9 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS:
I FOUNDATION TWO REQUIRED
FOR POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING
3. INSULATION
4 FINAL CON,qTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET
THE REQUIREMENTS OF THE N.Y.
STATE CONSTRUC'rlON & ENERGY
CODES. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
STATE OF NEW YORK, S.S
COUh'TY OF .................
......... '.'.././~.4~,~../,/..~... ~,Z.,q.~.q~:~..~., ........... being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
*hove named.
{e is the . ,,.,.., ....................... ~'x ....... : ............................... "'. ............
((Contracto~ 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
pplication; 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.
worn to before me this
......... /..e:2:...~.. ....'...day of...~'~"~.. .., 19 .~..
:otaryPublic, .r,D ......... ' ~e~-f.~t~.~.~,~. . ........ x County ~~..~~
Notary Publle, Stats of NewYorR [ ................
No. 4822563, Suffolk County ~]/~ . (Signature of applicant) ·
'' . l~rm Expires December 31, 19 Lr