HomeMy WebLinkAbout46460-Z rar. TOWN OF SOUTHOLD
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BUILDING DEPARTMENT
a TOWN CLERK'S OFFICE
SOUTHOLD, NY
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES
WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS
UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)
Permit#: 46460 Date: 6/22/2021
Permission is hereby granted to:
DiCarlo, Patricia
3 Driftwood Ct
Shoreham, NY 11786
To: demolition of fire damaged garage as applied for.
At premises located at:
1150 Terry Ln, Southold
SCTM #473889
Sec/Block/Lot# 64.-3-13
Pursuant to application dated 6/22/2021 and approved by the Building Inspector.
To expire on 12/22/2022.
Fees:
DEMOLITION $250.67
Total: $250.67
4-
\ j
uilding In pector
TOWN OF SOUTHOLD-BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O.Box 1179 Southold,NY 11971-0959
Telephone(631) 765-1802 Fax(631)765-9502
Date Received
APPLICA Ta"ON FOR BLY'1DRNG2 PER.-ININT
For Office Use Only
PERMIT NO. Building Inspector: JH t-202 2021 hlqr
114
Applications and forms must be filled out in their entirety.Inckplete B0,11D RNT G DEPT,
applications will not be accepted. Where the Applicant is not the owner,an 7,D,''Vii'C-7-`0 7 H 0 L D
Owners Authorization form(Page 2)shall be completed.
Date:
OWNER(S)OF PROPERTY:
Name
T' wSCTM#1000-
XL
Project Address: -7 7
Phone#: Emal
Mailing Address:
CONTACT PERSON:
Name:
Mailing Address:
-7 7
Phone#: 6nai!r4�
IV JZZZ
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name:
",-Z
Mailing Address: 11'?'71
Phone 1�# f/ Email-
,Kr
Z 2
DESCRIPTION OF PROPOSED CONSTRUCTION
[INewStructure ElAddition ElAlteration EIRepair demolition Estimated Cost of Project:
ElOther- $
Will the lot be re-graded? ElYes FFNo Will excess fill be removed from premises? E]YespNo
PROPERTY INFORMATION
Existing use of property: l Intended use of property-
:216
/
Zone or use district in whic premises is situated: Are there any covenants and restrictions with respect to
this property? ❑Yes ❑No IF YES,PROVIDE A COPY.
❑ The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by
Chapter 236 of the Town Code. 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,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(s)for necessary inspections.False statements made herein are
punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law.
Application Submitted By(print name): 1p►uthorized Agent ❑Owner
Signature of Applicant: Date:
STATE OF NEW YORK)
SS:
COUNTY OF 1
.� being duly sworn,deposes and says that(s)he is the applicant
(Name of individual sig"Contract)contract)above named,
(S)he is the fill lyuC�✓
(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/her knowledge and belief;and
that the work will be performed in the manner set forth in the application file therewith.
Sworn before me this
day of 20 �I
Notary Public'.
� .Y LOW
pdit State of N WyC*
Md.0111311469=''- c
(Where the applicant is not the owner) N.,
;
k Aix\ residing at ✓v ���%
I,
ldo hereby authoriz�cz /J� apply on
my behalf to the Town of Southold Building Department for approval as described herein.
Owner's Signature 1 Date
\
�aA -1 Cly 1, �
Print Owner's Name
2
P G1-
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i ``. �, .;- C dC v .�v rT ✓ m 1 r 525-45 MAIN R )A-
- — SOUTHOLD, N_1'. 11-971
(5;6) 765-2300
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