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Home My WebLink About17077-z 14'019,M NO. ! TOWN OF SOUTHOLD BUILDING DEPARTMEN4 TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON TtiE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 017077 Z Date I9~`6. Permission is hereby granted to: ct premises located at ....~~~A.......~ ......~.l~.1.Ge(° County Tox Map No. 1000 Section Block Lot No.......... ~ pursuant to application doted 19.D...~ and approved by the Building Inspector. Fee $...a~.:l.,r.~...... Buildln nspector Rev. 6/30/80 D On/7 BOARD OF HEALTH ~~~~ll 3 SETS OF PLANS FORMN0.1 SURVEY ~ TOWN OF SOUTHOLD CHECK . BUILDING DEPARTMENT SEPTIC FORM BLDG. DEFT, c TOWN HALL 7OWNUFSOUIHOLD .,OUTHOLD,N.Y.11971 NOTIFY TEL.: 765-1802 CALL Z , . , Examined ..~/..f!......., 19,~.~ MAIL T0: approved 19 `if. Permit No.. I ~ ~u n ~C~7~o~cR3~ Disapproved a/c ~epc`c-~-f' ~ ^ CIg35~0 ) ildir~spector) APPLICATION FOR BUILDING PERMIT Date . ~ ~ 15~~ INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 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 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 all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary ins ions. J • gnature of ap ~ licant, or name, t a corporauon) • (Mailing address o applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ~C- .t l ~ V~t-t :''?~l V`e (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 License No . . Plumber's License No . . Electrician's License No . . Other Trade's License No . . 1. Location of land on which proposed work will be done . ./.a.5'o........~.~r:le~.~e~..~Q`vl.~.. .G.~-ssac~, II ~..~'.l~ House Number Street J Ikamlet ~ ~ County Tax Map No. 1000 Section . l . ~ Block ~ - Lot ^ Subdivision Filed Map No, Lot . (Name) 2. State existing use and occupanc of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~~S! n L r" b. Intended use and occupancy .~.`.~~'•'l~• ^ • .;~Y-,` ' ~'o. JJJ . T 4`~c-.... ~ . ( 3 Ret air of work check whine applicable): New Building Addition i Alteration p moval Demolition , Ot Qrlc~ / S 3 r~al~scription) 4. Estimated Cost l! ~ Fee . (to be paid on tiling this application) 5 If daza,len number of cadwelling units Number of dwelling units on each floor . 6. If business, commercial ormi••••.•••••.•.••.•••••~•••~•••~•••~••~~~~•••~••~• d zed occupancy, specify nature and extent of each type of use , , , , , , , , , , , , • 7. Dimensions of existing structures, if any: Front . Rear . , Depth . Height . . Number of Stories . P with alterations or additions: Front Rear , Denth stuns o same s ructure Height . .......Number of Stories . Hei ht Struction: Front Rear ...............Depth 8. Di ~ensrons of entire new c Number of Stories . . 9. Size of lot; Front . . Rear Depth . 10. Date of Purchase ,,,,.,,,,',••,••,,,,••.•,,,,,,NameofFormerOwner 1 1, Zone or use district in which premises are situated . • p P g olate any zoning law, ordinance or regulation : . 14. Nameoof Ow erd d t emrses vl • • 1~'rll excess till be removed from premises: Yes No P • • • • • • • • , .Address .Phone No. . Name of Architect ' .Address .Phone No. . Name of Contractor ' .Address . .Phone No. ,lam IS.Is this property located within 100 feet of a tidal wetland? *YES. ? .NO.. *If yes, Southold Town Trustees Permit may be required. - PLOT DIAGRAM , Locate cleazly and distinctly X11 buildings, whether existing or proposed, and. indicate all set-back dimensions from. property lines. Give street and bloc~C number or description according to deed, and show street names and indicate whethel interior or corner lot. i G~z~- ice: ~~®?h - , \ • A ~ ~ STATE OF NE~V~, ~ S.S '"~-~a COUNTY OF . w.. , ? , ~I ~ A r k k eL , ' ' ' " ' ' ' ' ' ~ • • • ~t ~ ~ being duly sworn, deposes and says that a is the applicant (Name of individual si ing contract) above named. SHeisthe ....................f?, W.N~.l~.................................................... (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-)Ii,~ knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. 'Y""` Sworn to before me this . ~ .....day of ......~!,'~.l-A- 19~~. Notary Public . ~k?-C p.~,~ County EIJ7A6 ANN NEVILLE Notery PublletikatsofNewYOrk i (Signature of applicant) No. 6Z~812 , 3uHolk Co Term Expires Ootobar 51,19}~YS.