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Home My WebLink About21852-ZFO~M TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. No BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Date ... ~. ~.../~.....~.. ...................................... 21852 Z CounlyTax Map No. 1000 Section .....~/.~.~...~ Block ......,~.... .............. Lot No..~.'.:...?.. .............. pursuant to ~ppllcation dated ..... Z'~ ..................................... 19,,.~ ..... and approved bythe Building Inm~tor. Fee $./~. ~ ~.~ ~ ~ ~~~~ ......................... Rev. 6/~0180 Exalni"e .............. , Approved . ../. ~ ~. ..... FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT ToWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 BOARD OF HEALTH ......... 3 SETS OF PLANS ......... SURVEY .................. CALL ...... ~--~- ........ HAIL TO: Disapproved. a/c ..................................... . · APPLICATION FOR BUILDING PERMIT % ~_FO~_ 6 ~-i'~. (~'T//0~ Date...:...: ........... 19... w'D O'T, o INS*RUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 .*ets 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 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 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 demolitibn, as herein described. Tlie applicant agrees to comply with all applicable laws, ordinances, building end% houning code, a~Lr4gulations, and to admit authorized inspectors on premises and in building for nece~-~ inspects. ~ . ~ I ' ' ' (~ alt~"dant: or ~me, if a corp tion) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, en~neer, general contractor, electrician, plumber or builder. N~me of owner of premises . .~.~ ~,77... ?... CA ~]~./.--~... ~ t~o]~..,)t~. ... (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 License No Electrician's License No ................ . ....... Other Trade's License No ...................... Location of land on which proposed work will be done ................................... . ............... lfouse Number Street Hamlet Couhty Tax Map No. Il000 Section :.q,.~ ' Block ....~. ' Lot..~.'.] ............. · Filed Map No. Lot ...... : ........ Subdivision ........ . ........................ . .............. (Name) Stat~ existing use and occupancy of premises and intended use and occupancy of proposed constructioni Existing use and occupancy ........ ,:...t~.. ........ . ........ //~'/'.iP/ ......................... '%"' b. Intended use and occupancy ........ /~.4. ~ ....',; .,.,. .... , i · .................. · 3.Nature of work (check which applicable)- New Budding ....... AdditioJ~ .... Alte,.ratio~l~ .... Repmr .............. Removal .............. Demohtmn .... ~ ...... Othe~[r-~t .............. / gS~ ~ ' (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 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 shme structure with alterations or additions: Front ................. Rear ................. Depth ....................... Height ........... ' ........... Number of Stories .................... 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height ............... Number of Stories ........................................................ 9. Size of lot: Front ..... ;... .......... Rear ...................... Depth ...................... 10. Date of Purchase .../.~./.q l ?.3. .................. Name of Former Owner . ..g: .p.,g.o~. ...................... 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 No 14. Name of Owner of premises .................... Address ................... Phone No ................ Name of Architect ........................... Address ................... Phone No ................ Name of Contractor ...... . .................... Address ................... Phone N9 ............... I~ this property withxn 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. STATE OF NEW YORK, S.S COUNTY OF ................. .~..~eff~.. :~O... ~. '~.~¢~4 .~1 .................... being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized 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 filed therewith. Sworn to before me this Notary Public .............