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Home My WebLink About9623-Z FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined .................. ..~././. ~. c' Approved .................... .~.~:..~...~, 197..~.~.. Permit No..~...~...~....~....~ APPLICATION FOR BUILDING PERMIT ~ INSTRUCTIONS o. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Buildinc~~ 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 ofprpperty must be drawn on the diagram which is part of this applicatior~ 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 ssue o Bud ng Permit to the appl cant 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 Peri, nit pursuant to {he Building Zone Ordinance of the Town of Southold, Suffolk County, New Yor,~ and other ppplicable ~.aws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or fc~/r~moval or demo ition,/as here n described The applicant agrees to comply with all applicable laws, ordinances, builc~g/~ode, hous ng code, a~/d regulations, and admit authorized inspectors on premises and in buildings for necessa~.J'nsp6ctions. ,/ / State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises Rober'c. 6, M~r±e $Cal±a If 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 Trade's License No ............................................... Location of land on which proposed work will be done. Map No.: ........................................ Lot No ......................... Street end Number .... .t:to]~.~l-.~on...Rcl~ ........................................................................... ~ .i'~....~.¢~. ................ Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ................................................................................................................................ b. Intended use and occupancy ..... ~..t..o.?:..a:~.?.....~..~..e...~. .............................................................................................. $. Nature of work (check which applicable): New Building....~.. ............ Addition .................. Alteration ................ Repair .................. Removal .................. Demolition .................... Other Work .................................................... (Description) iL Estimated Cost ..........,2,~0.,,~ ................................... Fee ...... ].5.,D.Q ....................................................................... (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 ............. r'. ............ Rear ......T:. ........................ Depth ...~ ................ Height ......... ..-. ............ Number of Stories .......... ..-. .................................................................................................... Dimensions of same structure with alterations or additions: Front .............. .-: .................... Rear ........... .~ ............... Depth .................... .': .......... Height ............ ..~ ............. Number of Stories ................................ ' " epth ..~. .................... 8. Dimensions of entire new construction: Front ..... ..~....0. ...................... Rear .....~.'..~'..] .............. D "' 0" Height ...:'8'.'i'..q~] ...... Number of Stories ........... .~ ........................................................................................................ 9. Size of lot: Front ......... /1.,~,~. ....................................... ,~ ,1 -~, , Rear ...~.e ................................... Depth ......~..4 ..................... 10. Date of Purchase ....... ~/J.Q..~..~.~. ................................ Name of Former Owner ..,~^:..~'~?,~,.;'j ............................ 11. Zone or use district in which premises are situated ........ R~,,~i~.e~t~J.~.l .................................................................. 12. Does proposed construction violate any zoning law, ordinance or regulation: ..... ]~..o. ...................................... 13. Will lot be regraded .........N...o. .............. Will excess fill be removed from premises: ( ) Yes ( ) No 14. Name of Owner of premises ....~.,...~,a~,i~. ......................... Address .-~l~;~g~.~C.,~.~g,... Phone No..~'.~.T..2.~..~ 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. ~sting S~reet STATE OF NEW YORK, [ ¢ c COUNTY OF ............................... f~'~ ...................... ,..--~ .,~.;...(.'/4T- ................................ being duly sworn, deposes and says that he is the applicam (Name of individual signing contract~ above named. (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 thor the work will be performed in the manner set forth in the application filed therewith. Sworn tcz before me this 1-- ...... o, ................. , Notary ,~ublic, . ....... x~ ......................................... County NOTARY FUBLIC, Stat~ of New York