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Home My WebLink About15716-Z FORM NO. . TOWN OF sOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTH OLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 15716 z Date .d-.~.....;;)..X........., 19."1J Pennlssion is herebygran%-~....d~.k:'?L.......... ................................................................................ . ..~~~.....~.:!:\.:.....l.\.':l.~.(....~ . to..~~...~~.~...~....~..~...........~...~.:... .~....~....~...~.....9.;.~.~.-+..~...9.f~~............... at premises located at ....~~..~...~..~...~......Q.X~~ ................................................................................-................................................................................ ................................................................................................................................................................. County Tax Map No. 1000 Section ....1.9...'*=-......... Block .......~...~.... Lot No. ..L~:...L..... pursuant to application dated ..~~.~...d..Q............, 19~..J.., and approved by the Building Inspector. . If) / Fee $... .......:............ ^.~ J ...... ......................................................................... Building Inspector Rev. 6/30/80 V~ ~-d.,; ~ FORM NO.1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SQUTHOLD. N.Y. 11971 TEL.: 765.1802 BOARD OF HEALTH ...... 3 SETS OF PLANS ....... SURVEY. . . . . . . . . . CHECK .......... SEPTIC FORM .............. NOTIFY CALL MAIL TO: Examinedd-~X~.19~:1 APProve~.~.. .i. ..19~!.PennitNo.U(.7!.G;,.~ Disapproved alc ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .. . .. . . . . . . . . . . . \~ /;~. . . .. . /J .~ M.. ..... .. .. .. ~.. .. . (Bu' ing Inspector) APPLICATION FOR BUILDING PERMIT BLDG.DEPT TOWN OF SOUrHOLD "~ ."Ulll iWJ Date. . . . . . . . . . . . . . . . . .. 19. . . 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 r public streets or areas. and giving a detailed description of layout of property must be drawn on the diagram which is p rt of this appli- cation. c. The work covered by this application may not be commenced before issuance of Building Pennit. d. Upon approval of this application. the Building Inspector will issued a Building Pennit to the applic t. Such pennit 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 Certificat of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Pennitpursuant 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 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. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 'I~ ,~.j<rt(i'\fi.a A:S.NCrr.ro . . . . .. Name of owner of premises ... 5Cl? ."- .,(JJ. ~. . . . .3. . . . . L'~.i1,r '~):-i\9.L. 8..". t. . ''fIll. -to \ (as on the tax roll or laTest deed) . / c;: L If applicant is a corporation, signature of duly authorized/~cer. F;'.;l~f~w\~- ~:~;#TME~T 'AT -.c- ~ ~ l ~ YV; '.,' H:!(l, ,.\ ^'''' fl. , ,,'1\1\ .-oR THE . .... . ..).e>.S........n.. .. . ... 2l.... .. .1. ~.-e.<..<./.. .'~ ro.. OV\',Nh ,,,,,,,,,"CTIONS.. (Name And title of corporate officer) . FOUI.OA, r:u",:WO ",'UlJlREO ALL CONTRACTOR'S MUST BE SUFFOLK COUNTY LICENSED FOR POUk" :~Oj\!CF"" ., ,- Builder's License No. ......................... ',O\,.Gh F"<>\!,rHI\,\C' ~ !"!.Uh..'!I\J", ,\, INSULA fit i1' 4. FiNAl CO....;;..:-r.:UCT...11J". MUST Bt' COMPI ,,1'" FOR L 0 ''".' ALL CQ'\ISl'RUCTION St1AU, ,.R,,'" T THE t1t::QUll'\I'i'.IENTS at' fHE NY ~::~:l:;TI:~UC""ON /11 ENER(;;V ~ c DES NOT AESf'ONSl8Lf FOR . " . C:"NSTIlLlCTKW cr>RQRS 1. LocatJonof::::hProPosUk~lllbedone. .... .. .;...t..';.......-:-:................... H~~~~ N~~ b~r' . . . . . . . . . . . . . . . . . . . . . . . Sir~~i . . . . . . . . . . . . . . . . . . ':<;-. .e ~~ ~:--,-., . . . . . . . . . . . . . . . . . County Tax Map No. 1000 Section .... J. O.~ . . .. Block......O. ~ . . ... Lot...J. .;!..'. 1.. . ., . . . . Plumber's License No. ........................ Electrician's License No. ...................... Other Trade's License No. ..................... 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 . . . . . . . .\3~. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. Intended use and occupancy ....... .~~. . ( :?Q . . .m. ~ ) . . <. . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Nature of work (check which applicable): New Building........ .. Addition.......... A1teratioll .......... Repair .............. Remova~.~. ~~n .~Othet Work.. (D~~~ri~;i~~) . . 4. Estimated Cost. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /I.Jb.---<- '" (tQ be paid on filing this application) 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 eac2.tt5e of use . . . . . . . . . . . . . . . . . . . . . 7. Dimensions of exispng structures, if any: Front. . . . . . .'-to.. . . . . Rear .............. Depth... .?~ . . . . . . . Height ... :~t'. . . . . . . . . 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 .... '3 ?? ~ .. .. .. .. . ... Rear.......?,.. of.? .. .. .. ... Depth .... 4 ~?.. .. .. .. .. .. . 10. Date of Purchase ............................. Name of Former Owner ............................. II. Zone or use district in which premises are situated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Does proposed construction violate any zoning law, ordinance or regulation: ................................ 13. WiIllotberegraded ............................ Will excess fill be removed from premises: Yes No 14. Name of Owner of premises .. -s;,.,+.I.,.-/:...~.k.. Address............ ..... .. Phone No. ............... Name of Architect .... '-"-' . . . . . ~. . . . . . . L . . . . . Address . . . . : . . . . . . . . . . . . . . Phone No. . . . . . . .:: . . . . . . Name of Contractor . . . . S~ . . . . . .... . . . . . Address . . . . . . . . . . . . . . . . . . . Phone NQ. ., .~~-. . . . . . . . 15. Is this property located withi 300 feet of a tidal wetland? *Yes ..... No~. *If yes, Southold Town Trustees Permit may" be re.<lu:j.,ed. PLOT DrAG RAM 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. J ,--- i n ~~ /,r/ \. / ~ \) "'-\ 3TATE OF NEW YORK, :OUNTY OF . . . . . . . . . . . . . . . .. S.S (Name of individual signing contract) .bove named. being duly sworn, deposes and says that he is the applicant 1e is the. . . . . . . . . . . . . . . . . . . . . . . . . . . . (C~~ir~~i~r: ~~~~t', 'c~~~;at~ ~'ffi~~;, 'e't~.)' . . . . . . '" .!., ~. . . . . . . . . )f said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this Ipplication; that all statements contained in this application are true to the best of his knowledge and belief; and that the york will be performed in the manner set forth in the application filed therewith. ;worn to before me this ~ . . .. ... . . . . . . . .,;" .'f. ... . .day of. . . . .. ;to .. . . . . . . ...,19 t7 -lotaryPublic, ...... .~. .K.. .fJ.<<!/&-. County Ha.fN It DE VUE IlOrNlY PUBlIC, StIle of New Yon ~ 4701878. Suffolk ~nIltr "1 .... Expires March ~ l~ ....... ... ........... (Signature of applicant)