HomeMy WebLinkAbout48813-Z r TOWN OF SOUTHOLD
BUILDING DEPARTMENT
N f" TOWN CLERK'S OFFICE
SOUTHOLD, NY
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES
WITH ONE STET OF APPROVED PLANS AND SPECIFICATIONS
UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)
Permit#: 48813 Date: 1/27/2023
Permission is hereby granted to:
Walsh Park Benevolent Cor
161 Oriental Ave
PO BOX 684
Fishers Island, NY 06390
To: Construct fire repairs to existing fire damaged cottage as applied for.
Additional certification and / or plans may be required.
At premises located at:
Montauk Ave, Fishers Island
SCTM # 473889
Sec/Block/Lot# 9.-5-8
Pursuant to application dated 1/26/2023 and approved by the Building Inspector.
To expire on 7/28/2024.
Fees:
Total: $0.00
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
Date Received
I IIID 711 10111V FOR BU11111 MING PEIIU "l
For Office Use Only
PERMIT NO. Building lnspector° JAN 2 4 2023 FD
Applications and forms must be filled out in their entirety. Incomplete
i not be accepted. Where the Applicant is not the owner,an
IL I
applications will p PP ,. tnrN M� n'rn'n
Owner's Authorization formPag e 2 P
shall be completed.
Date:
OWNER(S) OF PROPERTY:
Name: I✓AL5A, .4/L4 1?gJ✓Z dd L£ r SCTM#1000-
Project Address:
Phone#: Email
Mailing Address: O C �s �SG y OCP39,0
. �WvD
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CONTACT PERSON:
Name: MA-7T. ��w�►,�S
Mailing Address:
Phone#: V--(P O Z a /:7 ZV Email: ME/ kV-4AZ 5
DESIGN PROFESSIONAL INFORMATION:
Name
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION: /'
Name:. /->�4
_J . 0--00 2 r r>d `O,
Mailing Address: 0 �sb7� �� V Q�o35a
Phone#: &?/ - 3-;?V-0Email: JZC.DU 7N 7-0 bCDIPPAW.COM
DESCRIPTION OF PROPOSED CONSTRUCTION
p Estimated Cast of Project:
❑OtheStruct�re ❑Addition ❑Alteraticr�� � airs❑Dem9oliti�/A $sti� 0�0 .--
V roe
Will the lot be re-graded? ❑Yes Fe Will excess fill be removed from premises? ❑Yes o
1
PROPERTY INFORMATION
Intended use of property:
Existing use of property: s F
. Are there any covenants d restrictions with respect to
Zone or use district in which premises is situated: this property? ❑Yes No IF YES, PROVIDEall A COPY.
by
Box x t�!I' �l� rG�q,l9k�: y'he owner/contractor/design professional is responsible for
issuance of aeBuilding P nit pursuant to tNroaand storm water issues as iauRYdicrog lone
i liIw�i.a A
applicable Laws,ordinances or Regulations,Fear the construction , qull in gcode,
Chapter���of the Town Code. AppLMCFtTiQPri IS i�iN»k�imBw MADE to the ituiNciing i�epartrraent for with all applicable iee�as,¢arciinances,building
Ord of tiros ovwn of Southold,Suffolk,County,New York and other app inspections.raise statement
made herein are
additions,alterations or for removal or demolition as herein described.ilte applicant agrees (s comply r necessary pp
housing code and regulations and to admit authorized inspectors on premises and In building(s)
punishable as a Class A misdemeanor purswrant to Section 210AS of the New"Cork State penal Law.
O S � uthoriaed Agent ❑Owner
J
Application Submitted By (print name):
Date: /-If-Z3
Signature of Applicant:
STATE OF NEW YORK).
SS:
COUNTY OFA )
being duly sworn, deposes and says that(s)he is the applicant
10a
(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 pe
or have performed the said work and to make and file this
application;that all statements contained in this application are true to the i e st f his/her knowledge and belief; and
applic application that the work will be performed in the manner set forth in the app
Sworn before me this
20 rotary Public
day of 2- ,&5
(Where the applicant is not the owner)
W ''" residing at
�U Gc-P-5CtNT Int—
AU A � fCi� to apply on
Y 0b3� do hereby authorize
my behalf to the Town of Southold Building Department for approval as described herein.
µ ..
-�- --- Date
Owner's Signature
Print Owner's Name
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