HomeMy WebLinkAbout16983-z FO~M' NO. o
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
NO 1678.~ Z
County Tax Map No. 1000 Section ......... .~.., .~.. ...... Block .......... ~;~... ..... Lot No.....~,...~..~...~,..
pursuant to application dated ........ . .~..~...~..~J ................................. , 19~ and approv~ by the
Building Inspector.
Rev. 8/30/80
Examined .................
Approved.. '.~../-3 .......... 19 ff.O~. Permit No/.~?.~.~.. '.~.
Disapproved a/c .....................................
/ ' J (~fildin~ Insl~ector)
APPLICATION FOR BUILDING PERMIT
BOARD OF HEALTH ......
3 SETS OF PLANS .......
FORM NO. I SURVEY ..........
TOWN OF SOUTHOLD CHECK ..........
BUILDING DEPARTMENT SEPTIC FORM ............. :
TOWN HALL
NOTIFY
$OUTHOLD, N.Y. 11971
TEL.: 765-1803 CALL ................
MAIL TO:
BLDG. DEFT.
TOWN OF SOUTHOLD
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 inspections.
..........
(Signature, o~ applicant, or LanCe, if a corporation)
P.. f3o . JJ.ta 7.
: :, (Mailing address of applicant)
State whether aplSiicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
't...%.0 ..............................................................
Name of owner of,premises... ~.~4~...'~..'T}3OA,q~x-~).. ..........~.~ ~ .~..J~. .~':~ t'~ .........................
· .' ...... ~... ' (as on the tax roll 6'r Pfitest deed)
If apphcaniI is a cotporahon, mg~lature of duly authorized officer.
"' ' ~'. ', '-','C;~,' ": ' · * ...... 5 '~' ~ ...................
' · u~arne and title o[co¢orate officer)
AL~ CO~TRACT~OR'S BU~T BE SUFFOLK COUNTY
, lumher s J ease No .........................
Electncmn s L~cense No .......................
Other Trade's License No. ~ ~.~o
LICENSED
Location of land on which proposed work will be done ..................................................
House Number Street Hamlet
County Tax Map No. 1000 Section ..... .~.(.~ ....... 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 .1~.. ~ *> .¢,~ ~ e~e,~ . l:~r~.., gcx. c .~.,1,~ .~ ~'. J ..........................
b. Intended use and occupancy .~'. · J .~. ,5.,~. j.~..~..~,~, ca. ~-~ex,~.. ~,~.,~ ih, pr~e':r'6,x~ ] i a o~.. .......
3. Nature of work (check which alpplicable): New Building ..... ' ..... Addition .......... Altera~kn ..........
Repair .............. Removal .............. Demolition .............. Other Work ./f~, r~e-,~.~ ....
i ~ (Description)
' ' (to be paid on filing this application)
5. If dwelling, number of dwellin~ units ............... Number of dwelling units on each floor... ............
If garage number of cars
6. If business, commercial or m~xed 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 samq structure with alterations or additions: Front Rear
Depth .... ' 'i' · · Height ...................... Number of Stories ......................
-'-8. Dimensions of entire new construction: Front .......... ~ ..... Rear ............... Depth ...............
Height ............... Number of Stories ........................................................
9. Sizeoflot: Front .......... . ............ Rear ...................... Depth ......................
10. Date of Purchase .......... i ................... Name of Former Owner .............................
1 1. Zone or use dmtnct ~n which premmes are mtuated .....................................................
12. Does proposed construction violate any zoning law, ordinance or regulation:
13. Will lot be regraded ........ ! .................... Will excess fill be removed, from premises: Yes No
14. Name of Owner of premises ..:~.~r~ . .Addres~.u:~r.~e.[~.~o~T~J~PhoneNo .......... ., .....
Name of Architect ......... i ............... Address ....... Phone No .....
15. Is this property locatL~f~ithin 30~feet of a tidal wetland? Yes ..... No .x/...
· If yes, Southold Town TrCstees Permit may be required.
~. i PLOT DIAGRAM
Locate cleariy and distinctly al'l buildings, whether existing or proposed, and. indicate all set-back dimensions from
property lines. Give street and bloc~ number or description according to deed, and show street names and indicate whether
interior or corner lot.
APPROVED AS NOTED
NOTI[:Y BOILOING DEPAR'I~ENT AT
7~b~ 1802 9 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS:
I. FOUNDATION TW~ REQUIRED
FOR POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING
3. INSULATION
4. FINAL CONSTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET
THE REQUIREMENT8 OF THE N.Y.
STATE OF NEW YORK, STATE CONSTRUCTION & ENERGY
COUNTY OF .... ............. = S.S CODES. HOt 8~8~18111~ FOR
· dul sworn--'-" -- -"' "~E~o~sU~OR'CONS'L'UCll¥~'FRROn'S
(~ame of individual signing contract)
above named· I
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to m~e 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 1
........ · ~ {q. ............ day oi .... ~ ......... 19.
tary Public, ................ [~~4....
Not,~ Publlo, State o[ N~w Yo~f~b,
- No. 48226_63, Suffolk Cou_nty
mrm Expires Deoember 3~, 19
(Signature of applicant)