HomeMy WebLinkAbout28347-Z FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Hall
Southold, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
PERMIT NO. 28347 Z Date MAY 2 , 2002
Permission is hereby granted to :
TERESA POLYWODA
PO BOX 234
SOUTHOLD,NY 11971
for
DEMOLITION OF A 144 SQUARE FOOT FRONT PORCH AND A BASEMENT ENTRY
ONLY, AS APPLIED FOR
at premises located at 2675 MAIN BAYVIEW RD SOUTHOLD
County Tax Map No. 473889 Section 078 Block 0001 Lot No. 013 . 001
pursuant to application dated APRIL 29, 2002 and approved by the
Building Inspector.
Fee $ 35 . 00
/f
Authorized Signature
ORIGINAL
Rev. 2/19/98
TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIS
BUILDING DEPARTMENT Do you have or need the following;before applyin
TOWN HALL Board of Health
SOUTHOLD,NY 11971 3 sets of Building Plans
TEL: 765-1802 Survey .
PERMIT NO. 0-g3H4� Check
Septic Form
N.Y.S.D.E.C.
Trustees
Exa_m?ned J 'oL ,20__c� Contact..
Approved ,f- b2 ,20 a2 Mail to:
Disapproved a/c
Phone:
Building Inspector
APPLICATION FOR BUILDING PERMIT
APR 2 9 2002 . a
Date o2 200,
If
INSTRUCTIONS
a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with
sets of plans, accurate-plot plan to scale.Fee according to schedule,
b.plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or
areas, and waterways.
c. The work covered by this application may not be commenced-before issuance of Building Permit.
d..Upon approval of this application,the Building Iuspector.will issue a Building Permit to'the applicant. Such a permit
shall be kept on the premises available for inspection throughout the work.
e.No building shall be occupied or used in whole or in part for any purpose what-so-ever until,a Certificate of Occupat
'is issued by the Building Inspector.
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, or alterations or for removal of demcifign 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 for necessary'inspections.
(Signature of applicant or name,if a corporation)
(Mailing address of applicant)012
�D
State whether applicant is.owner, lessee;agent, architect, engineer, general contractor, electrician,plumber or.builder
Name of owner of premises � -�� ® S A- a L IJ A-
(as on the.tax roll a= sWeed)
If applicant is a corporation, signature of duly authorized officer
(Name and title of corporate officer)
Builders LicenseNo. _
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which proposed work will be done:
S M Ad A) 3 'V l Ew R 0 l,fib f-To
House Number Street Hamlet
County Tax.Map No'. 1000 SectionBlock Lot l e
Subdivision _ Filed Map No. Lot
(Name)
2. State existing use anid,occupaney of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy t A
b. Intended use and occupancy L
3. Nature of work.(check which applicable):New Building Addition Alteratio
Repair Removal Demolition ; Other Work
(Description)
4_ Estimated Cost Fee
(to be paid on filing this application)
5. If dwelling, number of dwelling units Number of dwelling units on each floor
If garage, number of cars
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use.
7. Dimensions of existing structures,if any: Front .' ;2� o Rear Depth y
Height [f Number of Stories
Dimensions of same structure with alterations or additions: Front a Rear
Depth �,� Height �` —. Number of Stories
8. Dimensions of entire new construction: Front Rear Depth
Height 'Number of Stories
9.. Size of lot: Front G / Rear 5-0 Depth r9.-0 ,2
10. Date of Purchase .7 A. 2 Name of Former Owner r b z- I
11.Zone or use district in'which premises are situated
12. Does proposed constriction violate any zoning law, ordinance or regulation:
13. Will lot be re-graded Will excess fill be.removed.from premises: YES NO
14.Names of Owner of premises , 1� I At Address 2 -74 c._C; alt°-done No. `?�f V
Name.of Architect �,�. Address Phone No
Name of ContractorAddress Phone No:•
15. Is this property within 100 feet of a tidal wetland? *YES NO
• IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED
16. Provide survey, to scale, with accurate foundation'plan and distances to property lines.
17. If elevation at any-point on property is at 10 feet or below;must provide topographical data on survey,
STATE OF NEW YORK)
SS:
COUNTY OF )
Sq being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)He is the � � ���� 'S
' Ftractort, Corp
:)f said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application;
hat ali statements contained in this application are true to the best of his knowledge and belief;and that the work will.be
?erfomied in the manner set forth in the application filed therewith.
Sworn to bgfore me this
--�( day.of
Notary Public Signature of Applicant'
STEPHEN G.REMUZZI,JR.
NOTARY PUBLIC,State of New.-Yolk
02-RE251965
Qualiried in Suffolk Cou
Commission Explres July 31, ��'
TONIN OF SOUTHOLD 0 OPERTY RECORD CARD _ ?
ri
DWNER STREET (�75 VILLAGE DISTRICT SUB. LOT
=ORMER OWNER N ACREAG€_
S
W TYPE OF BUILDING
�`".' -..�d:�3'' �<.. �� .;: :'.,-��:,.:r_e'.t, u?:.,-"�^"..,� ,. .' •.: F t `�sof Ca� t Q 7 sem' `� � �°k�'�'�•,�„* r.,. v�'�a
ES. SEAS. VL. I" COMM. FIND. I CB. � I MISC. I Est. Mkt. Value
-'SAND IMP. TOTAL DATE REMARKS
' 6 IX P d G u at/
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0 w•` ' .�3 �,giyi� Ovfje�f.�s �c'- /'- ��3 - �eE€'es quo Vv V—
AGE BUILDING CONDITION
NEW NORM .L BELOW ABOVE FRONTAGE ON WATER
Farm Acre Value Per Acre Value FRONTAGE ON ROAD
liable 1 BULKHEAD
liable 2 DOCK
liable, 3
oodland
mmPland %
ushland
)use Plot
)ta l
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MMMMI MEN
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Ext. Walls Interior Finish
Fire Place Heat
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Porch Roof Type�..
Patio Rooms 2nd Floo
• •a- Driveway �• -
REV. DATE ITEM
NO.
PLOT AREA = 41,264SS.F.
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ORWG. BY:SB
CHK, BY:CB
DATE:FEB.2002
FILE NO:02-127
THE EXISTENCE OF RIGHT OF WAYS AND/OR EASEMENTS OR RECORD, IF ANY, NOT SHOWN ARE NOT GUARANTEED. of NEW Y SHT.
THIS SURVEY WAS PREPARED IN ACCO"DANCE WITH THE EXISTING CODE OF PRACTICE FOQ LAND SURVEYORS A �
DOPTED O
BY THE NEW YORK STATE ASSOCIATION Ur PROFESSICNAL LAND SUPVEYOPS. d` RF2
UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 SUBDIVISION 2 OF THE g i`
NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING THE LAND SURVEYOR'S INKED SEAL
OR EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. CEPTIFICATIONS INDICATED HEREON
SHALL RUN ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED, AND ON HIS BEHALF TO THE TITLE ` 44 '
COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON AND TO THE ASSIGNEES OF THE 4 044
�O
LENDING INSTITUTION. CERTIFICATIONS ARE NOT TRANSFERABLE TO ADDITIONAL INSTITUTIONS OF' SUBSECUENT OWNERS. `JCbJ4
S`.,0 LAND S�
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APPROVED AS NOTED
DATES 6=�:a B.P.# �
FEE: t 3'5BY: �P6?
NOTIFY BUILDING DEPARTMENT AT
765.1802 9 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS:
1. FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING
3. INSULATION
4, FINAL - CONSTRUCTION MUST
56'2 BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET
7'g 13'10 14'4 6110 9'4 1'3 2'10 THE REQUIREMENTS OF THE N.Y.
STATE CONSTRUCTION & ENERGY
CODES. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
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