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HomeMy WebLinkAbout11684-Z FOR~ NO. ~ TO~N O~ $OUTHOLD BUILDING DEPARTNiENT TOWN HALL SOUTHOLD, bi!. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N©. 116S4 7 Date ........................... ..~...~....~?./......~.d.., 19...,,,.~'~'''-- ...................... .~.....~. .............................................. :..:~ ........ i ........ ....~......: ......................................... County Tax Mop ,o. 1000 Section ....... ../...~....E... Block ...... ~ ...........Lot No ....... Z:...{Z.. pursuant to application dated ...................................................... 19 . .., ant approved by the Building Inspe. ct~r. Fee $ ........................ Building Inspector - Rev. 6/30/80 FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined ................ , 19 . . . Application No. ................ ff' 7 _ Approved 9~'; 19 . . . Permit No ............ Disapproveda/c ....... :....,.-'~....................:' ...... (Building Inspector) APPLICATIOItl FOR BUILDING PERMIT Date ....... 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 dc:a/led description of layout of property must be drawn on the dia~am which is part old:his ap cation. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon apprc.'al of this application, the Building Inspector will issue a Building Permit to the applicant. Such per: shall be kept on the premises available for inspection throoghout the work. e. No buildiag shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupm shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for th~ issuance of a Building Permit pursuant to Building Zone Ordinance of the Town ~f 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 descfib Th.e applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, :md admit authorized inspectors on premises and in buildings for necessary inspections. (Signature of f~plicant, or name, if a corporation) / (Mailing address of applicant) Builder's License No....~ ~.~ ~. ~ ............. Plumber s L cens. N~. E12ctrician's License No.' ...................... State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or built ...& ........................................................ , .................. . ...... Nmne of owner of premises . .)J.~ ./~ .% g../J.i.R...~-.//t?.C.4 .S ./.<. ,~ ....................................... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly attthorized officer. .............................................. (Name and title of corporate officer) Other Trade's License No ...................... 1. Location of land on which proposed work will be done House Number Street Hamlet County Tax Map No. 1000 Section ...... [.0.¢ ........ Block ........ C( ......... Lot 7, [Z Subdivision [~il"/~tl~ [flS~ ESTg~¢ ~1 Filed Map No. ~0~ ~ Lot /.~ (Name) 2. State existing use and occupancy of premises and intended ns~ and occupancy of proposed construction: a. Existing use and occupancy ~1~6 ~ : ~7 D~a~?~Z : b. ~tended use ~d occupancy · · .~ * ,~ · ~v ......... ¢- · N3L. ~ o~ ".'or[: (check whicl, applicable): New Building .......... Addil~ion .......... Alteration ........ Repair .............. Removal .............. D2molitlon .............. Other Work ............. (D~scr,r. Estimated Cost '~ ~5 % ~--_ ............................ Fcc .......................... ~r ......... (to be paid on Filing this application) If dwelling, number o£ dw¢iiing units ............... Number o£ dwelling units on c,~ch floor .............. If garage, number of cars If business, commercial or mixed occupancy, specify nature and extent of each type of use ................... Dimensions of existing structures, if any: Front ' Rear .............. Depth ............. Hei,,ht ............... Number of Stories Dimensions of same structure with alterations or additions: Front ................. Rear ............... Depth ...................... Height ...................... Number of Stories ................... Dimensions of entire new construction: Front Rear Depth Height ............... Number of Stories · . ........... Size oflot: Front ........... -..'.........' Rear... ................... Depth ........... . ... Date of Pt rc ,se Name off Zone or use district in wi?ch p. rcmises are situated.., i ............................... :.. ............ Does proposed construcaon vmlate any zoning law, ordinance or regulation: .............. Will lot be rcgrad::d .......... - .................. Will excess fill be removed from premises: Yes Name of Ov.'ncr of premises .................... Address ................... Phone No ............... No,ne o, Arclu£ect ......................... '.. Address ................... Phone No ............... N:mm of Contractor .......................... Address ................... Phone No .............. PLOT DIAGRAM Locate clearly ~d distinctly ~I buildings, whether existing or proposed, and. indicate all set-back dimensions fro: ?roperty lines. Give street and block nmnber or description according to deed, and show street names and indicate whetN ',ntcrior or corner lot. ~'FATE OF NEW YORK COUNq'Y OF ;~..'... S.S (Nanie of individual signing d~ntract) above named. ~eis the ............................... ~ ......... ) ontractc corporate officer, etc. of said owner or owncm, and is duly authorized to perform or have performed thc said work and to m~e and file ~t)plication; that all su~tcmcnts contained in this application are true to the best o~ knowledge and belief; and that th ~ork will be performed in thc manner set forth h~ the application filed therewith. ~orn to before me this . · Connty