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Home My WebLink About22622-ZFORM NO.$ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. N? BUILDING PERMIT [THIS PERMIT MUST BE KEPT ON THE PREMISES UNtiL FULL COMPLEtiON OF THE WORK AUTHORIZED) ~o,~ ............... ~.~......~ ....... 22622 Z Permission is hereby granted to://) · ......... ~.~...~. ~..,. ~.~./..,~ ............. ..... ~~...//.~..~Z.....Z..¢..~.~... .......... .~..~.~../....~...~.~, ........ ~ ~7 ,o ...... ~.<~¢~.~2.....~.~..~.....~¢.~.~..~..~. ....... ~.....~:~.~.~... ~%~... ¢~ ;..~,.~/~)' ........ ~,,,,,,,~/~..~,~..~.~,,,,,.~......~ ........................................................... ~t premiss I~ot~ of .................................................................... ......... ~ ................................. ~...~.~,~.~./ ............. ~..~X.~ ....... oou.~,~x~,,o. ~000 ~,,o. ...... X~ ~,~, ........ .~ ........... ~o,~o...~..~ ............ Building Inspector. Rev. 6/30/80 FORM NO. 1 TOWN: OF SOUTHOLD . ~.,,~i, mALL SOUTHO~.D.N.Y. ~o~ TEL.: 765-1802 BOARD OF HEALTH ........ 3 SETS OF PLANS ........ SURVEY CIIECK .................. SEPTIC FORH ............. CALL MAIL TO: Disapproved a/c ..................................... ' .. · . // (Building'Inspector) Date ....... ; .......... 19... INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 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'eet or areas, and giving a detailed description of layout of property muit 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 i~sued a Building Permit to the applicant. Such permi shall be kept on the premises available for inspection throughout the work. e. No building shall be c coupled or used in whole or in part for any purpose whatever until a Certificate of Occupanc,. shall have been granted bY the Building Inspector.. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pti~uant to th( Building Zone .O,rd~n. ance of the Town of South°Id, -SUffolk County, New York, and other applicable Laws, OrTt~ances o: Regulations, fo'r ire 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 tc admit authorized inspectOrs on premises and in building fornecessary inspections. -- . ~;f'applican , '"~ if a cor~oraUon. 4Mailing address of applicant) State whether'applicant is owner, lessee, ·agent, architect, engipeer, general contractor, electrician, plumber or builder. (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 l~i~ense No .......................... Plumber's License No ......................... E ectnc~an s License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done .................... ~ ,W,r?~ ...d~...~..~. ............................. ~...~. C'....~ ...... ..... ,,R..~....,,~.......~- ..... i...' ............. /. ,e~,~-.. ...... /.-7.-.../.< ? ?:,?... House Number Street Hamlet cotmty Tax Map No. 1000 Section ... '~.~...~.. Block ....~..2'7'.. ...... J... 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 ............. ta..~l ~-- ~'~'.' .x .... 3. Nature of work (check which applicable j: New Building .......... Addition .......... Alteration ........ Repa/r .............. Removal .... Y~. ........ Demolition ...~: ......... Other Work...- ............ (Description) 4 Estimated Cost ..//.~.~.q ..... ~ ,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 same structure with alterations or additions: Front ................ Rear .................. Depth ...................... Height .................... ... Number of Stories ...................... 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height ............... Nqmber of Stones. ...................................... · · , . ~ ~ .......... Sizeoflot: Front..~./.~:.6.~/.'. ............ Rear... /,','/~.: ??. ......... Depth .~"~'~ ........... Date of Purchase ...l~.f. .................... Name of Former Owner ................ iiiiiiiiiiii Zone or use district in which premises are situated...t~fJ~ ..................... Does proposed construction violate any zoning law, ordinance or regulation: ............................ ~ Will 10t be regraded ... ~.6-.s.. .................... Will excess fill be. removed from premises: -~ ~ ~es, ,.- ~ Name of Owner of premises ~/.~,~' ¢'~../~.././(£r~-... Address ~.~..z~. ?. ~..,?~..~,ff... .... Phone No. ,F.'~..'.'Ea.~.z:.. ~... Name of Architect ........................... Address ................... Phone No ................ Name of Contractor .......................... Address ................... Phone No ................ Is this property within 300 feet of a tidal wetland? ~¥es ........ No..~. ..... · If yes, Southold Town Trustees Permit may be required. PLOT DIAGRAM Locate clearly and distinctly ail buildings, whether exisfin~ or proposed, and, indicate a11 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. 10. 11. 12. 13. 14. 15. ~ ~ ~OR POUR£D CONCRETE ~ " ~ ~ / ALL CONSTRtlCT~O~ SHALL MEET [ I THE REQUIREMENTS OF THE COO~S. NOT ~ESPOMSISLE FOR DESIGN OR CONSTRUCTION ERRORS STATEOF NE~OR~ /// e e ~/~..~...~ ...................... being duly sworn, deposes ~d says that he is the applicant (Name of individual siguing contract) ~bove named. / ............... Js the ........................................................... ' ..... (Contractor, agent, corporate officer, etc.) said owner or owners, ~d is duly authorized to pcrfo~ or have perfo~ed the said work and to m~e and file this ~pplic~t[on: that all statements contained ~ this application are true to the best of his ~owledge and belief; and that the york wQl be perfo~ed in the m~ner set forth in the application filed therewith. ;worn to befor~ me t~(// ~ ............ ........ 4o'ta~ Public~..,.5 .... /.~.~ , .... County ' ' . ................. ~ ~BLtC. 8~te of ~ ~ (Signature of applic~t) · ~. 4879~5 . ~ in Sufo~k ~ ~/~ ~mi~ Ex~r~ ~em~ 8, I~