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HomeMy WebLinkAbout42420-Z TOMWOFSOU TH-OLD: "BU'ILDING?ERMITAPP'LICATION'Cli"E-C;' " KLIS'l' BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLIP#,N � i�a 7�L n A S%srp 5WIdjugj Wns 12 TEL: (631)765-1802 1 P -Pi anningEt6a4 approval,. FAX: (631)765-9502 Survey ' Southoldtownny.gov PERMIT NO .:,Cheek,,, -SepLporm. ets Flood Permit Examined -20 4 Single&Separate Truss Identification Form - 4essmentForm ontaci. Approved N4&1 to,, Disapproved a/c J4onc:' Expiration '20 Building,ins t Inspector APPLIC'AT16N-14)IR 8U'x,1.J)JN8,�P Data 20 /1 'INSTRWTFK-)NSS � --- a..This-application MUST-be ronipletely�bY,t*0Mti6 teO-'T Id'ifiliftiud-submittedto the sets of plans,accurate plot plan to scale.Fee according to schedule. b.Plot_plan-showing location of lot and dbuildiqgs on n C& 0 to, streets or _pBL_�is irdati nship- adj*ing!prcmises� ji�ablic sh or areas,and waterways. c.The work covered lay this qpl;licadppA,-q4yn()t,4qjWpy0 q.is paqpe cif B 10i J'en 'ng, p.Wed,�,qf r s d.Upon approval of this application,the Building Inspector will issue a'Building�P'ermit to the applicant.Such a permit. shall tie,kept on-th�premises,ayi�4ab'�Sor inspWipu'" o Q.No buildm'"gshall be'occ'u`pf`W0"r'"used' 'in vvfiole o�in p for an�,TW "�O issues a Certificate of Occupancy, egeFfa� o � Building Inspector N C_�-ver"til the Build' 1-6 i tl ybn6nlhs'aftert�c tlatc of f-n&�zo* '�Id ntg$ Ul essua wodbiveg ationsaffeciiiigthe p Pe fff6i in ro addition authoioj dd to *rtht�tsWanae)df atAtillding Permit pvrmaub to the i Building Zone Ordinance ofth&Td*kot)Sbikth6ld4"SiiffolEM)iatl,]N&w-'Ydrk ;'. lteg =MM' ",Dild' "additions,oraltoolptis-0t4g , 4 DI livable i iu'� - - appti'! t -ab e laws,ordlitances,huilding�qoog; u', g pd And regulations;and to admit, building auth rig d inspectors on premises b Iding for necessary inspections. FEB 2 1 2018 dhr '(Si e of,�pplicaut oi-pa�je,if a c orp.9�4tiou) rowN BUELDING DEPT. 6>.31 v , OF S017r' 091 g,A'&,Llss 0 pplili Y State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,,plumbpy,or builder Name of owner of premises let'A M 46-1,-vCr roll or-latest deed) % If ap is t a CoII' ry Mature of duly atithorized officer (Name andfitle of coy pqate,ofiicer) Builders License.No. S 3 H Plumbers License No. 3�f q P �' I � J"Y' ElectriCians'LicehseNb. Mi Er- J'IL11 virn'!, rY r '1 ?'Y J�1 P'9 JN eV) 'Other TradeNLlc&teNo. 'Yl I' 1, Location of land on which proposed work will be done: 0 4P Eq U,,-3-F Atu House Number I Street County Tax Map Not oQ�iSecfilt)n lock S idi iigion i Filled Map No, ^, d>``_k�: d ';@i `? aid � • .tu ,,�� 2. State eadsting_use`t d'occ4ancy�of premises d%mended use and occupancy of proposedWtjstrdct'@h 'G 3 i a. Existinguse.And'occtapahey b. Wended use.and occtipahey 3. Nature-of work-(check Nrlli&,p hcable):New BuildingAddition Alteration V"' Repair y0-, ^MMDemolition Other Work d: (Description) 4. Estimated CUL-21-21L2 Fee 1.,w' G � r.. (To be paid on filing this application) 5. If dwelling,number of dwe4ing units Number of dwelling units on each floor If garage nbrtiber o�dura '"" 6. If business,cotumexcial.or mixe8 occupancy,specify nature and extent of each type of dlse- _ 7. Dimensions of existing structures,if any.Front Rear l eptln Height dumber of Stones g s or additions: Front Rear Dimensions of same structure with alteration Depth Height �� : rlsi,([y a Number of Stories 8. Dimensions of entire new construpgni4Frq � •, : ems„ �� m G�,. Depth Height Number of Stories 9. Size of lot:Front` Rear Depth 'CIMS pQ 10.;Qate,Q4'PWpP1 r. �ti31`esitt tied A I!^I Ki^^r�P p:.,ns^Ir.r)tp br!P' jo G}h 1 1 y,, ry� 11.17..OflS..Q�'USC�I�IS't71t'E.�r$1'rvl;ltphp�� i5e5� � �� flk .dR,„4t ' ^r4Ff�: 11:Ir1 ,^• ” 12.Does proposed cornstfucti'on-vibNCexnry 13.Will lot be re t raded?YES NO Will exbess�1' xenio�a dCo pre° Gds" N j' r ^ i 14.Names , �, 4 Cly er,of ise T A �a ¢w+ eJl Al ct � or l'' 'NQ Fii"1 '3 N ,^ J. d� . ss Name of Ccp rqc pF �: ass .,Pkrozlp o �S17 i 15 a.Is this,property,withiri 100 efcetiaf a tidal wetland.cor.a sh a i wetly ?+t ES i� r �' a ,I flsltwtet+ C)e IF YBS�SOt:lTHOLD,TOWN�TRuSTEES&Drr&C,°I)Erc&S,MAYI3EREQUIf�E1�.`". , b.Is this property,wthin^-00 etaof 9:lidalmetland? ,Mj;a � <NO W: r�*IF YES,,D.'E!0,PERMIT, MAY'^BE REQt4RED L� r 16.Provide survey,to scale,via accurate foundation plan and distances to property �i ,•. 17.IfAvgioti ai t y poffi`V sifp�bpet Wdflt6 feef or-below,must provide iopograptiioal, .�ata on survey, 18.Ate Cher -any q pl,y�p� fi=ts pnil str%ctions with respect t6 this property?*YES l�au iJ©t'it1 7V,' =T *IF YES, [ O4Ii A � EW �,� �).,, -�,��"A r r .. a^r ,r�o.x ��.��aub � SS: r� C01JI',l'TY:OF�tA.....< c l" 7-2 being du rrorel deposes and says that'(s)h e isthe a hcant (Name of individual signing,c.�o(^n-tract)above named, ray , (S)He•isthe _ _ (Contractor,Agent,Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have peifoim3 the: d work and tb make apd fate this application; that all statements contained in this application are true to thebest"of'hss knowledgc and belie"that tiic, o C wvill Jac performed in the manner set forth in the application filed therewith. Sworn, efore me this', a 1 . r day of N a ...alalic. }, _. t atatre cifc ^�x: �Ap�libant 31f_6 122 c5;;3 Town Hall Annex Telephone(631)7651802 54375 P.0.Boax�I11R7s rCtad er.riiert �4 Ccoo (631)71tlh .n .41;5 Southold,NY 11971-0959 BUR DING DEPARTMENT TO' OF SO TTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: k,,mo-S a, Date: .? iConpan Name: 11"C4 - Narne: cC $ tec� License No.: g E Address: �o Ts taL1.J 0 (o3a !Phone No.: r L.,,3I JOBSITE INFORMATION: (*Indicates required information) *Name: rTaLle v re-S C--a *Address: rOL +? U-4? *Cross Street: *Phone No.: Permit No.: Tax-Map District: 1000 Section: Block: _ Lot: x *BRIEF DESCRIPTION OF WORK(Please Print Clearly) Gh o Vr _ `e-Y-LSfi l �� row fi1-4 (Please Circle All That Apply) *Is job ready for inspection: YES O Rough in Final *Do-you need a Temp Certificate: YES l NO Temp information(if needed) *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other I *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION c 82=Request for inspection Form