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Home My WebLink About872-Z FORM NO. 2 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) No. 872 z Permission is hereby granted to: Date .......................................................... 19 ........ to at premises Ioc¢ at pursuant to c Building Inspecto 19 ........ , and approved by the Building Inspector FOB, M NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Approved .................................... , 19 ........ Permit No. ~ °c 7 ~-~ Disapproved a/c .~'m~..,.'.: ,~.~.....~..~'....~...~...~...~..~-......~.....~-~'-'''~ ................. ........................................ (Building~lnspector) APPLICATION FOR BUILDING PERMIT Dote ................... ..o..S.Z...~ ................... , 19£L. INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building Inspector. 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 location. 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 issue a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the progress of 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 Deint for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Su~, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, adjiitior~or ~Jjpl'ations, or for removal or demolition, as herein described. .......... ....... ................................. (Signature of applicant, or name, if a corporation) ....... LL.?.....~.:~....~.....~..~?..~.~..~?..~...~f. ........... (Address of applicant) State whether c~pplicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ............................................... ......................................................................................................................... Name of owner of premises.....-~....~ ....... ~.~.~ .................................................................... If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) 1. Locatior* of land on which proposed work will be done. Map No: ...~.:.-/...~..c.:...~?..~..~.?..~...~..~.... Lot No' / Street arid Number ........... ~ .................................................................................................................................... Municipali~ State existing use end occupancy of premises and intended use end occupancy of proposed construction: a. Existing use and occupancy ~//~ ~- /~ ~J '~ b. Intended use and occ.upancy ....................... ./.?....-~....5:..!..('..!.~...../~.....c:...~..~. .................................................................. 3. Nature of work (check which 'applicable): New Building .................... Addition .................... Alteration .................... Repair .................... Removal .................... Demolition .................... Other Work (Describe) .................... 4. Estimated Cost ~. c,-~o ~ ,- c~ ........................................................ tee ./.~...,.... ................................... (to be paid on filing this application) · / 5. If dwelling, number of dwelling umts .......................... 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 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 ............... ~.~.....o. ..... Rear ...... .PT......°. .............. Depth ....~.....~. .................. Height .................... ..-7 ..... Number of Stories ......... ...::~'... ................. 9. Size of lot: Front .........~...L.~....~. ...... Rear ......... (..~'L.~..? ...... Depth ../...Z.~.Z ............... 10. Date of Purchase ............./. ..?. .. .~. .. ~. ............................. Name of Former Owner ......................... . .....c 11. Zone or use district in which premises are situated ~ ~J/_z~ , 12. Does proposed construction violate any zoning law, ordinance or regulation? ........ ~.?..~. ........................................ 13. Name of Owner of premises.../.'~..?..?.....3'..c....F?./..Z..a.?..c/..~../Z. Address .......................................... Phone NO ..................... Name of Architect .................................................... Address .......................................... Phone NO ..................... Name of Contractor .................................................... Address .......................................... Phone NO ..................... PLOT DIAGRAM Locate clearly and distinctly oil buildings, whether existing or proposed, and indicate oil set-back dimensions from property lines. Give street and block numbers or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEWcYO~J~ ,,') /, ) S S COUNTY OF ....~....~....~.~......) ' ' .......................... .....,./,./._~...~...,~,..~.~..~~/.-~-~V/. ,-~ __ ~ ,~ .............. being duly sworn, deposes and says that he is the applicant (Name of individual signing application) above named. He is the .............................. ~:. ........ '.'E. .................................................................................................. (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this ................ ./...O.... day of .............. ~..Z.~...~.~... 19...?...~.... Notary Public, . ......................................................... County (Signature of applicant)