HomeMy WebLinkAbout46885-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
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#: 46885 Date: 9/27/2021
Permission is hereby granted to:
Town of Southold
Attn: DPW
53095 Route 25
Southold, NY 11971
To: Modification to existing wireless communication tower: T-Mobile (3) new antennas, (3)
RRU's, (2) Hybrid feed lines and (3) tie backs ( antennea frame stiff-arms) as applied for
and per Planning Board approval.
At premises located at:
165 Peconic Ln, Peconic
SCTM # 473889
Sec/Block/Lot# 75.-5-14.1
Pursuant to application dated 9/16/2021 and approved by the Building Inspector.
To expire on 3/29/2023.
Fees:
WIRELESS COMMUNICATIONS -MODIFICATIONS $500.00
CO-COMMERCIAL $50.00
Total: $550.00
Building Inspector
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TOWN OF SOUTHOLD—BUILDING DEPARTMENT
R Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
Telephone (631) 765-1802 Fax(631) 765-9502
Date Received
APPLICATION
For Office Use Only
PERMIT NO. 14866-866 Building l victor;
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Applications and forms must be filled out in their entlrety.Incomplete
application's will not be accepted. Where the Applicant is not the owner,an
Owner's Alunhorization form{Page Z}shall be completed.
Date:June 11,2021
OWNER(S)OF PROPERTY:
Narne:Town of Southold scTM#i000-75-5-14.1 i
Project Address:.41405 Route 25, Peconic, NY
Phone#:531-765-1800 Email:
i
Mailing Address:53095 Rt 25, Southold, NY 11971
CONTACT PERSO :
Dame:Marie Russo Highlander Consultants, Inc., on behalf of T-Mobile Northeast LLC l
Mailing Address-1 55Carleton Ave, East Islip, NY 11730
Phone#:631-581-8105 Email:mrusso@highlanderine.com
DESIGN PROFESSIONAL INFORMATION:
Name:WFC Engineering -
Mailing Address.,12-01 Technology Dr, Setauket, NY 11733
Phone#:531-689-8450 Email:neil.macdonald@wfcaia.com
CONTRACTOR INFORMATION:
Name:Corncell Construction
I Mailing Address:1373 Lincoln Ave, Holbrook, NY 11741
Phone#: mikeA@com-cell.com
531-6r5 -5915 7EMail:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition @Alteration ❑Repair ❑Demolition Estimated Cost of Project:
910ther upgrade to i r telecammunicstions facility 865,000.00
Will the lot be re-graded? ❑Yes I+s No Will excess fill be removed from premises? ❑Yes ❑No
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PROPERTY INFORMATION
MExistingoperty:police Dept&telecommunications I intended use of property:Police Dept&telecommunications I
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
{g,pvt ( this property? i7Yes MiiNo 1F YES, PROVIDE A COPY.
pa ck SoxAfter Reading: erl tr or/d ign professional is responsible for all drainage and storm water lumn as provided by
Chapter 235 of therown Code. APPUCATION IS HEREBY MADE to the Buildingrt of a Building Permit pursuant to the Building Zone
ordinanceof the Town of Southold,Suffolk,County,New York and a9w applilcableLaws,ordinances or Regulations,for the const ion of build
add3" _ or for removal ordemolition as he .n d . e a" _carA agreft to comply with an applicable laws,ordinances,building code,
housing code and regulations am to admit StAhonzed lnm>ectm on premim armdIn buildings)for necessary impectlons.False statements made herein are i
punishable as a Clm A misdemeanor - ns to Section 210. 3 of the.*ftw York State Penal Uw.
Mari usso
ApplicatIO Submitted By(print name). Authorized Agent ❑Owner
Signature of Applicant. = 3 Date:
STATE OF NEW YORK)
S5:
COUNTY OF Suffolk )
Marie Russo being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the Agent
(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 fil herewith.
Sworn before me this
)L
a y:of
da u n C- 24
Notary Public
PROPERTY OWNERtc Slate- Now iOk
No C. r_ , 483
Where the applicant is not the owner) �A, 3
t lam£ a
residing at F
do hereby authorize mafapply on
my behalf to the To, of Southold Building Department for approval as described herein.
QI
Owner's Signature Date
Print Owner's Name
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