HomeMy WebLinkAbout23526-z FORM NO. f
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.,Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
TV so 23526 Z Date ................ ................ .............,
Permission is hereby granted t
.............
�... ... ... a ......
Lai&.: .. .... .-�.. �:�.., ...... �
. . .. � %. A
. ..... . :�..........�.' .....
atpremises located at ......... . .. ...............................�`.....��.................................................
..............................................................!�... .... ...... ..... ....................................................
. ...................................................................................................................................
County Tax Map No. 1000 Section .... ....r�..... Block ..... .��............ Lot No. ../.................
pursuant to application dated ................. .. . .. ... ......c ............I 19./�a, and approved by the
Building Inspector.
Fee3.. C ...
...... . ......... . ..... .... ..................
... . .. .. . . ... .
Building Inspector
Rev. 6/30/80
BOARD OF HEALTH . . . . . . . . . . . . . . .
FORM NO. 1 3 SETS OF PLANS .
TOWN OF SOUTHOLD SURVEY - . . . . . . . . . . . . . . .
f i U BUILDING DEPARTMENT CHECK . . . . . . . . . . . . . . . . . . . . . . . . .
TOWN HALL SEPTIC FORM . . . . . . . . . . . . . . . . . . .
-� � SOUTHOLD, N.Y. 11971
BLDG.DEPT- TEL: 765-1802 NOTIFY:
TOM OF UTMOLn
19.F.� MAIL TO: �.Y.
F�,munecb--FF-.. .... /� oS 3 �� . . . . . /
Approved_.4J.�'4!!`Q14
19.l,1� Permit No. .. ....................................
Disapproveda/c ............................. ....................................
....... .......... . ...
wilding Inspector)
APP ATION FOR BUILDING PERMIT
Date . . , 19.��j
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector wit:
3 sets of plans, accurate plot plan to scale. Fee according to schedule.
1u. 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 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 thro p)-lout 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 MAIZE 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 of premises and in building for necessary in Lions.
(Signature of a licant, or name ,-,if a corporation)
A 11 7"A
iL' (Mailing •address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general l"contractor,.'electrician„plumber or builder.
...............� ..................................._..... `... ....._... ...............................
Name of owner of premises ......... a� .: .. .. U. ., Il•�..................................
(as on the tax roll or latest deedY'-,,1.
If applicant is a corporation, signature of duly authorized officer. .
- - - • .' ...............
(Name andtitleof corporate officer)
Builders License No. .........................
Plumbers License No. .........................
Electricians License No.
Other Trade's License No. ....................
1. , Iocation of land on which proposed work will be done...... YCA.
... - -• J .......... ....Z7h . t ................. . Sic .............
lkxuseNmber Street (LekLk 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 ..................................- ......._........................
b. Intended use and occupancy .......... .........�' `, ce' s :�`o ;} �sy ..................
.1. N•el.iire of woik (dred( %Audi applicable): New Milding; .......... Acklition _...... .. AIterati ... /f
Repair ._.__....... Raroval ............. Dernol i Lion ............ Other Work
4. lsCiukited Cost ...... ........ Fee ........................................:..... ..
(to be paid on filing; this application) _
5. Lf d(aelling rxzdmer of dwelling units timzmber of dwelling (nits cxm each floor
Ifgarage, mxni>er of cars ..........I...........................
6. if Ixusiness, cannercial or mixed occupancy, specify nature and extent of each type of use......................
7. Dimensions of existing; structures, if any: Front................ Rear ............... Depth .................
lk iglu Mni>er of Stories ....................
Dimensions of szme structure with alterations or additions: Front ............... Rear ..... .........
I>epLh .................... 11eig)iL .................... Nu(ber of Stories ...............
13. Dimensions of: entire new construct:ion: Front Rear ............... Depth ..............
ileig1lt ......................... Uzdmer of Stories .....................
9. Size of lot: groat .................... Rear .................... Depth ....................
10. ikrte of Purchase T..................... Name of Former (Mier ........................................
II_ Zone or use district in wlmidr premises are situated ..............................................................
12. ioes proposed construction violate any zoning law, ordinance or regulation: ........................
13. Will lot be regraded .................... Will excess fill lie removed from premises: YL.S NO
Ili. Names of Owner of premises ........................... Address ...___........................ Plmone No. ........ .___
Name of Arclm i tect .................................... Address .............................. 11)one No.
Name of Contractor ................................... Address ...............................Phone No. ..............
15. Is Lhis property within 300 feet of a tidal wetland? * YES .......... NO ..........
*IF YES, aullun lum 'IiAjsii-,9 PERMIT MAY IIG RE-gnRGD.
PLOT DIAGRAM
Locate clearly and distinctly all Wildings, whether existing or proposed, and indicate all. set-back dimensions
frcxu property lines. Give street and block rx-imher or description according to (geed, and slrow street Hanes and indicate
whether interior or corner lot.
P 0 D AS Nbm
DATE: � � B.P.#
FEE:
NOTIFY BUILDING D A
765-1802 9 AM TO 4 E
FOLLOWING INSPECTIONS:
1. FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE
2- ROUGH - FRAMING & PLUMBING
3. INSULATION
4. FINAL - CONSTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET
THE REQUIREMENTS OF THE N.Y.
STATE CONSTRUCTION & ENERGY
CODES. NOT RESPONSIBLE FOR
SUM, (V t1V Y(UPIGN OR CONSTRYII;TION,ERRORS
'D60M- -S............................being duly sworn, depo.ws and says Lhat he is Lhe applicant
(N:zme of indivldrk"11. signing conLracL)
alxnre wined,
�Ik! is Lhe .......................:®WV�f.� ......
(C)nLracLor, agent, corporate officer, etc.)
of said owner or owners, and is (July authorized to perfonn or have performed (.he said work and to nuke and file this
applicati(nq that all sLatenents contained in this appllcation are Ln)e to (be best of his knowledge and Nll.ief; and
OmL Lhe work will. lie performed in,the n4umer set- forth in Lhe application filed Lherew.ith:
Stx)rn to before me this
.........I .....day o .. .... 19. �..
Notary Public . ........... ... _:...... l
ROBERT1. CCITT.JR.
NOTARY PUB C.State of N.Y. ( ignature of Appl.i.canl)
No.4725089,Suffolk Courr��tt��r��
Term Expires May 31. 19_7,�
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