HomeMy WebLinkAbout9315-Z FORM NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
(THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N°. 9315 Z Dote .....~¢~<~'~-.....~ia ............. , 19...7....7
Permission is hereby granted to: ~'" , /
............. '
pursuant to apphcat~on dated ...................... , 19. and approved by t e
Building Inspector ~'
Building Inspector
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
~ ~..19.2.2 SOUTHOLD, N. Y.
, .......
19 ........ Permit No.
Disapproved a/c ............................................................................................
.............. {Buildin/a InSpector)
Application No ..............
APPLICATION FOR BUILDING PERMIT
Do,e
INSTRUCTIONS
a. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate 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 od oining premises or public streets or ~
areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of th s application. ~'
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 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 Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of SouthoJ~, 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 buildings for neces~a~,, nspecti(~'~
........
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Builder's License No ...........................................
If applicant is a corporate, signature of duly authorized officer.
Plumber's License No .................................................
Electricion's License No ............................................. i
,_ -?Z-~ t~ o~ ~c'~e-~,~ / ~
Other Trode's License No ............................................... ~t~ ~ ~ 7 J~
Location of land on which proposed wa/lt, will be done:~ Ma_p,~/: ................ ;.....;= ......... ~_..~.L....~.~ ......
Street and Number .... _,:~-. , ~.~____.,~....,~~(~...~..~, .................................. ~ .---ar ~, ,z,/~'~
State exist ng use and occu~Jncy of premises and intended-~-- _ ,/' "~ ~ ,,o 'use and occupancy of pmj~osed construction:
n J/~
b. Intended use and occupa cy ..>.'-'~/~-......~-/-....~,-~-7'"'~--~/_'f '; ..............................................
Repair .................. Re m ova~:~. ................ Demolitior ..................... Other Work ..................................................
'~/~--~O ~' ~"~/0 ~- (Description)
Estimated Cost ............................................................ Fee ..........................................................................................
(to be paid on 'filing this applicatiop)
Jf dwelling, number of dwelling units .= .......................... Number of dwelling units on each 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, Jf any: Front ............................ Rear ................................ Depth ....................
Height ........................ Number of Stories .................................................................................................................
Dimensions of same structure with alterations or additions: Front ....................................Rear ............................
Depth ................................ Height ............................ N~l~er of Stories .........7'"' ................ / ~ ~
Dimensions of entire new construction: Front .................................... Rear ............................ Depth ........................
Height .................... Numb~er~'f~J;tories ...................................... ~ .~T~t .................................... "?7:0..................
Size of lot: Front .................. ./.~;2..7.(~) ................... 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: ........................................................
13. Will lot be regraded. ........................... Will excess fill be r~moved from premises: ( ) Yes ( ) No
14. iName of Owner of premises .................................................... Address ................................ Phone No .......................
Name of Architect .............................................................. Address ................................ Phone No .......................
Name of Contractor ............................................................ Address ................................ Phone No .......................
) PLOT DIAGRAM
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.
STATE OF NEW YOF~I(,,
-
COUNTY OF .. ~ ....
..................... ~,~'.~-g-~,~......(.C~..~..~'~...~ ........................... being duly sworn, deposes and soys that he is the opplicom
(Name of indivi,dmpI signing, contracf)
above named. ~,
He is the .................. ~...~..:.~ .....................................................................................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to perform or hove 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 fo~h in the application filed therewith.
Sworn ,o before me this :~.~. ~....
..... day of ...... '~.~. ................... , 19...~ - .
P~b~c,
Notaw
...: ........... ................................ Co,. ............ .....................................
~~. ~.~t, (Signature of applicant,
~ ~ RYE DAWSO~
7~ ~pJres March ~,
TOWN CLERK'S OFFICE
/ ~ SOUTHOLD, N. Y.
v 19 ........ Permit No ...........................
Disapproved a/c .................................................................................
Application No .....................
APPLICATION FOR BUILDING PERMIT
Dote .................... ,
INSTRUCTIONS
a. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate 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 or public streets o~
areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is port of this application.
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 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 Deportment for the issuance of a Building Permit 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.
]'he applicant agrees to comply with all applicable laws ordinances b.~d~lding code_, housing code, and regulations, and to
admit authorized inspectors on premises and ir~ buildings for necess~lfy?inspectiO~n~.
~_~.~ignature/of applicant, or name, if a gbrporation)
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No .....................................................
Plumber's License No .................................................
Electrician's License No. ~
Other Trode's License No ...............................................
Location of land on which proposed woJ~, will be done., Mop~.: .......... ::~..:;::z....Z ....... L~t No -- = -~
Street and Number-"~'.~..~..~-~ ................................ ~iiiiilMunicipality
State existing use and occupancy of premises and intended use and oc~gupancy of proposed construction:
a. Exisiting use and occupancy ....~...~.~~ ~
_ ............... -7 ...................
whether interior or corner lot.
3. Nature of work (check which applicable): New Building~-./..(.....~.. ....... Addition .................. Alteration ..............
Repair .................. Removal .................. Demolition .................... Other Work ................................................ .
(Description)
~ Estimated Cost ................. ~..~..g.~..~.....~. .............. Fee
(to 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 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 ...... ..7.....~. ............... Depth ...../....~'.. .............
Height .................... Number of Stories ....................................................................................................................
9. Size of lot: Front .............../....~_..O.. ............................... Rear ....... ..~...%....~.. ........................ Depth ..?..~..~. ........ , ..........
10. Date of Purchase .................. /...~...../.....U.. ................... Name of Former Owner ........................................................
1 1. Zone or use district in which premises are situated .....................................................................................................
}2. Does proposed construction violate any zoning law, ordinance or regulation: ........................................................
13. Will tot be regraded . ........................... Will excess fill be removed from premises: ( ) Yes ( ) No
14. Name of Owner of premises .................................................... Address ................................ Phone No. ......................
Name of Architect .............................................................. Address ................................ Phone No .......................
Name of Contractor ............................................................ Address ................................ Phone No .......................
PLOT DIAGRAM
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
STATE OF NEW YORK,FO I S S
............................ .~....~...zcf..~,c~.c.:r. .............................. being duly sworn, depo~ses a_,nd says that he is tne' applicam
(Name of individual s~gni)~'" ' - contract)/1 .
above named.
He is the ................................. L~....~../.....(r:~....~ ...............................................................................................
(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, ..... ..................... ·
//.////~ /i,? c~' ../.~. ~../~'~ (S'g~ n Ure of o[at e o opplicont)
· ! MA.~/ E. DAWSON
NOTARY P~'.~LIC, State et New York
No, 52-4r643721, Suffolk Cocp:~t~
Term Expires March 30,