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Home My WebLink About21780-ZF~RM NO.$ TOWN OF SOUTHOLD BUILDING DEPARTMEI~n' TOWN HAiL $OUTHOLD, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Dote .../.~..,~,. ......................................... 19..~.,,~,, 21780 Z County Tax Map No. 1000 Section.._/~ ......... Block ........ ~ .............. Lot No......~.../. ................. ............................. and approved by the pursuant to applicatlondated ..... ///./.~ .................... 19 /~'~ , Building Inspector. Rev. 6/30/80 ,' /'""~'~ ~ oF SOUT, O,D /,f---~/..,-~f.,i__ _ ~ / - BUILDING DEPARTMENT ~ ~.~ ~,/~:~ , ,, TOWN HALL / . ~ /,? /./i/ 80UTHOLD, N.Y. 11971 E×amined .///:.'7.. ......... , l~ ?_,~ · Approved ).,.,Z.? .' -- permlt o. Disapproved aJc ..................................... '. (~Buildifl/g Inspector) APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH 3 SETS OF PLANS SURVEY ................... CllECK ..................... SEPTIC FORH .............. NOTI FY; CALL ................... HAIL TO: 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 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 igsued 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 inspectors on premises and in building for necessary inspectio_ns~_ . . . ~ . . -- (Signature of applicant, or name, if a corporation) ... (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, generai contractor, electrician, plumber or builder. .... ........ .............. . .................... ....... Name of owner of premises ....~..~..L .... ~. .o..M~..q,,. ....... ¢3..'p,. . . ... (as on the tax roll or la[~t deed) Builder's License No .......................... Plumber's License No ......................... Electncmn s License No ....................... Other Trade's License No ...................... Location of land on which proposed work wilt be done ............................. ^...; ................ ltouse Number Street Hamlet Cou'nty Tax Map No. l'OOOSection ...:..~....Q~. ..... Block ..~. ' .. Lot ....... .~...k ....... 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 0~, b. Intended use and occupancy ..................... ' ......................... ...................... Alteration ........... .... ~ (check which apphcable). Ne Demolition .... ~ .... (Descrlpt~on/ ~at,~;°'V.'.:~ ....... Remora' .... . :': ...... . - . ................. ~ Rep ; ............... Fee ..... ~tZ{ipaid on fihn~ th,s appi,cat,on~ ' · er of dwelling urals ............ . ........................ . ............. , ...... 5. If dwelhng, nu,mb _v ~ars ................ .;'": re -~d extettt of each t~P~-~°,f~ 'r~onth.,--'~." '~' .... lfgarage, numvero~, f...ixedoccupancy, specttyn~ak~ ~' Rear .... ~''?'~';"k:~'~-~_.~ ....... 6 ' If business, commerc~m o~ ..... s if any: Front .... :-4.-4'. ~ ..... {.D.kO.L~ ·..~ ' ·" ........ ., 7. Dimensi°ns°fex'stmgstrUct~lrme';erofStories ............ /' ........ .. Re~ ...... ......... . ,eight .... . .... "''"~re with ~lt~r~o~ or ~dditions: Front ..- ¢/,/~;o~r of Sto~eS ..................... Dimensions of same struct Height ......... : ........ l~;~r . Depth ............... Depth .....'/"; .... Z kkk~t~¢tion: Front .......... . ........................ 8. Dimensions ot entire new ~,~,, ' ' ' ' ; .............. Number of Stories ...................... . Depth ...................... might ....... . ........ .....',.. ~ear.. ~;:~: k~'~;;e, Swner ............... ~'~ ......... 9 Size of lot: Fron~ ........ . ............. ~a, ..... . ...... .............. . ..... ~ Date of Purchase · .. .... . ....... ises are situated ....... ....... .',~t~n· . ..................... J~, ~1o ..,~ 10. 7rme or use district m which l~rem ..... i~ law ordinance or regm~ · · ~ ' ~ [~ ¢oes proposed constructionv'°late an~ ~ ....... ' . Wille Phone No ............. "'' .' ............... xcess fill be removed from premiseS: ~of premises 13. ,6/illlotberegrad&d ...... ' Address ................. ].PhoneNO .......... :" 14. %V.ae~~ 15. *I~ yes, Southold Town Trustees Permit may..be required- Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Gi~e stree[ and block number or description acCOrding to deed, and show s~reet names and red,cate whether STATE 0 F NE~,~.~O~ couNTY OF.,~. ~-'trn~ ........ . ~ being duly sworn, deposes and says that he is the applicant .. . .,~ ~...'.~-..~,l~"J'"'"' ........ ..... · ~(~a~o f individual signingc°ntract) above named. e officer, etc.) ~ or h - -~ ~-st of his ~owledge an of said owner or owne~;~s'~ont~ined ~ this' apphcat}~n.?-- ~d therewith- application; the[all st~t~ ,h~ m~ner set fo~h in the appucauon work w~l be perlo~eu m Sworn to before me this ' t Pt , 19~ ~ot ~ub~ ~ 4~ ' ~ re ~f apphc~t) "