HomeMy WebLinkAbout47294-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
20
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#: 47294 Date: 1/5/2022
Permission is hereby granted to:
Country House by Bay LLC
12680 Route 25
East Marion, NY 11939
To: Construct accessory pavilion at existing single family dwelling as applied for.
At premises located at:
12680 Route 25, East Marion
SCTM # 473889
Sec/Block/Lot# 31.-14-13
Pursuant to application dated 1/4/2022 and approved by the Building Inspector.
To expire on 717/2023.
Fees:
ACCESSORY $172.00
CO-ACCESSORY BUILDING $50.00
Total: $222.00
Building 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 hyips g � �
Date Received
AP113TICATION FOR BUILDINIG
For Office Use Only
PERMIT NO. Building Inspector:
Li
Applications and forms must be filled out in their entirety.Incomplete
applications will not be accepted. Where the Applicant is not the owner,an TOWN SOUTHOLD
Owner's Authorization form(Page 2)shall be completed.
Date. 12 -30 s Z i
OWNER(S)OF PROPERTY:
Name: lw SCTM# 100-
Project Address:
d �i� S� "LS
Phone#: �b Email: AC E TW ele-T aAon. .qzm
Mailing Address: 12 hid �i!•�ti� �,jj ���. Z.�� EA-sT ���� J��39
CONTACT PERSON:
Name:
Mailing Address: � ,c S +DIi I-+oLJ�s N`4 11.`x'71
Phone#: 6--,I — 111 S—9Email: �� rJ�,c,�
DESIGN PROFESSIONAL INFORMATION:
Name: KEI-A ._ P�ESt�rA
Mailing Address: �r► -.1� 5 + niF�. t-14 SOU ail l
Phone#: ( q Email:
CONTRACTOR INFORMATION:
Name: NA -
Mailing
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
,NNew Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estirpated Cost of Project:
Other ` c &. �11 A,
Will the lot be re-graded? ❑Yes [�N0 Will excess fill be removed from premises? ❑Yes JXNo
1
PROPERTY INFORMATION
Existing use of property: -S,� ��tit✓ Intended use of property: ��11
1iS Q4"z Tc ilp.
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
®Ltothis property? ❑Yes Mo IF YES, PROVIDE A COPY.
lif 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 Gass A misdemeanor pursuant to Section 210.45 of the New York State Penal Law.
Application Submitted By(print name): Authorized Agent ❑Owner
i '
Signature of Applicant: Date: --30
STATE OF NEW YORK)
SS:
COUNTY OF SXM -te - 1
. F,(4L- being duly sworn, deposes and says that(s)he is the applicant
(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
day of 20
Notary Public
LATION
(Where the applicant is not the owner)
�eio ---r->- s c+IFF-T
I, residing at
do hereby authorize to apply on
my behalf to the Town of Southold Building Department for approval as described herein.
Owner's Signature Date
Print Owner's Name
2
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