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HomeMy WebLinkAbout17092-z FO$M NO. A 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) ~ ~ 1.7 ~ 9 2 ~ Date .....(~/.,r..(~ 19....... Permission is hereby ranted to: . (~/J ~~y~ ` //~S to ...~~SW~""" /"""~i...../.~~.~j~r~.~....Cd~r.:...... ct premises located at ~..~4-c~71v~C'i ~F~./..::.~.... ""f County Tax Map No. 1000 Section .Block .............~F Lot No...............~..... pursuant to application dated 19.r~~ and approved by the Building Inspector. Fee~.~~. ~ ..........1........ wilding ecto Rev. 6/30/80 W b ~ . l _Y - ~ z ~ - a ~ ~ _ ~ 1 1~~%~d ~'~M~~~~ = I~• l~w!>~M~ BOARD OF HEALTH D lJ 3 SETS OF PLANS ::::::0./t^a.: FORM N0. 1 SURVEY ~`1 ~ ~ 4 TOWN OFSOUTHOLD CHECK BUILDING DEPARTMENT SEPTIC FORM BLDG. DEt''T. TOWN HALL TOWN UP SOUTHOLD SOUTHOLD, N.Y. 11971 NOTIFY / / TEL: 765-1802 CALL 7~O:5.~.~'. y MAIL T0: Examined /.D... • • • . • 19~r~V Approved .~~/O....... , 194. Permit No. ~~~.©,r~.~~ Disapproved a/c . ~ . .~.L . c==r~~s~il t e Inspector) APPLICATION FOR BUILDING PERMIT ~p ~j Date ../'/.~~....~!~A 19 p..~ INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 srts 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 p"t'emises or'public streets of areas, and giving a detailed description of layout of property must be drawn oh 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 BGildino P`eTiitit to the applicant. Such permit shall be kept on the premises available for inspection throughout the work. 1 t`~`"'a~t~ e. No building shall be occupied or used in whole or in part for any purpose t~%ft"afe~ieA"t~rittY ia'Uei~ificate o~ Occupancy shall have been granted by the Building Inspector. ` '"4 "`''"~11 ,~<at~^t:c: APPLICATION IS HEREBY MADE to the Building Department for theaissuanCe ofca'Bwsldiltg~Ret'rri`it pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New Yor-k~:an~o~th~a~ptid~b'1e~a~*IS, Ordinances or Regulations, for the construction of buildings, additions or alterations, or f©r i~emc~val or demolition, as~tterein described. The applicant agrees to comply with all applicable laws, ordinances, buildi~g~cLOde;-ho~srng c~c~e~aaldxregul~ations, and to admit authorized inspectors on premises and in building for necessary inspections. s~ trk,a t•r .rg ~,a~;,,~t~ y~~..~.~............ (Signature of applicant, or name, if a corporarion) ~J e ~ ~ (Mailing address of applicant) JJ~ f'~ State whether applicant i owne ,lessee, agent, azchitect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises 6.K.~.'~~ . (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. !,'~;«?n-`h? ~ House Number Street Hamlet County Tax Map No. f 000 Section r Block Lot . Subdivision Filed Map No. Lot............... (Name) 2. 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 I I i 3. Nature of work (check which applicable): New Building Alteration}.- . Repair Removal , Demolition ,Addition Other Work . ~ ~/U ~ d (Description) . . 4. Estimated Cost . t .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 ' . . business commercial or mixed occu anc s ec>f nature and extent of each, 7. Dimensions of exnstin structures rf an Fronp ...Y Rear , . (type of use . . Hen ht g Number of Stones Depth............... g Dimensions of same structure with alterations or additions: Front Rear , . , , , , , , , , , , , , , , De th . • Hei t Number',of Stories . 8. Di ~ensions of entire new cNumberiof•Stories . . . . . . Rear Hepht ~ Depth 9. Size of lot: Front Rear , . , Depth 10. Date of Purchase . .....Name of Former Owner . p 11. Zone or use district in which remises are situated . . , , , , , , , , , , , , , , , , , , 12. Does proposed construction violate any zoning law, ordinance or regulation; . 13. Will lot be re rade P ' ' ; : ; Address , , , , . , ved from premises: .Yes No 14. Name of Owner of remises , Fill excess fill be remo phone No . P P ...y .....Address Phone No............... . Name of Co tractor ,I~, , , , , ,Phone No............ . . • • • • • • Address 15.Is this ro art located within 100 feet of a tidal wetland? *YES...,NO.~ *If yes, Southold Town Trustees Permit may be require~,d. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and.',indicate all 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. AV_yC~~ AE NdfED DATE: ~ 6.R N ~ O NOT U G D~E~f34 AT 786-1802 AM TO 4 PM FOR THE' FOLLOWINV` INSPECTIONS: 1. FOUNDATION TVNO REOIlM1ED FOR POURED CONCRETE ~ 2. ROUGH ~ FRAMING 8 PLUMBINQ 3. INSULATION A. FINAL ~ CONSTRUCTION MUST BE COMf!LETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N.Y. STATE COf~STRUCTION & ENERGY CODES. NQT RESPONSIBLE FOR DESIGN OR'CONSTRUCTION ERRORS STATE OF NEB ~R S.S l1 ~ v Name of ind~i~~signing contract) ~ • ' ' ' ' • being duly sworn, del5oses and says that he ns the applicant above named. He is the ~A(.l1!Y~.Qe?.......... . (Contractor, agent, corporate officer, etc of said owner or owners, and is duly authorized to perform or have performed thesaid work and to make and file this application; that ali 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 ..c)ay of 19~ Notary Public, OLAIRE ~ aLEVII , , , , County Notary Pubko,.$tete o1 New Yolk Na4879806 (Signature of applicant) QualHled in Suffolk County Commissbn Explree December 8.18.....