HomeMy WebLinkAbout47068-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#: 47068 Date: 11/1/2021
Permission is hereby granted to:
Hansen,John
320 Mount Beulah Ave
Southold, NY 11971
To: construct accessory in-ground swimming pool as applied for.
At premises located at:
1115 Farmveu Rd, Mattituck
SCTM#473889
Sec/Block/Lot#121.-7-8
Pursuant to application dated 10/21/2021 and approved by the Building Inspector.
To expire on 513/2023.
Fees:
SWIMMING POOLS-IN-GROUND WITH FENCE ENCLOSURE $250.00
CO-SWIMMING POOL $50.00
Total: $300.00
B ' ing Inspector
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 htti}�.3','NvNvW,soaltholdtownit .E!o,
For Office Use Only - Date Received
PERMIT NO. X Building Inspector: {
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Ii
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 Li
Authorization form{Page 2}shall be completed. UI!DING DEPT
T�4 aFN SOUPHOLD
3
APPLICATION FOR BUILDING PERMIT Dater t
OWNER(8}O OPERTY:
Name- ` Tax Map#:SCTM#1000-
Physical Address: y in rI C VV
.
Phone#: Email: cf
–71
Mailing Address:
CONTACT PERSON: '
Name:
Mailing Address: }
Phone#: }. Email: f I
r
DESIGN PROFESSIONAL INFORMATION.
Nam 1 -
i
; Mailing Address:
2-7'--S # Y
Phone#: ` rMail:' .
CONTRACTOR INFORMATION., 1
Name: _
j Mailing Address: Lo
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a
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
' w Structure ❑Additi n ❑Alteration ❑Repair ❑Demolition Estimated Cos"f Pro' t
her
i
Will the lot be re graded? ❑Yes*0Will excess fill be removed from premises? 6 e ,❑No
y
PROPERTY INFORMATION
Existing use of property: Intended use of property:
Date of Purchase: Name of Former Owner:
1
Zone or use district in which premises is situated: ; Are there any covenants and restrictions with respect to
this property? ❑Yes ONO 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
s 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 i
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,
j 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 n 2100 of the Now York State Penal Law.
Application SubmittedB Tint name ❑Authorized Agent ❑O•Jvner
Signature of Applicant: Date:
STATE OF NEW YORK)
SS:
COUNTV OF )
being duly sworn,deposes and says that(s)he is the applicant
44u,-
(Name of individual signing contract)above named,
(S)he is the
(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 ji I
day of 6�4N)Xr
,201 XJ
6uc
Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
g t a `. I €
I, residin at y I r
do hereby authorize K to apply on
my behalf to the Town of Southold Building Department for approval as describ erem.
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Owner's Signature M It Date
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