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FORM NO.3
TOYiM OF SOUTHOLD
BUILDING DEPARTMENT
V
TOV M HALL
SOUTHOLD. N.Y.
BUILDING PERMIT Uv'q
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
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Date w 19..9..
N6 22572 Z
Permission Is hereby granted to,
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to. /.2.Q. °s....'..... . ....f .
'I /r. u.C.. C....... /',g2 .....,C...iSlizi. e.d
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at premises located at............../jT.(.~1..C.N~
....u// y..........................................
County Tax Map No. 1000 Section Block Lot No.
pursuant to application dated J ....~d.....,19./..J........, and approved by the
Building Inspector.
Fee $
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. . .
/,0D Build g or
Rev. 6/30/80
FIELD INSPECTION REPORT nDATE n COMMENTS it 11 11
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FOUNDATION (2ND) II 11
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ROUGH FRAME & 11 11
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- ADDITIONAL COMMBNTS:
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TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSU
[ ] FRAMING/ STRAPPING [ NAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] ME RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
REMARKS: _ 4cli~L
DATE V INSPECTOR
v BOARD OF HEALTH
FORM NO.1 J SETS OF PLANS .
t TOWN OF SOUTHOLD SURVEY
BUILDING DEPARTMENT CHECK
- - - ` TOWN HALL SEPTIC FORM
7uwrU 5 SOUTHOLD, N.Y. 11971
- TEL.: 765-1802 NDTI Y Z
Examined CAL~L ?
J~.l!.!! 19? MAIL TO:
Approved ! .7.... 19~" Permit No. S/ .
Disapproved. a/c
.
(Building Inspecto
P ICATION FOR BUILDING PERMIT
Date , 1945
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with
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 sties:
or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this apl,l
cation.
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 issued a Building Permit to the applicant. Such perm:
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 Occupanc
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to th
Building Zone. Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances u
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 t.
admit authorized inspectors on premises and in building for necessary inspections.
NORTH FORK $occEQ A. CA GoC
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(Signature of applicant, or name, if a corporation)
P.o.box 1~9ff
!KI.t17?.e r!+ ~ N Y
.
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
PRESipyr ••N.F.S.L........................................................
Name of owner of premises m! T? ITvcle PA RAC p t 5T X1 eT
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
F, PA•. c W 1= ; PAVI W Il56GQG - QRfSiOEMT
(Name and title of corporate officer)
Builder's License No. Gr/G G2GCG! G%~El~Il
Plumber's License No. Ox -/off 2~l 3_
Electrician's License No .
Other Trade's License No .
• • .....i egwtQ
1. Location of land on which proposed work will done . -If 0- Aj~r-i,41
House Number Street Hamlet
County Tax Map No. 1000 Section
Block ....I Lot...~.D
Subdivision Filed Map No. Lot
(Name)
State existing use and occupancy of premises and inten.'_ „J e y of proposed construction`.
a. Existing use and occupancy ';s41. ,
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b. Intended use and occupancy 0111141
IIAPI,b p. • • . . . . .
ell 0 AA WAW m*T
3. Nature of work (check which applicable): New Building Addition Alteration
.
Repair ..............))Removal . , • • Demolition . Other Work..
7. ~:P (Description)
4. Estimated Cost Fee ?U/f~iar?~
(to be paid on fling this application)
5. If dwelling, number of dwelling units Number of dwelling units on each floor
If garage, number of cars i>rff'asi ' ' '
6. If business, commercial or mixed occupancy, specify nature and extent of each t . k
7. Dimensions of existing structures, if any: Front Y.. of use „x.... , , , • , •
. Rear .Depth ,
Height Number of Stories • • • . .
Dimensions of same structure with . • , " • . '
alterations or additions: Front
Depth.... Rear ..~.t..
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 ofFormer Owner
1
12. 1. Zone or use district in which premises are situated • ' ' ' ' • '
Does proposed construction violate any zoning law, ordinance or regulation: • • . • .
13. Will lot be regraded '
• • • • • • • • • • • • '..Will excess fill be removed from premises: Yes N,
14. Name of Owner of premises Address .
Name of Architect • • • • • • • • • Phone No .
.........................Address .Phone No..
Name of Contractor . . Address . . Phone No. .
15. Is this property within 300 feet of a tidal wetland? *Yes „ No..
*If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dirlaiItshlns fron
property lines. Give street and block number or description according to deed, and show street names and in4ipte.Whethe;
interior or corner lot.
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'LRUREL COMMON Z.6 AtCl
\qP Q~L\ SCHOOL DISTRICT NO. 11
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STATE OF NEW YORK,
COUNTY OF S.S
• . , . PAUL .p Ar. • • , being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named.
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He is the PAS-3
...............NOaTH FPpK SoecE2 t. ...GU6 '
(Contractor, agent, corporate officer, etc.)
If said owner or owners, and is duly authorized to perform or have performed the said work and to make and rile this
Ipplication; that all statements contained in this application are true to the best of his knowledge and belief, and that the
.vork will be performed in the manner set forth in the application filed therewith.
;woo^m to before me this p
....day of . , 19/.5/
rotary Public Cep ounty
EDITH F.JACK80N
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LAUREL COMMON
HOOL DISTRICT NO.11 2'9 A(C)
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APPRO DD AS NOTED \ ~P\ \ y 4 , ! I
DATE: l B.P• # o~ Y
FEE: BY: ET `
NOTIFY RU(LDiNG DE
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ALL s€f)NFLTR•4CTP,,, ^,HALL EET 2.3
THE REQUIREMENTS OF THE Y. 11.6A(r)
STATE CONSTRL16TION & ENO
V4fiffSPONSIBLE FOR'' o-' - z
CODES. a4rcN
DESIGN OR CONSTRUCTION ERRORS \,ESS DRAWN ,'-ERA Se
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