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Home My WebLink About22978-ZFORM NO.$ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. N? 22978 Z BUILDING PERMIT ITHIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLEllON OF THE ~,~ORK AUTHORIZEDI ~,e ......... ~~...2.~. ................... Permission is hereby granted to: ~..~.~ .~..~.. ,.. ~~..~?A ~',~ ~ .././...~......~~..~....~ ............... to .... ~ ~.....~....~ .... ~ ... ~.....~.... ~z/z~,. ...... ~:~......~; ~.... ~ .... m ............ ~/x..~.~~ ...................................................................................... at premises located at ........... .~.~...~....,~..~.~.....~:~-~... ~: .................................................... CountyTax Map No. 1000 Section ......... ..'~...../. ....... Block ....... Z .~... ......... LotNo...~ ............. 19..~..~and approved by the pursuant to application dated .................. ~~...,~.... ......... Building Inspector. _. ~e S...~C...7....~ Rev. 6/30/80 Approved FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 ., 19 it No BOARD OF IIEALTll . . .. ...... 3 SETS OF PLA~IS .......... SURVEY ................... CIIECK ......... ~ .......... SEPIIC FORH .............. t,O't t I=Y ~ CALL ........ HAIL TO: Disapproveda/c ....................../..../...,~....~-a_ .~-~ ,'¢~ ..... :..;, ~ . ~ //.(,uildiugI,,spector) ,; · · ~ Date ....... : ........... 19 ... INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 sets of plaus, accurate plot plan to scale· Fee according to schedule. b. Plot plan showing location of lot and of buildings ou 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 applicatiou 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 permit shall be kept on tbe premises available for inspectiou throughout the work. e. No building shall be occupied or used in whole or i~ part for any purpose whatever.until a Certificate of Occupancy shall have been granted by the Building luspector. APPLICATION 1S HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of South01d, Suffolk County, New York, m~d otheraptzUeable Laws. Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as hereiu described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing ¢Ode, and regulations, and to admit authorized inspectors on prelnises and hi boilding for necessary inspectious. . , . · (Signature of applicant, or name, if a corporation) (Mailing.add~ess of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contrac~r~ elg~triCja.~ plilln,bec·~r builder. (as on the tax roll atest deed) If applicant is a corporation, signature o[ duly authorized officer. (Name and title of corporate officer) Builder's License No .......................... Ph ~ ber s LmenseNo ..... ' .................... Electrc n's License No ....................... Other Trade's License No ...................... I. Location of land on which proposed work will be done ............. ~ ....... ,~ ............ .j .............. 1/ .... ........... . .,59. . :. ............... I louse Ntnn ber Street tlamlet Connty Tax Map No. 1000 Section .... ·.. i '.'~..[ ........ Block ...... [.L.~. ' Lot ....... ~ ........ Snbdivision ..................................... Filed Map No ............... Lot ............... (Name) State existing use and occupancy o£ premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ........................................................ : ............. b. Intended use and occupaucy ......... ............ · .................. ~ ................. ·..~ ......... 3. Nature of work (check which applicable): New Building . ] ........ Adgition .......... Alteratio'h .... : ..... Repair .............. Removal .............. Demolition ............. 1/: Other Work ............... · ~ C~ (~ ~', ..~)0 . (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 nsc ..................... 7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............... lleight ............... Nnmber of Stories ........................................................ Dimensions of shine structure with alteratious or additions: Front ................. Rear .................. Depth ...................... tteight .......... : ........... Number of Stories ........... ~ .......... 8. Dimensions of entire new constrncfioo: Front .............. : Rear ............... Depth ............... lleight .......... ;; ',,. Num bet of Stories ........................................................ 9. Sizeofl0t: Front ......... : ............ Rear ...................... Depth ...................... 10. Dec- .}f Purchase .................... · ........ . Name of Former Owner .................... ~ ........ 11. Zone or use district in which premises are situated ..................................................... 12. Does proposed constrtiction violate any zoning law, ordinaoce or regolation: ..... : .......................... 13. Will 10t 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 ................ j Name of Contractor .......................... Address ................... Phon~ No ................ 15. Is this property within 300 feet of a tidal wetland? *Yes ........ No..F. ..... · If yes, Southold Town Trustees Permit may be required. PLOT DIAGRAM Locate clearly and distinctly all ibuildings, whether existing or proposed, and. indicate all set-back dimensions from property tines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. N~I~ BUI~ING OEPA~N~ a~ 765-1802 9 AM ~- 4 ~FOR ~E FOLLOWING INSPE~ONS: 1. FO~AT~N - ~O REQUIRED FOR POURED CONCR~E ~ z .OUCH - F Mm; a P UMem / STATE OF NE~ Y~O..J~, .. S.S COUNTY OF..',,-,~.~..L~.9..c..'r~. .... .... ~..h~7/C~..~....."'~.. ................... being duly sworn, deposes m~d says that he is the applicant (Name of individual signing cootract) above named. ~le is the ................ · ,. (Contractor, agent, corporate officer, etc.) of said owner or owners, ~d is duly authorized to perform or have perfo~ed the said work and to in~e 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 . .... .... : ........... ~ ~u~lc S~e ~ ~ ~ ~ -- (Signature of applicant)