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Home My WebLink About21666-ZFORM NO.3 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HAU. SOUTHOLD, N.Y. N~ 21666 Z BUILDING PERMIT [THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLEllON OF THE WORK AUTHORIZED) at premises located a ............................................................................................ CountyTax Map No. 1000 Section....~./.. ............. Block ................ ./....~.... LotNo .......... ~ ............... pursuant to application dated ......... .~./~.~... ..................................... Building Inspector. F~ $....~..~.s~ 19...9...~'... ....... and approved bythe / /,~.~uilding InspecTor Rev, 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.; 765-180:3 i I~L~':. Oa;~ L ~ Disapproved a/c . ................................ (~Idin~spector) APPLICATION FOR BUILDING PERMIT INSTRuCTIoNS BOARD OF HEALTH ......... 3 SETS OF PLANS ......... SURVEY .................. CIIECK ................... SEPTIC FORH ............. CALL .................. I'IA I L TO: 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 sti'eets or areas, and giving a detailed description of layout of property must be drawn on the 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, 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 Bt{ilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or R,gulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all apphcable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. ~,~ ~ . ............. -- (Signature of al~plicant, or name, if a corporation) .. (Mailing address of a~'plicant) /,' ?-g7~ State whether applicant is owner, lessee, ' agent, architect, engineer, general contractor, electrician, plumber or buildc: Name of owner of premises . j.~...75...//../;.9 ..... t ~.. ! ~ ~'J o.T"7% .............. (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 LicenseNo ......................... Electrician s Lmense No ............... , ...... Other Trade's License No ................... Location of land on which proposed work will be done ............ ltouse Number Street Hamlet connty Tax Map No. 1000 Section ...:.~]. .......... Block i..,/c~. ' 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 ....... '~r..r?'" .r./f.~. ..... . : 0. . . . .. .z?..: -3. Nature of work (check wh~cable): New Building ........ ... Addition .......... Alteration ....... ].. Repair .............. %Removaf~ .............. (Demoliti~n~ ~. ~.: ......... Other Work ............... · - ¥-~,/ ,-,~ .' (Description) 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 roi.xed occupancy, specify nature and extent of.each type of use ..................... 7. Dimensions of existing structures, if any: Front ../.~c£. ..... :.. Rear., .~.~C.4~. ....... Depth . A'ff/£ff~. ........ Height ...dz. F.~. ........ Number of Stories ... t . ] .................. ................................ Dimensions of shine structure with alterations or additions: Front .../:~f~-~../...~?.~:?.z. Rear . ! :~47~ .~. ........... Depth .... ' ... Height ... ~.C.U-....' ......... ... Number of Stories ...t ....... · ...... 8. Dimensions of entire new construction: Front ...~.,.a,.ff- ........ Rear ............... Depth ............... Height ............... Number of Stories ....................... , ................................ 2. Sizeof~ut: Front ..... ~..~,rT. ...... Rear ..... ~.,l~d~. ............ Depth ../.f.'z:.,~7.'/7..5 ........... 10. Date of Purchase ...... ,C/'. ~? ./.~.~( ..... ......... Name of Former Owner . .fi~.--??. · .5 .'4.~5.3.-?..~ ~. .... 1 1. 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 14. Name of Owner of premises/YJ¢~P. ~.~ .~.7: .~.~./., ;*.~.~.?Address/~ .*/-~ffq~ .~...V'./~.~t z."~.~hone No. ~2 ?..~5.' Name of Architect ........................... Address ................... Phone No..Q.[.6. ~: .~.-*~. Name of Contractor .......................... Address ................... Phone No ................ 15. Is th±s property with±n 300 feet of a t±da~ wet:land? ~Yes ........ No..,~V ..... · If yes, $outhold Town Trustees Perra±t may be requ±red. PLOT DIAG RA/Vl Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from property 1/nes. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. ~ ~QHNDATION ~NO ~EQU{RED 3 ALL COHSTRUCTION SHALL T~E REQUIREMEN~ OF THE NY ST.~TE CONSTRU~ION ~ ENERGY CODES, N~ RESPONSIBLE FOR OESt~N OR CONSTRUCTION ERRORS TATE OF Ill S S (Name of individual sig~ng contract) :bore named. (Contractor, agent, corporate officer, etc.) f said owner or owners. ~d is duly authorized to perfom or have perfomed the said work and to m~e and file this pplication; that all statements contained ~ 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. ......... ..... (Signature o f applicant)