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Home My WebLink About17124-z FOBM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDlblG I~ERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) NE 01712~ Z .,.,~~~..~.~, ........ ;~...~ . ,o...~~~ ........ .~.~.,...,~.....~~...~. ..................... ............ : .................................. ;':;';'"0~ ........................................... ~ii'"'i'i .................... i ........ ~, ~,,,~,,,, ,~o,.~ o, .....~ .................................. ~.~.........~,~..../...,. ................................. County Tax Map No. I000 Section ....... :.~,,.~? .......... Block ............ ~ ......Lot No ........ ..~,~.. ,/,., ..... Building Inspector. Rev. 5/30/80 Approved· ~?~. ...... , 19~Permit No./(. ........ Disapproved a/c ..................................... ............................. · ' ~3~l{t;i~gg 'i~ ~pi~t o r) ....... APPLICATION FOR BUILDING PERMIT 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 Received ........... ,19... /o INSTRUCTIONS a. This application must be completely filled in by typewriter or in m,k~a~sulcxOj~te~,![{~ke~Btttl~Wmg/ff~pector. . . with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b Plot plan show~g location of lot and of build~gs on premises, r~[~6g{h$~t~tn~r~?~( public streets or areas, and giv~g a det~led description of layout of prope~y must be' ~[aw~tdi~m:~ iS6~g~ of this appli- c. The work covered by t~s application may not be commenced before ~s~ance of d. Upon approval of this application, the Building Inspector w~l issue~.~l¢~g~mit to the ap. pli~g~ Such pemit shall be kept on the premises available for inspection throughout the work.$ e. No bufld~g shall be occupied or used in whole or in part for any pur~~f~j~gf Occup~cy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Dep~tment for t~h~j~c~o~,~ ~ldig~P~it~suant to the Building. Zone Ordinance of the. Town of ..... Southold, Suffolk County Ne%~r~;. _~,, ~gt,~¢;a~li~?~;~rdh~ces. ... ..~ ~ ~ ...- ..... ,~ ~: . or Regulatmns, for the constmctmn of bmldmgs, add,boris or alterahons, o~_[~f r~o*~l dr~e~l~on, as hereto described. The applicant agrees to comply with all applicable laws, ordinances, bu~d~} co~.~n~ ~gffiat~ons, and to admit authorized inspecto~ on premises and ~ build~g for necessa~ inspe~'~. ........... (Signature of applicant, or name, if a corporation) . (Mailing address of app]iq~t) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder· ............. Name of owner of premises .... /~..~.....?....~. '.03(..~. · ....L~).' .~..lC ........................... (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.../.'~ .~./...P/./ .... ~ Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done .................................................. · o o o ................· ........................ · d.'. ............................. .- .... House Number Street Hamlet - County Tax Map No. 1000 Section ...... 0.7.0. ....... Block ..... .~. ........... Lot Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: occupancy .......... .t~...~t-A<...'.~....~ ......................... ~.. Existing use and b. Intended use and occupancy ........... ~ --~..~ 3. Nature of work (check which applicable): New Building ..... ' ..... Addition. ~ ........ Alteratiorl ...... ' ..... Repair .............. Removal .............. Demolition .......... ,... Other Work.. f7 "' I - (Description) 4. Estimated Cost .'Y7 Fee ~ .......... ' ........ · ~ (to belpaid on filing this application) 5. If dwelling, number of dwelling units ' " ..... ............. , .~ Number of dwelling units on each floor ........... If garage, ndmber of cars .................................... : ...... i ............................ 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ..................... 7; Dimensions of existing structures, if any: Front ............... Rear ...... ~ ....... Depth ............... Height ............... Number of Stories ........................................................ Dimensions of same structure with alterations or additions: Front ................ Rear .................. Depth Height Number o:' Stories Dimensions of entire new construction: Front ............... Rear ............. Depth ............... Height ............... Number of Stories .......................... Size of lot: Front ...................... Rear ...................... iDepth ............. ; ...., .... Date of Pgrchase .: ...................... Name. of Folmer Owner .! ............................ Zone or use district in which premises are situated ................ i . Does proposed construction ~olatept_o any zoning law, ordinance or reguiat;on':' i i' Will lot be regraded ....... : · :~c~ ..... . .......... Will excess fill be remove!d from premises: Yes (/qoJ Name of Architect .......................... Address ............... ~ ....Phone No ................ Name of Contractor ......................... Address I . Phone No ................ PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. inldicate all set-back dimensions from >roperty lines. Give street and block number or description according to deed, and show street names and indicate whether nterior or corner lot. 9. 10. 11. 12. i13 ~14 FEE:~By:~ NOTI.ev BEqLDING IDEPAI~ I. F~NDA~ . ~' FOe · INSu~OM 4. FINRL BE COM~L~E FO8 C.O. ALL ~ONS~RUCWON ~LL M~ THE ~EOUiS~E~ STATE coN~u~ i ~y CODES. N~ O~S~G~ OR CONS~U~ ,STATE OF NEW YORK, COUNTY OF ........ S.S ................................................. being duly sworn, deposes and says that (Name of individual signing contract) above named. he is the applicant He is the ............................................................. . ............................ (Contractor, agent, corporate officer, etc.)i 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 manner set forth in the application filed therewith. Sworn to before me this ...... : .....~: ............. day of ..... ~-. ......... 19 $otary?~li'c, ..~. ~:..D.~:...~...d~.. ...... County ::' ?i''~ H~EN ~ DE ~E ..,. ' ....... (Signature of applicant)