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Home My WebLink About21750-ZFORM NO.3 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALl. $OUTHOLD, N.Y. N~ 21750 Z BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permission Is hereby granted to: ~.~.~-....~?~..: ~', ~. .......................................... ..~~..,..~:....., ~./~ .............. ,o ........ ...... a, prem,ses ,o~at~ a,.....~..¢...~.~..~.;?.~..~.__ ...................................................... .................................................................... ~~"*~':~ ........................................ CountyTax Map No. 1000 Section ........ .~..~.. ......... Block ...... ~ ............... Lot No ....... ;..M~..~ ..... pursuant to application dated ..... ..~..~..../../..~.. ....................................... 19, ,~...-~., ....... and approved by the Building Inspector. Fee $,../~..~ _~ ..... ' ~ / ~" Building Inspector Rev, 6/30/80 · BO^RD OF HE-AI..TH FORM NO. 1 .3 SETS OF' PLANS ......... TOWN OF SOUTHOLD SURVEY ................... 0t~'*J' ~"JSJ~9~ BUILDING DEPARTMENT CllECK .,~ ................... ~ ~EPTIC ',I ~ TOWN HALL FOR,'! .............. ~, "fOr, i, ¢,~ ; SOUTHOLD, N.Y. 11971 ................ TEL.: 765-1803 . Examined ..... , 19. Approved ..... "[./~.'/.')~.., 19 ..mermitNo.~/7.~.~.~.5~ Disapproved a/c ..................................... APPLICATION FOR B~'I~G PERMIT INSTRUCTIONS O?i I= ¥: '.0..~. c ^ L ,. . 23.%'.6..7. ...... HAIL TO: Date.. (0./1.¢ ........... 197.3. a. Tkis 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. ~I. 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 tq admit authorized inspectOrs on premises and in building for nece ry inspections. ~g/~ }-/o~ -- (Si°nature of apph'cant, or game, if a corporation) (~,4~{; "/Od.>/ (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. (as on the tax roll or latest deed) cant is a corporation, signature o[ duly authorized officer. · ( t'tle ot corporate officer) Plumber's License No ......................... Electmcmn s L~cense No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done.%0. ./.~. i~.~..r..~.ff..~, .~.~./.~...~..t'4. '(~5~'f~.. ~.'~.~ ........... :,... ......... ....... ............ · Cot nty Tax Map No. 1000 Sect on ... :~...~ ........ Block .'..~. .......... 5... Lot ./. 4.-5../l''.~'' ~t~v. ?.; .' Subdivision ' Filed Map No ............... Lot ............... (Name) . State existing use and occupancy of premises and intended use and occupancy of proposed constructioni a. Existing use and occupancy . ~./~..c-../°CY..~.., .~./?(~.~....~. ~T. ]-J...5J~7. i .... ,,~, ,.,-...-.. ~ .~ ............. b. Intended use and occupancy ........................... ...................... · 3.Nature of work (check which applicable): ~ Building .......... Addition .......... .vtn~AIJe-rali°n .......... Repair Removal ..... ....... Oemolition .... : ......... Other ....... '~ (Description) 4. Estimated Cost ~.~..~(~10...~.'Y.~.. ~/'~.ff~.t.) ......... 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 ...t.~.~.JT... Depth .... ~ ..! O..~.. ~. ......... Height .... [0 ~..T. ,' ........... Number of Stories . .~ ........ : .......... 8. Dimensions of entire new construction: Front .............. : Rear ............... Depth ............... Height ............... Number of Stories ....................... , ................................ 9. Size of lot: Front ......... , ......... ~.. Rear ...................... Depth ...................... I0. Date of Purchase ............................. Name of Former Owner ............................. 11. 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 orOwner of~d .................... Address ."~. ~' .... .-' · ,.. ....... Air:~ c,,,g,v,M,nt c?" Nai,,~ ,~, .~u,mactor .............................. r~ss .................. 15.' Z.s this property within 300 feet of a t±dal wetland? *Yes .......... eI£ yes, Soul:hold Town Trustees Perm±l: may be required. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate ail set-back dimensions fi'om property lines. Give street and block number or description according to deed, and show street names and indicate whet, her interior or corner lot. RPP,,R~t~EO AS ~OTED / a02 ~,:~ AM TO ~ PM FO~ THE COMPLETE FOa C,O CCD~S, NOT RESPONSIBLE FOR BESIGN OR CONSTRUCTION ERRORS STATE OF NE~g~YORI~,~__ ( L/- s s ..... ut. . . .-). . . . . . .%. .%.ct. . . (Name of individual signing contract) above named. being duly sworn, deposes and says that he is the applicant ((Contractor, a~gent, corporate officer, etc.) . of said owner or ownem, and is duly author]g~ed-To-13fi3form 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 .. ...... NM~y Publl~ S~e o~ New yMt[ ................. No. ~879r)05 /~//' (Signature of applicant) Ouelifled in Suffolk CouMy