HomeMy WebLinkAbout11723-Z FORM NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y. \11/ D
? Doi fe-i-y\ zv-e_d
BUILDING PERMIT
_ (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
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N . 11723 Z
Date / , 19
Permission is hereby granted to:/
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to av" ,'✓
at premises located at -5-
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County Tax Map No. 1000 Section 0 7C) Block ...., 0 Lot No. 4'
pursuant to application dated G��- / , 190Q-,V-and approved by the
Building Inspector.
Fee $ f
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f Building Inspector
Rev. 6/30/80
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FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1802
Examined 19Zy Application No
ApprovedV' f ( , 19 . . . Permit No //725
•
Disapproved a/c
4197 ,
(Build ng Inspector)
APPLICATION FOR BUILDING PERMIT
Date I -t , 19a
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 descriptionof 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 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 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 buildings for necessary inspections.
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(Signat f applicant, or name, if a corporation)
- (Mailing address of appli nt) 1/1-4-4
State whether a„pplicant is -owner, lessee, agent, architect, engineerr,,general,contractor, electrician, plumber or builder.
•
Name of owner of premises . . .
(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. . . . .
Plumber's License No. �(
Electrician's License No. . .��?�n .��J� 9 • -
Other Trade's License No.
1. Location of land on which proposed work will be done.
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House Num rib treet Vnet
County Tax Map No. 1000 Section 0 70 Block I �, Lot 034
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 -
b. Intended use and occupancy . .C - !` - . .�Q.�,�.,t�,�.i:Y�✓>� n�.c . Di-f31
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3. Nature of work (check which applicable): New Building Addition Alteration
Repair Removal Demolition Other Work .D. &:12.._
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4. Estimated Cost 4(4-4 O.O Fee / 4
(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 o 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 Depth
Height s . . ( x a-e
9. Size of lot: Front .2_00 Rear Q 0 Depth 1 4-0
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 ?'1-0 Wiliexcess fill be removed from premises: , Yes No X.
14. Name of Owner of premises .0c...4----\.c'nv,. Pcxir��ddresc,ch.
.s. P J.`n hone No.``�b
. S:fl?'.7.`L .w. .
Name of Architect Address . . . " 1A '-Cdne 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.
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STATE OF NEW tr.K, S.S
COUNTY OF . r- _ . . i -, ./ '•
riTh // • ► .' ' 'I being duly sworn, deposes and says thie is the applicant
( 0 e of individual signing contract)
above named:
5He is the cz,_._.-Ceis -4.-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 ofjaj,cnowledge and belief;and that the
work will be performed in the manner set forth in the application filed therewith.
Sworn to before me this/ 60-_____-
of. . 9,..,...--,,,e._-- , 19.x'
N. - Public, Il �. .( �11 County
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ELI' ' ANN NEVILLE (Signature of applicant)
MIR MX, State of New Yafk
.,,_ . . a 111141112595® Suffolk Co take -
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