HomeMy WebLinkAbout46705-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
1 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 #: 46705 Date: 8/18/2021
Permission is hereby granted to:
Mazur
180 W End Averk, 28L
New Yo .. ......._.....
....................NY 10023
To: Construct additions to existing single family dwelling as applied for.
At premises located at:
tc ao ue
555 West Rd.., Cu
.... .__._..._.
SCTM#473.8.8.9_M............................................ .......----......_
Sec/Block/Lot# 110.-7-7
Pursuant to application dated 7/7/2021 and approved by the Building Inspector.
To expire on 2/17/2023.
Fees:
SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $513.60
CO-ADDITION TO DWELLING $50.00
Total: $563.60
Building Inspector
. TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
µ oTelephone(631) 765-1802 Fax(631) 765-9502 ht /www.smogif o iw ��r�L�lyLg� r
Date Received
IP" LIQAT UILII`)I PERMIT
For Office Use Only
fJ'l
PERMIT NO. L� Building lrc iaect rr s _............�. .. 'JUL - 2(.x'21
Applications and forms must be filled out in their entirety.Incomplete
applications will not be accepted. Where the Applicant Is not the owner,an ,
Owner's Authorition form(Page 2)shall be completed.
Date: '7 ,
OWNER(S) F 'RAPER :
Name:Stephanie Mazur SCTM#1000-110-7-7
Project Address: 555 WeSt Road #1218, Cutchogue, NY
Phone#:917-930-9663 1 Email:St.mazur@verizon.net
Mailing Address: 555 WeSt Road #1218, Cutchogue, NY
PERSON:CONTACT
Name:Karen Szczotka or Rob Brown of Robert I. Brown Architect, P.C. ..
Mailing Address:205 Bay Ave., Greenport, NY 11944
Phone#:631-477-9752 Email: karen@ribrownarchitect.com
ESI PROFESSIONAL INFORMATION:
Name:Robert I. Brown, AIA
Mailing Address:205 Bay Ave., Greenport, NY 11944
Phone#:631-477-9752 Email: rob@ribrownarchitect.com
CONTRACTOR INFORMATION:
Name: TBD
Mailing Address:
Phone#: Email:
DESCRIPTION OF PRP SED CONSTRUCTION
❑New Structure RAddition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
❑Other 200,000
Will the lot be re-graded? ❑Yes WJ No Will excess fill be removed from premises? ❑Yes MNo
1
PROPERTY INFORMATION
Existing use of property: Int ided use of property:
Zone or use district in which p miser is situat d:qx�
Are there any covenants and restrictions with respect to
,. ,. this property? ❑Yes�wNo IF YES, PROVIDE A COPY.
Check Box After Reading: 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.
`
6uth,orized El Owner Submitted ed By(print e) dAgent
�
...
Signature of Applicant:
e '
14/1 7 Orate: � . 2,
STATE OF NEW YORK)
SS:
COUNTY OF
�.,
�" ,,,�,�°�' ,being duly sworn, deposes and says that(s)he is the applicant
Na ie f individual signing r bola named,
( gning cont act) a
,y
(S)he is the
...
(Contracto ,AgenCorporate 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
..mmm_...._m._.._day of _ _ _1202- 1
_.. _.
NotaryPublic
T AC Y L. DWYER
NOTARY PUBLIC,STATE OF NEWYORK
PROPERTY NER AUT1,10RIZA1 ION NO,01 DW6306900
QUALIFIED IN SUFFOLK COUNTY
(Where the applicant is not the owner) COMMISSION EXPIRES JUNE 30,2
residing at a ,, 4 ,
; .,.. . do hereby authorize :: � . .. ." to apply on
LA
,.
my behalf to the Town of Southold Building Department for approval as described herein.
,� / �, � �
, ��.�,.� .� , b
_. „ �CL,.
Owner's Signature Date
not Owner's Name
2