HomeMy WebLinkAbout30809-ZFORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Hall
Sou~hold, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES
COMPLETION OF THE WORK AUTHORIZED)
NgTIL FULL
PERMIT NO. 30809 Z
Date NOVEMBER 30, 2004
Perlnission ,s hereby granted
ROBERT R LAWRENCE
465 EASTWOOD DRIVE
CUTCHOGUE,NY 11935
for :
DEMOLITION OF ~/q EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR
at premises located at 800 WEST CREEK AVE CUTCHOGUE
County Tax Map No. 473889 Section 103 Block 0013 Lot No. 006
pursuant to application dated NOVEMBER 29, 2004 and approved by the
Building Inspector to expire on }~Y 30, 2006.
Fee $ 238.00
Authorized Signature
ORIGINAL
Rev. 5/8/02
LII
P!.~ be a~ivtmed ti}at LIPA ~'~ r~nl~o'~{l ail of itl olec~fl¢~l i~iiiii~ ~om :?,~ above
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
~nx~v. northfork.net/Southold/
Examined l//) f ·
20
Approved I I/~0'-) . 20 O q'
Disappro,. ed ac
Expiration ~, [ ~ . 20 ~C
2OO
PERMIT NO. ~ 52~ '~ ,
BUILDING PERMIT APPLICATION CHECKLIST
Do you have or need the tbllowing, before applying?
Board of Health
4 sets of Building Plans
Planning Board approval
Survey
Check
Septic Form
N.Y.S.D.E.C.
Trustees
Contact:
Mail to:
Phone:
Building Inspector
APPLICATION FOR BUILDING PERMIT
Date }Qeq ~2~ ,20U-(
INSTRUCTIONS
a. This applicatiou MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4
sots 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 adjoiuing prenfises or public streets or
areas, and waterways.
c. The work cox ered by this application may not be conmxenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a permit
~hall 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 what so ever until the Building Inspector
issues a Certificate of Occupancy.
f. EveD' building permit shall expire if the work authorized has not colnmenced within 12 months after the date of
issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the
property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an
addition six months. Thereafter, a new pemtit shall be required.
APPLICATION IS HEREBY MADE to the Building Department for the issuance ora Building Pemfit 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, ordinauces, building code, housing code, and regulations, and to admit
authorized inspectors ou premises and in buildiug for necessaw inspectious.
(Signature amc, if a corporation)
(Mailing address of applicant) ~
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Name of owner of premises l~',._m,~--, ~ ¢-&'M~:':'~ ~""'¢¢~-
(As on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer
(Name and title of corporate officer)
Builders License No.
Plumbers License No.
Electricians License No.
Other Trade's License No.
Location of land on which proposed work will be done:
House Number Street
Hamlet
Count.,,' Tax ~vlap No. 1000 Section
Subdivision ~L~'?> ~
(Name)
Block
Filed Map N~,,v,,<~-;~ ,..'..; ii~::-',Lo~'ql .....
~,~oO~.,~ c,~.g-.. ,,,~ ~...I
~ ~ ~u~ ~q~ m~l
2. State existing use and occupancy of premises and intended use 9nd occupancy of proposed construction:
a. Existing use and occupancy _T,'-~,~ e%~,,.~.~ ,~,~
b. Intended use and occupancy
3. Nature of work (check which applicable): New Building_ . Addition Altcratitm
Repair Removal Demolition v/7 Other Work
4. Estimated Cost Fee
5. If dwelling, number of dwelling units
ff garage, number of cars
6. If business, commercial or mixed occupancy, specif3' nature atld 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 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
11. Zone or use district in which premises are situated
12. Does proposed construction violate any zoning law, ordinance or regulation': YES NO
13. Will lot be re-graded? YES NO ~-Wgill excess fill be removed from premises? YES NO _
14. Names of Owner of premises
Name of Architect
Name of Contractor
I Descfipti{m)
(To be paid on filing this application}
Nutnber of dwelling units on each floor
Address Phone No.
Address Phone No
Address Phone No.
15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES O- NO _ * IF YES, SOUTHOLD TOVCN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED
b. Is this property within 300 feet ora tidal wetland? * YES ~ NO__
* IF YES, D.E.C. PERMITS MAY BE REQUIRED.
16. Provide sum'ey, to scale, with accurate tbundation plan and distances to property lines.
17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey.
STATE OF NEW YORK)
SS:
COUNTY OF
~:~,~r,N~ being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named.
rS)He is the
(Contractor, Agent, Corporate Officer. etc.)
of said owner or owners, and is dui3' authorized to peffm'm or have pertbnned the said work and to make and tile this application;
dmt all statements contained in this application are tree to the best of his know[edge and belief: and that the work will be
pertbrmed in the manner set forth in the application filed therewith.
Sworn to before me tiffs
:L~, ~ I'~ day of , ]'C,~'~, , 20 c'c/'
(/fl N0ao' Public
NO. 0.1wl,t~Ba24e, Suffolk
S i ~ r ~r~6"f A~'~lic ant