The URL can be used to link to this page

Home My WebLink About21897-Z21597 FORM NO,3 TOWN OF SOUTHOU) BUILDING DEPARTMENT TOWN HAIJ. SOUTHOLD, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Counh/Tax Map No. 1000 Section ...... x~...~...~.. ....... Block ......~....~. .............. Lot No......-~.... .................... pursuant to application dated .......~.~ ..................................... 19...?..~., ...... and approved by the Building Inspector. Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL Box'//',7~ SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Disapproved a/c ..................................... BOARD OF HEALTB ......... 3 SETS OF PLANS ......... SURYE¥ .................. CIIEC/ ................... SEPTIC FOR~I ............. HAIL TO: · . APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by Wpewriter or in ink and submitted to the Building Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedula. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets 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 demolition, as herein described. The applicant agrees to comply with ali applicable laws, ordinances, building code, housing code, and regulations, and to admll auti~oiized inspectors on premises and in building for necessar~ inspectig~ns. ~ x ........... ........... [Signat'ure of applicant, or name, if a corporation) (Mailing address of applicant) State whether applicant is owner,.lessee, agent, architect, engineer, general contractor, electrician, plumber or builder· Nme of owner of premises. ~..~.. ~Qa[ ~e' ;a~l~;;t' ~;~) ......................... If applicant is a corporation, signature of duly authorized officer. ..... ~ (Name and title of co.orate o~;r~ ......... Builder's License No.. }? ~7.~ ............ ~ Plumber's License No ......................... Electrician's License No ....................... Other. Trade's License No ...................... ~ V ~6' .d'/Y cQ Location of la?d on~ w~hlch proposed work will be done ...... ~.. ~. ...... ~.7.~,~... ~./~. z .......... ............. ............ ....................... County Tax Map ao. lO00Section '/~) y Block /0 Lot...~... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: b. Intended use and occup~cy ......... ~~.~ ..................... U .................... 3. Nature of work (check which applicable): New Building .......... Additi..tLon .......... Alteration .......... Repair .............. Removal .............. Demolition .., .t-:~T. ......... Other Work ............... O , ~ , (0p~scription) 4. Estimated Cost ...................................... Fee...~?.~5.,.. 4.. ~,...~...~-~.~..(--'~.~.. ..... (to be pai~ on filing this applic'afion) 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 same structure with alterations or additions: Front ................. Rear .................. Depth ...................... Height ..................... ~ Number o~ Stories ...................... 8. Dimensions of entire new construction: Front ............... Rear ....... i.. ...... Depth ............... Height ............... Number of Stories ........................................................ 9. Size of lot: Front ...................... Rear ...................... Depth ...................... 10. Date of Purchase ............................. Name of Former Owner ...... : ..... .~ ............ 11. Zone or ~,~e district in which prgmis~: 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 .................... Address ................... Phone No ............... Name of Architect ............................. Address .................... Phone No ................ Name of Contractor ~//.~...Z-~..~.//..W.. ~/.U.~.'.C ff.O. (~. Address dOT/. f.~. ~".'.'~/..'~./OL Phonl No.>5..~e.O..).'..'01D. Is this property within 300 feet of a tidal wetland? *~es ........ No..~.'.... *If yes, Southoid 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. 15. STATE OF NEW YORK, S.S COUNTY~ OF ........... ; ..... .....--.~/..O..~.~.fi}..~...../.Q/~/;/.O ..................... being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. Heis the ~../Q (Contractor, agent, corporate officer, etc.) )f said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this ~pplication; that all statements contained in this application are true to the best of his knowledge and belief; and that the york will be performed in the manner set forth in the application filed therewith. ;worn to before me this ~-~.~-'"' day of '. ~.u~. ........... .ii, i'i'.i' 7/ ..... ";t"" (Signature of applicant)