HomeMy WebLinkAbout23356-ZFORM NO.3
TOWN OF $OUTHOLD
BUILDING DEPAETMENT
TOWN )~,LL
SOUTHOLD, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNtiL FULL
COMPLETION OF THE WORK AUTHORIZED)
23356 Z
Permission Is hereby granted to.'
Building Inspeotor.
F~ ,.....7.~._~),~,
l~ev. 6/30/80
FOP, M NO. I
TOWN OF SOUTI1OLD
BOIl. DING DEPARTMENT
TOWN IIALL
SOUTIIOLD, N.Y. 11971
TEL: 765- IS02
BOARD OF IIEALTI1 ...............
3 SETS OF PLANS ...............
SURVEY ........................
CIIECK .........................
SEPTIC FeRN ...................
NOTIFY:
c^,.L _:~3:.2. 5 8...5 .....
HAIl. TO: ....................
a. ~ds application nust be conpletely filled in by typewriter or in ink and mflmitted to the Pidlding Inspector witl
3 sets of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan sho~ing location of lot and of buildings on pr~nises, relationship to adjoining pr~nises or public
streets or areas, and giving a detailed description of layer of property mmt be dra~m on tim diagram ~ich is part of
this application.
c. ~lhe ~ark cozened by this application may not be eommnced before issumme of Building Pemit.
d. Upon ~plno~al of this application, the Building Inspector will issue a Building Perndt to the applicant. Such
pemit slmll be kept on the pr~nlses available for inspection thrc~hout the ~ork.
e. ~ building ~ball be occupied or treed in ~dnole or in part for any l~trpose ~dnatever anti1 a Certificate of
Occupancy shall ha~e been granted by the Building hmpector.
APPLlCATIClq IS ItEI~BY ~ to the lluilding Deparl~rent for the isananee of a Building Pemit paranant to tim
Building Zone Ordinance of the Tcr~n of Southold, Suffolk County, ~ York, and other applicable La~, Ordinances or
Regulations, for the construction of buildings, additions or alterations, or for remaval or demolition, as herein
described. The applicant agrees to c~ply with all applicable lams, ordinances, building code, housing code, aM
regulations, and to ad,it authorized inspectors on premises and in building for necessary inspections.
.......
(Signature of applicant, or nam, if a corporation)
(Hailing address of applicant)
State ~hether applic2mt is ~mer, lessee, agent, architect, engineer, general contractor, electrician, ph~ber or builder.
ZiZ'2; ..... :22 ........ .... ...... .........................................................
(as on the tax roll or latest ~{'
If app~rpar~tion, signature of duly authorized officer.
(Nam and titl~of corporate officer)
Builders License No ..........................
Pltmhers Licertse lqo ..........................
Electricians License I~ ......................
Other Trade's License ~ .....................
I. l~cation of land on ~ddd, proposed work will be done C~+C~O~ ~.~
llouse NL~ber Street ll~nlet
Cotmty Tax ~ No. 1000 ,Section ~ O~ Block
............... ..~Z.~ .................. P-ed ~ ~ ...... eZd .... i~t ...... --..~Zd...
Subdivision
(~)
2. State existing use and oecupanc~ of premises and intended use and occupancy of proposed construction:
a. Existing ~me and occupancy ~¢re ~C+
b. lnteeded use and occupancy //~c~ ?t
t.
I0.
II.
14.
15.
I~UHre ol ~k (d~:k Mdd~ alqdic.hle): Nt.~ l~sihlinl~ .... :.~.. ~kliti~ .......... Alteration ..........
i~q~,ir ............ ~l~al ............. I~g~lition ............ ~ Oilier I~rk ..................................
Esi in~tnd Ikmt ....... ~I~-~ ............ fc~ ..............................................
(lo I~ fid ~ fil lng this al~l icati~)
IH.~nsi~m off ~istieg s~rocttnes, if any: Fr~,t ...... ~ ....... l~ar ..... ~ ....... I~pth .... 4.7 ..........
I)in~nsi~m of si~ stsx~ture ~ilh allerati~m or i~litions: Front ............... ~ar ...............
I~ptls .................... I~i~t .................... ~si~r off ~lorie~ ...............
I~i~c ......................... ~mi~r of ~tories .....................
lid~ of IMrcha~ ..................... ~s~ of Forn~r ~r ........................................
7z~ or u~ district in ~sid~ pr~,fi~s are si~t~l .......... ff~(~. .........................................
l~s prol~l ~lrsx:ti~ viol~t~ any ~sing 1~, ordi,~e or regulat, i~l: ...... ~ ...............
~ill lot I~ regr~ ......
ls this pm~rr~ ~ithin ~B f~t o[ a ti~l ~tland? ~ ~1~ .......... ~ ...~ ....
PI.OT I) IAGIIAH
l~cale clearly and distinctly all I~Hhlings, ~hether exist:lng or proposed, and indicate all set-I~ck dimensions
property lines, giv~ street and block r~d~er or descripti~ according to deed. and shc~ street nmos and indicate
tds~lber interior or CraTer lot.
(Cz~ilractor, ai:eliC, eorlx)rate officer, elc.)
of tmid ~r or ~r~, a*~l is duly m~thori~l to i~rFonn ~r have I~rfon~l Ihe said ~)rk and to ~ke and file Ihi~
Notnry Public, Stnte Of Now
No. 52-4649732, Suffolk CO~
Term Expires *~¢~,~ ~- :3 ~, t q q 7