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HomeMy WebLinkAbout11638-Z FORM NO. 2 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) 2 11638 Z Date .... ..................................... 119. w19 Permission is hereby granted to: .........zlvV ............... kOO4 ;7.*....................... to ......... .............................................................................. at premises located at ....................................................................................................................................... a/ Z TAL,-* ...................(:�h ............... ................................................................................................................................................................. ................................................................................................................................................................ County Tax Map No. 1000 'Section .....G.I.r.... Block ...0/.......... Lot No. ..-OK0. ........ pursuant to application doted i and approved by the ...........�.O:.................. Building Inspector. Fee ........... ......................... ...................................................... Building Inspector Ce L L4-J r(f Rev. 6/30/80 FORM NO. 1 TO'.JN G; S0UT.;OLD BUILDING DEPARTNiENT TOWN HALL SOUTHOLD, N.Y. 11971 y TEL.: 765-1302 ' Examined �`? . . . . . ., 19 L Application No �ff. . . . . . Approved/ :?• . a. . ., 1q�l>. . Permit No. . . . . . . . . . /1 Disapprovcda/c . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . ... (Building Inspector) . APPLICATION FOR BUILDING PERMIT Date 4r,1.1l3. . . . . . . .. .(T2 INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Build 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 stre or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this apj cation. c. The work covered by this application may not be commenced before issuance. of Building Pern?.it. d. Upon apprc-:al of this application, the Building Inspector will issue a Building Permit to the applicant. Such p!nr. 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 Occupar shall have been granted by the Building Inspector. APPLICATION IS HEREBY IMADE to the Building Department for the issuance of a Building Permit pursuant to Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable-Laws, Ordinances Regulations, for the construction of buildings, additions or alterations, or for removal or demolition., as herein describ The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and admit authorized inspectors on premises and in buildings for necessary inspections. , . . . . . . . . . . (Signature of applicant, or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, are!iitect, engineer, general contractor, electrician, plumber or buile c�Zv'v E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nzune of owner of premises . . . . . N-E. . . . . l!V. ��. .-1 �. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (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. .! �Q-1i . Y�. . :. Plumber's License N:. . . . . . . . . . . . . . . . . . . . . . . . . Electrician's License No.. . . . . . ... . . . . . . Other Trade's License No. . . . . . . . . . . . . . . . . . . . . . 1. Location of land on which proposed work will be done. . . . . . . . . . . . .. . . . . . . . , . . . . . . . . . . . . . . .X&v.�. S . . . . . . . . . . . . . . . . . 8., . &-7u r . . . . . . . . . . . . . . . . . . . House Number Street Hamlet County Tax Map No. 1000 Section . . .1. . . . . . . . . . . . Block .l. . . . . . . . . . . . . Lot . . . . . . . . . . . Subdivision . . ... . . . . . . . . . . . . . . . . . . . . . . . Filed Map No. . Lot . . . . . . . . . . . . . (Name) 2. State existing use and occupancy of premises and intended use aad occupancy of proposed construction: a. Existing use and occupancy . . . . . . . . . . . . . . . . .'.L`(�t'� ; . . . . . . . . . . . . b. Intended use and occupancy . :: G ". . . . . . .`t./, j C , , . GIB . . . . . . . . ,��' 3. Nature of wor l; (check which applicable): 1INTCW Building . . . . . . . . . . Addition . . . . . . . . . . Alteration . . . . . . . . Repair . . . . . . . . . . . . . . Removal . . . . . , . . . . . . . . D molition . . . . . . . . . . . . . . Other Work . . . . . . . . . . . . . (Description) Estimated Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fee . . . . . S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (to be paid on filing this application) 5. If dwelling, number of dwelling tanits . . . . . . . . . . . . . . . Number of dwelling units on each floor . . . . . . . . . . . . . • If garage, number of cars . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G. If business, commercial or mixed occupancy, specify rattire and extent of each type of use . .. . . . . . . . . . . . . . . . . . I. Dimensions of existing strictures, if any: Front . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . Depth . . . . . . . . . . . . .. Height . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . . . . . . . . . :. . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimensions of same structure with alterations or additions: Front . . . . . . . . . . . . . . . ... Rear . . . . . . .. . . . . . . . . . Depth . . . . . . . . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . . . . . . . S. 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 . . . . . . . . . . 11. Zone or use district in which premises are situated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . • • • • . • . • . • • . 12. Does prbposcd;construction violate any zoning law, ordinance or regulation: • . •. • • . 13. Will lot be regraded . . . . . . . . . . . . . . . . . . . . . . . . . . . . Will excess fill be removed from premises: Yes N 14. Narne of O% ncr of premises . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . Name of Archicect . . . . . . . . . . . . . . . . . . ... . . . . . . .Address . . . . . . . . . . . . . . . . . . . Phone No. .. . . . . . . . Name of Contractor . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and,indicate all set-back dim-znsions fro: property lines.:Give street and block number or description according to deed, and show street names and indicate wheth� 'interior or corner lot.- STATE OF NEWCOUNTY OF S.S • • • • • • • • • • • • • . . . . being duly sworn, deposes and says that he is the applic:m (Name of individual* nditiidual ignuig contract) abov•-� named. He is the . . . . . . . . r am W .. . . . . . . . . . . . . (Contractor, agent, corporate officer, etc.) Of said owner or ow:iers, and is duly authorized to perform or have performed the said work and to make and file thi r-j)plication; that all statements contained in. this application are true to'tlie best of his knowledge and belief; and that th. work will be performed in the manner set forth in the application filed t:,.ercwitli. Sworn to before me this . . . . . . . . . . . /° . . . . . . .dav of. . . . . . . . . 19 Notary Publi • , \ _ �--�` �� • • • . . . County JUDITH T. TERRY • • �• • Notary Public, State of New York...' 'G t :Np 52 034963 Suffglk GouhtY . . . . . . . . . . . .: . . ... . :. ;(;o rl�itslon) xpires March, (Signature of applicant SUFFOLK CO. HEALTH DEPT. APPROVAL H. S. NO. -VF >e, /r < \Aj D L 0, STATEMENT OF INTENT THE WATER SUPPLY AND SEWAGE DISPOSAL If, SYSTEMS FOR THIS RESIDENCE WILL OF SOU THOL� N CONFORM- TO THE STANDARDS OF THE SUFFOLK CO. DEPT. OF HEALTH SERVICES. (S) APPLICANT SUFFOLK COUNTY DEPT. OF HEALTH 7 SERVICES — FOR APPROVAL OF CONSTRUCTION ONLY DATE: LIS n! Lu 13 ir H. S. REF. NO.: APPROVED: AL E 40" 67 SUFFOLK CO. TAX MAP DESIGNATION: 11 tl o"N N'l DIST. SECT. ' 'BLOCK PCL- 10 OWNERS ADDRESS: 05 -A 0 DEED: L. 446� 0 - P-14-7 621:-F}. TEST HOLE STAMP ALTERATION OR ADDITION SU,;VEY IS A VIOLATION OF c"l ON!7209 OF THE NEW YORK STATE 0- DON LAW. 1 CONES OF Ti-,'!S SL;PV;Y,'AAP NOT UARING 40 THE LA,'.:I) -Z- tt,: ro EMDOSSED SEAL Sl,ALL NOIT D�l A Yo BE A VAUD 70UE COPY. GUARANTEES :,N,-;!CA-,;:D lik-KON SHALL RUN ONLY TO THL FC", ME SUayE' 11v 0 0 A PREPAUD, A'U-Ciq )7 A. ORTLE C01MIANY, GOVE,%IV14i6TAL AG-L]"iCy A' > usTED iO THE AMCMUS GF THE LENDl,,4 INS)I% J—UM01%.GUARANTEES A,'E K-OT TJZANMM�l C) �_Q�kDDITIOHA_ JINST11-UnOM OR SUBS'pop-11 40 SEAL GUA;RANTE-ED TO THE TITLE GUAqANTCE,_.CQ RODERICK VAN TUYL—, A�AEWDETI "JuLy /0. SEPT LICENSED LAND SURVEYORS GREENPORT NEW YORK