HomeMy WebLinkAbout48675-Z rt 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 #: 48_675
Permission s hereby� X22
Date: 12130/2
granted to: ._.
halErika
1800 Little eWette
NY nic Bay Rd .. .._ ..
To-
Construct an accessory pergola to an existing single family dwelling as applied for.
At premises located at:
800 Little_Pec nic B _
SCTM #473889 � ay Rd, Cutcho ue
ec
lock/Lot# 111--
Pursuant to application dated 10/31/2022 and approved by the Building Inspector.
To expire on 6/30/2024.
Fees: .�._.�,.�.._.._.
ACCESSORY $132.00
CED TIS 1%'-'ATE Or OCCUPANCY
$50.00
Total: $182.00
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 littps://www.southoldtownny.gov
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only „
PERMIT NO. Building Inspector:
0 a_� 3 21-1"J
k;
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 AuthdrUatI6n forM,"(Page 2)shall be completed:
Date: ( i ....
OWNER(S)OF PR PERTY:
a
Name
SCTM # 1000-
Project Address: j i'l
„Phone#: 1.µ�. "�"�� .� YEma :
Mailing Address: e��
CONTACT PERSON:
Name: '`
Mailing Address: ����
Phone#: �u ��mm � � °°� Email:
M
a "
DESIGN PROFESSIONAL INFORMATION:
Name:.
Mailing Address:
Phone#: Email:.
CONTRACTOR INFORMATION: .,
Name:
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTROCTION
Np_ Cost of Project:
New Structure ❑Addition ❑Alteration ❑Re air ❑Demolition Estimated
01ther $
Will the lot be re-graded? ❑Yes No Will excess fill be removed from premises? ❑Yes XNO
1
.� IT
PROPERTY INFORMATION'
Existing use of property: ", untended use of property;
Zone or use district in which premises is situated: Are there any covenant and restrictions with respect to
this property? ❑YesNO IF YES, PROVIDE A COPY.
i�hec BOX After Leading; The owner/contractor/'design iprofessional Is responsible for all drainage and storm water issues as provided by
hapter 36 of the Town Codd. APPUC TION IS HEREBY MADE to the ullding Department for the issuance of a Building Permit pursuant to the"'gulldlrtg'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. 1
Application Submitted B rjnm ; ❑Authorized A ent " Owner
PP Y(Pw, ". g
Signature of Applicant: Dater
CONNIE D. BUNCH
Notary Public,State of New York
STATE OF NEW YORK) No. 01BU6185050
SS: Qualified in Suffolk County
Commission Expires April 14, 2DQ�_y
COUNTY OF )
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 � 'Q 20
Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
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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