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HomeMy WebLinkAbout21470-ZFORM NO.3 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. N£ BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Date ...... ~ .~..~. ............................................... 21470 Z Permission is hereby granted to: ~~~'""~"~/"~~:~~.~.~.~ , _ ~,~ ...... , . ......... ~~.....,.~.~....,....~z.~ ,o ....... ................... pursuant to application dated .......... .~./~,~.~.../ .................................. 1 9....~... .... Building Inspector. Fee $..,,,..~...~..~.~ and approved by the ~ ,.~uilding inspoc~or Rev, 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y, 11971 BOARD OF HEALTH ......... 3 SETS OF PLANS ......... SURVEY CHECK ................... SEFTIC FOR~I ............. ~./.~ TEL.: 765-1803 Examined ...... 19 .~.-~. ' Disapproveff a/c ..................................... ...... . ~ ~t5 .~uil~ Inspector) APPL~C~T~O~ FOR aU~LD~ PERmT ~1~ ~m~ ~C~ ~ Date .... A.-~ .......... ~ ~STRUCTIONS NO?I FY I CALL ~ ................. t'iA I L TO: .~7.s~. ~,~....k. ..... a. Tiffs application must be completely filled in by Wpewriter or in ink and submitted to the Building Inspector, with 3 se~s 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 st?eets or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- fiation. c. The work covered by tiffs 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 Building Permit pursuant 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 regulations, and to admit authorized insr)ecJors on premises and in building for necessa¢,, inspections. /7 ,~ - ' -- ......... -:~- - ' - (Signature of applicant, or name. if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, en~neer, general contractor, electrician, plumber or builder. Name of owner of premises .. ~.e.~e.u,e ~e...O~o.~..z.'~,~.Y:,f. ....................................... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Budder s L~cense No ................ Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... Location of land on which proposed work will be done .................................................. · ~-~ .... · .~-V~-'...~..~. ~W~o%~ ~ .... .~...~.q~. ltouse Number Street Hamlet County Tax Map No. 1000 Section . . . :C[Lo. .......... 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 ............................................. ' ....................... b. Intended use and occupancy . . . Demo k ~ h ~DR..~, .,., ~.~ · 3.Nature of work (check which applicable): New Building .......... Addition .......... Alterat~n .......... Repair .............. Removal .............. Demolition .... : ......... Other Work .~. ....... ·" (Description) 4. Estimated Cost ...... ti.O.c.q....O..©. .... ' .................. 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 roi.xed occupancy, specify nature and extent of.each type of use ............... ~ ..... 7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ..... i .................. ' ................................ Dimensions of shme structure with alterations or additions: Front ................. Rear .................. Depth .... ~ .................. Height .......... : ........... Number of Stories ........... 2 .......... 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height ............... Number of Stories ....................................................... 9. Size ofl61:' Front ..'.: .................. Rear ..................... Depth ...................... 10. 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: ................................ 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 ............ ' .... 15. 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 description according to deed, and show street names and indicate whether interior or corner lot. 765-1802 9 AM TO 4 PM FOR THE FOILLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POURED CONCRETE 2. ROUGH - FRAMING & PLUMBING 3. INSULATION 4. FINAL CONSTRUCTION MUST 8E COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N.Y. STATE CONSTRUCTION & ENERGY CODES. NOT RESPONSIBLE. FOR DESIGN OR CONSTRUCTION ERRORS STATE OF NEW~--OR~!r~f' /~' S S COUNT~O~. :-,,~..-CT-D./..q~, .. ' ...... .~.../T~ .f'.~ .~/...~.' .~,.. ',~.~..'.'.~. ............... being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. He is the ..... .........................................(Contr~t'~corporate officer, e't~.') .............. ' .............. of said owner or owners, and is duly author/zed to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application flied therewith. Sworn to before me this .............. .~.'., '.P~..day of....-~.~J.~ .~.~....., . CLAIRE L. GLEW No,,,v N. yo,k ..... · ..................... No. 48?9506 ~./' Qualified in SuffOlk Cpunly_ .,,C//_~ (Signature of applicant)