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Home My WebLink About14761-Z FOB, M NO. Jl TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 19...~...(P ....~-~.o~_ .~...~.~.~...~. ....................... '. ................ ot premises Iocoted ot .....~:....~...~....~. ..................... County Tax Map No. 1000 Section ..... ~..~..'~.'~.. ..... Block ...... .1~....~... ...... Lot No......~...~.~... .......... pursuant to application doted ...... ~,.....]....O, ................... , 19.~.g.., and approved by the Building Inspector. Rev. 6/30/80 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL ~OUTHOLD, N.Y. 11971 TEL.: 765-1802 Approved .~... ¢ .... 19 .~.. Permit No. )..~..~..~./..~.. Disapproved a/c ..................................... ................................ ...... (Building Inspector) APPLICATION FOR BUILDING PERMIT BLDG. DEPT. TOWN OF SOUTHOLD Reoeived ........... ,19. Date....],t::/ -7...I ..~). ..... , 19~.~o 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 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 appli- 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 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 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 necessa_q/inspections. - .S. ......... (Signature of/applicant, or nam4, if a corporation) ~..,..~. ,...~ o.~..%.:. 67. ~.-.D .~ ~rr ¼ o.1~ ~4¥.'.1.~ .~ I (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ..~...ag. D ~.~.c'.,>.~.. C~..~.'T.~.q,,~-'r'.~ .'~..' ............................................................. Name of owner of premises ~ r'<~-r.T. ~.r3 ~ ........... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No....~..~..(E. ............... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done .................................................. ..~-. --. ,-, .. ~ -, _ ,-. C ~,T ~ o,ts" el, , ......... ......... ............ House Number St te~t Hamlet County Tax Map No. 1000 Section ...... ~..~.. ....... Block ....... .~. ......... Lot .... · .~.....~. · .'~.... 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 ...~..~..e~.~...~.L~M.~..~,~_,~...~.,.~c,r~'q:.~,~ ............... b. Intended use and occupancy . .C~_~J .~...~.~ffo.~. ~ .~% .~-~< .~.c~.~_~..T.o. f:.l .L..SI ~ ........... 3. Nature of work (check which applicable): New Building ..... ' ..... Addition .......... Alteration .......... Repa~r..~~ ~. ]. ~ ..... Removal .............. Demolition .............. Other Work..~-~. (Description) 4. Estimated Cost....~.. ::c~D..~ ...................... Fee ...... ~ ~ ........................... ~ ... ~ (to be p~d on filing th~ application) 5. If dwelling, number of dweHing units ............... Number of dwelling units on each floor ................ If garage, number of c~s ........................................................................ 6. If business, commerci~ or mixed occup~cy, specify nature ~d extent of each type of u~ ..................... 7. D~ensions of existing st~ctures, if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ........................................................ D~ensions of s~e structure with alterations or additions: Front ................. Rear .................. Dep~ ...................... HeiSt ...................... Number of Stories ...................... 8. D~ensions of entire new construction: Front ............... Rear ............... Depth ............... 9. Size of lot: Front ...................... Re~ Depth ...................... 10. Date' of Purchase ............................. Name of Foyer Owner ............................. 11. Zone or use district in which premises are situated ..................................................... 12. Does propossd construction violate any zoning law ordinance or re~lation: ................................ 13. Wffi lot be regraded ............................ Will excess fill be removed from premises: Yes No 14. N~e of Owner of premises ...~ ~:.~.~ ...... Address .~.~.t.~..~o%-... Phone No. D.~.~: .~. N~e of ~chitect ........................... Address ....... ~9~hone No N~e of Contractor~ ~c~.~ 5 . n ddress ,. &. .... Phone No. 9 a~: .~ ~.. PLOT DIAG~ Locate cle~ly ~d dis~cfly ~1 bu~d~, whether existing or proposed, ~d. ~dicate ~1 set-back d~ensions from prope~ Unes. Give street ~d block number or desc~ption according to deed, ~d show st~et n~es ~d ~dicate whether ~te~or or corner lot. STATE OF NEW YORK, S.S COUNTY OF ................. ................................................. being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. He is the ......................................................................................... (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 f'fle 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 .............. ./.0. ....... day of ........."' '- ' "~ ..... , 19 ~.~. Notary Public,...,~e-r~....../~.~...~)..,~..g.~-~..,.,, .v . County ~F.L~N & I~ ........ .~ .... J.... NOTARY PUBLIC, State of N~ Ymlt (Signature of applicant) NO. 4707878, Suffolk County ~o Term F. xp~res Match 30, 1~...~./