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Home My WebLink About16959-z FORM NO. ~1 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~16}5} Z Permission is hereby granted to: ~ I ~ , ...~.~..~.....e.~.~...~ ......... ...~..~.~.~. .................................................... ...~....~¢~.~..~.~..:..e..i.~..~.~ ..... ........................................................................... , ................. County Tox Map No. 1000U~/Section ....... ~..(~) ........ Bilk ....... (~.~ ..... Lot No....J...~.. ............. pursuant to application dated ...... ~......)...c[ .................... , 19.~..~., and approved by the Building Inspector. Rev. 6/30/80 FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 Disapproved a/c ............................... · (Building Inspector) APPLICATION FOR BUILDING PERMIT Received ........... ,19... Date .......... 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 pre'raises or public streets or areas, and giving a detailed descript!on of layout of property must be drawn on the diagram which is part of this appli- cation. c. Tile 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 ttEREBY 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 o"'~" ..... ~ .... ~ . Tile a-~licant a-rees to cum I ..... %, ... .-. ....... ,~,,~, .uti.mr remov.~.jai or ach}out,oX% as herein described. vt, ~ p y wan au appncame ~aws, ordinances, building cod~, hoeing c~ode, aj~d regulations, and to admit authorized inspectors on premises and in building for necessary inspections. \ y~ ~ ,/ , ..... · .... (Sianature of apgl, icant, 0,r name, if a ~orporation) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. - . APPROVED AS NOTED '(as on the tax roll or lates=~T~.e'~~ '' ~ ~, L- If applicant is a corporation, signature of dtdy authorized officer. N~IFY 8U I~ING O~PARTMENT ~'~ 768-1802 g AM TO 4. PM FOR THE .............................................. FOLLOWING INSPECTIONS· (Name and title of corporate officer) 1. FOUNDATION TWO REQUIRED ~,~.~) ~.. FOR POURED CONCRETE Builder's License No ................... ~.. ROUEN - I~IAMING & PLUMBING Phnnber's License No ......................... 1{. INSUlaWrIoM ~. FINAL CONSTRUCTION MUST lie COMPLETE FOR C,O. ~lectriciau's License No ....................... AU. CONSTRUCTION SHALL MEET THE ,REQUIREMENTS OF THE Other Trade's License No .................. ' ....., 81'A31~ ~ONSTRU~rION & ENERGY CODE8. MOT RESPONSIBLE FOR 1. Location of land on which proposed work will be done ................... O~$IG{N.O8 .C~,N~TR.I).C.TI.O.N..E.B.R.O.R.S... Ilouse Nmnb~r .............. Street ' ' ' ~ .................... · Hamlet County Tax Map No. 1000 Section ...... ~. ...... Block. ~ . Lot.. ~..~.. .......... Subdivision ............... ' Filed Map No. (Nmne) .............. Lot ............... 2. State existing use and occupancy of premises and intended use and occupancy of proposed coustructinn: a Existing use and occupancy .J~.. ~.-~. [ ~.~.b.~ "3 Natnre of work (check which applicable): New Build; Addition'.. ................. Alteration ......... Repair .............. Removal .............. Demolition ~.. ~.~.~ ~ .............. Othe~'S~ork .... '~ ~"/fia~-' ~ ?. ..G'.t..O. ~ ~ (Description) 4. Estimated Cost ......... ? ......................... Fee ....... .~. (to bo paid on filing this application) 5 If dwelling number " ' Nmnber of dwelling units on each floor · , of dwelhpg umts ............... If garage, number of cars : , 6. If bt smess, omm. e?ml or m~Xed occupancy, specify nature and extent of each type of use ............... 7. Dimensions ofexmtmg stmc, t0res, if any: Front ...... ~ ..... Rear ........ " -, ' ~ ' l-' ,. _ __ . , · .... l. Jeptu rtelgtt ............... i'4BmDer or stones . , Dm~enmons of same stmcmrelw~th alterations or addmons: Front ]~,,o~ ' ' ' Depth .................. Height ............... Number ~e 8. Dimensions of entire now constmctmn Front. . oe .... ' ....... ~ . · .... ~x m ............... ,12eptn .............. .eight ............... NUmber of Stones ..... ; ............................. 9. Sizeoflot Front.,"... .' : : . ~ .... ,- ~ ~. '.. ' .............. 10. D~te ,~cp,~,.h~ i ............... :; .... : ............ ~epm .................. '... ....................... j .................... mame et' Former Owner ....................... 11. Zone or use district in which premises are situated ' ' ' ' ' 12. Does proposed construction wolate any zomng law, ordinance or regulation 13. Will lot be regraded .. .; . w ...... -~. , ' ' '2 '~ ......................... 14. Name of Owner ofpremisesJ~.0i0./~ .09~41?p..q~ ~.,., .... ^~,, ~,otv~; ~;~°~voe ~[n~gt[enuses.,~t ~ Y~ ~,; _,,Nc . · ...... ~,uum~,~ ~-t,..~..~O~"~O~,~-P. Phone No.-/.Lo,b,.''. .o.,/.0~.... Name of Architect Address Name of Contractor ........ [ ..................................... Phone No .... ., ........... ........................ Address ................. Phone No 15 Is this property located withlnl;06 feet of a tidal wetland? '~ Y;a ~'o~.~ · If yes, Southold Town T~ustees Permitp~3~ be required. ...: DIAGRAM Locate clearly and distinctly all b ' ' ' property lines· Give street and block uddmgs, whether existing or proposed, and, indicate all set-back dimensions from interior or corner lot. number or description according to deed, and show street names and indicate whethel STATE OF NEW YORK, i~lflr&tu~t~oI ~ COUNTY OF..,~..~.,~ ,..;~o:s..: .J~t~.~ ........... %' %~.. -,., ~,>~..~ ............. being duly sworn, deposes and says that he is the applicant ...... (Contractor agent corporate officer otc) ......................... of said owner or ownem, m~d i~ duly authorized to perform or have perfo~ed the said work and to make and file tiffs applicafion; 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 tl~e manner[set forth in the application filed therewith, Sworn to before me this ............. ( ......... ........ Nota~ Pnblic, · · ~ .............. Co ~ ~USU[ ~ 0t ~ Y~ ............... ~. $70~78, S~lk C~n~p~ / (Signature of applicant)