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Home My WebLink About16874-Z · 0~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Yo BUILDING PERMIT trillS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) No- 16874 Z Date .......... t ......................... Permission is hereby gr~'~d to: ~ /~ .C-~..~..~...)..~.~. ................................................... ~.~........~..:~..:......!/..?..~..~ .................. ............................ ................. ................................... at premises located at ~...~..~.~. ......... .~..~'.. ........... ,/. ............................................................................ County Tax Map I~o. 1000 Section ....... ..~..I...~.. ...... Block ....... .~....'~. ..... Lot No....,,,~...~ .............. pursuant to application dated ....... .~.1~....~......'~...~.. .........., 19.].~).., and approved by the Building Inspector. Rev. 6/30/80 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined ....... , 19 .~.~. ~... ! .... 19 .~ .°°.. Permit No./..~.~. ?..c}..~. Approved kJ Disapproved a/c ............................. .......~ ................................ ...... (Building Inspector) APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH ...... 3 SETS OF PLANS ....... SURVEY .......... CHECK .......... SEPTIC FORM ............. : NOTIFY CALL ................ MAIL TO: I~LDG. DEPT. , TOWN OF S,OUTHOLD Date .................. ,19... INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Bffilding 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~.mox;hl or demolition)as herein described. The applicant agrees to comply with all applicable laws, ordinances, building ~ode, housin~ code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. (Signature of applicant, or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) ALL CONTRACTOR'S I~UST BE SUFFOLK COUNTY LICENSED Builder's License No ..... .~_/~ ............ Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... Location of land on which proposed work will be done~ ................................................. House Number Street Hamlet County Tax Map No. 1000 Section .. J..~t ........... Block . .3 ............. Lot..t ............. Subdivision ..................................... Filed Map No ............... Lot ............... (Name) 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 ....... ~'~ ~-~ ' 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration .......... Repair .............. Removal .... · .......... Demolition .............. Other Work ............... ~ - (Descrip~tion) 4. Estimated Cost ........ ~.. ................. Fee ...................................... ' (to be paid on filing this applicatio~O 5. If dwelling, number of dwelling units ............... Number of dwelling units on each floor ................ If garage, number of cars ........................................................................ 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 Numbefof Stories Dimensions of same structure with alterations or additions: Front ................. Rear .................. Depth ...................... Height ...................... Number of Stories ...................... 8. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height ............... Number of Stories ........................................................ 9. Size of lot: Front ...................... Rear ...................... Depth ...................... 10. Date of Purchase ............................. Name of Former Owner ............................. 1 1. Zone or use district in which premises are situated ..................................................... 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 .................... Address ................... Phone No ................ Name of Architect ........................... Address ................... Phone No ................ Name of Contractor .......................... Address .... : .............. Phone No ................ 15. Is this property located within 300 feet of a tidal wetland? *Yes ..... No ..... · If yes, Southold Town Trustees Permit maybe required. 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. COUNTY OF .,,~f.~..' .~ff~...L,.~_~ ~'~/~. ~ ~ ~ . ~L~ being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. He is the ......................................................................................... (Contractor, agent, corporate officer, etc.) of said owner or owne~, ~d is duly authored to perfom or have perfo~ed the said work and to m~e ~d file t~s application; that all statements contained ~ this application are true to the best of his knowledge and belief; and that the work will be perfo~ed in the m~ner set forth in the application filed therewith. Sworn to before me this ~ ; ............. .............. ~ ~ubl~ S~t~ ~ N~ V~ . ~ ......... //~. T ............................. ~o. ~79505 [ / // (Si nature of applicant) Qualified in Suffolk, CounW 0.~ - ~ g