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F01BM NO. D
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
('THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N o 017 0 3 9 Z Date 7 19
Permission is hereby granted to:
~ ..::::...::~~~~s:~' ~
tab-~~'..r~lf~~~.. .:.~J..:....~ .:~tl. ....Q~...../~`....r!.....:-.
ct premises located at ......~50.~.. .r....~~~~.......%!~~...~.'~!,1....~~;,1
T'
Caunty Tax Map No. 1000 Section ~ Block .........l.......... Lot No......
pursuant to application dated .....e'..~..~.zr~t~ 19. .~j and approved by the
Building Inspector.
Do
Fee $~,~`.3'. ,p
<~r~<~'~/
g.. Buil Inspector
Rev. 6/30/80
t
V'K'' ~-ea'/d MJ
BOARD OF HEALTH
3 SETS OF PLANS
" FORM N0. 1 SURVEY .
TOWN OF SOUTHOLD CHECK .CQ~;~„ • , , , , , .
BUILDING DEPARTMENT SEPTIC FORM
• TOWN HALL
SOUTHOLD, N.Y. 11971 NOTIFY
TEL.: 765-1802 CALL
MAIL T0:
Examined~..~~•••••••• ,19~~ ~ „
- ~ .r pw~
Approved ~ 7• • • • • • 19~Permit No............ ,
~
Disapproved a/c ~ 9 ~ /~~1~
(B ilding Inspector)
.APPLICATION FOR BUILD G ERP/IIT
Dat 19...
APP V D AS NdtED ~
DATE: c~`~7 ~B•P. M INST N
0
a. FIH&s~i~~>~ filled in by typewri 'n r nd submitted to uilding Inspector, with 3
sets of Pft4t c~!!t2 t T e according to schedul
b, s~~~++i {~~~a r ~t~iio~ d of buildings on prem s, elat' ns 'p to adjoinin emises or p is streets
or area j~PCN NOr~TN~ • S~~EaU~~~f layout of property mu b dra on the diagram which is pa f this appli-
cation.
c. h may not be commenced be a 'ssu of Building P
d, p _ a e Building Inspector will issu uil it to th plicant. Such permit
shall bee v ' ~ fpF,~pection throughout the work. ,
e. o ' s 'b"rr~"' sed in whole or in part for any p whateveryQltl
a
Certificate of Q~upancy
shall havAeL a ~•ng~~ctor. /T~ VJ )
APP>C1i~ARQ0~11R~~B~E~the Building Department for the issuance of a Building Permit purs nyFo the
Buildin~Ylaite BA~fI~CdlQ~e ~o~outhold, Suffolk County, New York, and other applicable Laws, y~
Regulat~9,E&3r 1AAicoi~~~@~bu~igs, additions or alterations, or for removal or demolition, as herein de d.
The apKi~~~Q~N11~4~~~t~R~licable laws, ordinance , uilding code, housing code, and regulations,
admit authorized inspectors on premises and in building for necessa •n ?e~~~~~Q1Vn~s.
(Signature o applicant, r name, if a corporation)
1. '
(Mailing address of appl ant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises p.~. ~i2.-:...~I~~nC.~l.~~-~..~:~ . .
(as on the tax roll or latest deed)
If applicant is a corporation. signature of duly authorized officer.
(Name and title of c~o~yporate officer) SE !S U LA~JFUL
Builder's License No. • ~ ~ • - lTOUT CETlFlCATE
Plumber's License No . .
y CF CC CY
Electrician's License No . .
_ Other Trade's L.irense No .
1. Location of land on which prgpgsed wor will be done. D .
lN~rrr zKlu~ SL!},~4_
House Number (~S/treet ~ Hamlet
County Tax Map No. 1000 Section ......./.lA•....... Block Lot....?
Subdivision Filed Map No. Lot .
(Name)
2. State existing use and occupancy of premises and intended use~a/n~)~dfoccup/ancy of proposed construction:
a. Existing use and occupancy sUr7'~G, L~~., ; •?~!~//Jv~ r...., .
,
, . ~ :a. ,e,
b. Intended use and occupancy • • • • • • • • • • • • • • • . .
3 Natur of work check which a ~ «
• e ( ~plicable): New Building Addition Alteration .
Repair Removal Demolition Other Work .
(Description)
4. Estimated Cost . ~.~0®,~:
, '
. Fee .
gl units Number o (to be paid on filing this application)
5. If dwelling, number of dwellin
~ f dwelling units on each floor .
Yf garage, number of cars .
6. If business, comm~Gy~, ,specify nature and extent of each type of use .
Height
7. Dimensions is~n~t c r i ont . ............Rear . , Depth
es
D ptrns~ons a ture ~t ns or additions: Front , p ~ j, , • , , , , , , , , , ,
~ Rear . .
Nu ber fStories
` 8. D ~a fsions fen ire new const •uctio • F nt . s34. Rear De th , .
er i Stu es
9. ;iize of lot:... Rear Depth .
10. Date of Purchase
1 I, lone " " " " " • • • • • Name of Former Owner .
or use district in which premises are situated •
12. Does proposed construction violate any zoning law, ordinance or regulation : .
13. WBl lot be regraded .......,,p ...Will excess fill be remove ~g.pre :tom.
14. Name of Owner of premises ~ J .Q ~ . ,~..~i~ • Address . ~~r~.~'1'~ion"No~? / ~67-v No
Name of Architect , ......'.".....Address w:.~,•~..~+PI(&~ns-No,•.-,-n~.,3:~:`:..... .
Name of Contractor : . .Address T. ~.A PI} ne No
~ii9 i~+1i'~~,:f-~sR..y:v41i~.N1fB . i; .
' i PLOT DIAGRAM <~.e~?~~#r'.i i ~ ,•+s ;:~3st4~tti., s . .
d7i9B~~ R~ '~4N'Y t' ,11+ R~E. •
Locate cleazly and distinctly all bpi~,idings, whether existing or proposed, and~indr t- ions from
property lines. Give street and block',number or d scri ti n a cor ' ~~r°"" i
p g to deed, a n~j.~~e tvhethex
interior or corner lot. q~,y~ ~ ~ ~l ~ ' ° ~~.,~y~,/
~2~~/"LG~°r!y,_ „~6'~ G~ d~[~ y~j~y
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• . ` , ~ , ` ~ ~ ` ' ~ G, rt„w dl C~tx.h.~ut•q ~i~rs s
STATE~OF NEW Y ,r~s ~ -7 F
COUNTY OF ..~..t'i ~L~~,~, ';S.S
(Name of individual si nl ~ ~ ~ ~ ' ' ' ' ' ' • • • • being duly sworn, deposes and says that he is the applicant
g ing contract)
above named.
He is the
(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 manne{ set forth in the application filed therewith.
Sworn tjo.~before me this i
.............day of~l...~~ 19 . .
Notary Public, , . ~(/.V C~a~; . , , , , , , , , , County
No. 6260 t1 JK. ' ' ,
MoiWpA t6
dN~MrYork .
hamtY~ ~ ~ .
CuNo~dln8 (Signature of applicant)
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