HomeMy WebLinkAbout48840-Z r
r TOWN OF SOUTHOLD
BUILDING DEPARTMENT
%q 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#: 48840 Date: 2/1/2023
Permission is hereby granted to:
Sommer, Hen
385 Grissom Ln
Southold, NY 11971
To: install pellet stove as applied for.
At premises located at:
385 Grissom Ln, Southold
SCTM # 473889
Sec/Block/Lot# 78.-1-29
Pursuant to application dated 12/1/2022 and approved by the Building Inspector.
To expire on 8/2/2024.
Fees:
SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $200.00
CO-ALTERATION TO DWELLING $50.00
Total: $250.00
Building Inspector
TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
y Telephone(631) 765-1802 Fax (631) 765-9502 htt :r/ soxthodtw� ov
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only DEC
II_ J pp
1202.2
PERMIT NO. Building Inspector. i
BUJILIANG DEPT
Applications and forms must be filled out in their entirety. Incomplete TOWN OF SOUTKOLD
applications will not be accepted. Where the Applicant is not the owner,an
Owners Authorization form(Page 2)shall be completed.
Date:
OWNER(S)OF PROPERTY:
Name:Henry Sommer&Bernadette Izzillo-Sommer SCTM# 1000-
Project Address:385 Grissom Lane
Phone#:646-287-0439 TFM;171..bernieij@aol.com
Mailing Address:385 Grissom Lane, Southold, NY 11971
CONTACT PERSON:
Name:Henry Sommer
Mailing Address:385 Grissom Lane, Southold, NY 11971
Phone#:646-287-0439 Email:bernieij@aol.com
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address:
Phone#: Email:
C+ Ii �,70 INFORM,001 IN:
Narrk< : .
Walling Address:
Phone#: Email;
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
[i]Other Installation of pellet stove with venting and air intake 3,000
Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ❑Yes WNo
1
PROPERTY INFORMATION
Existing use of property:residential Intended use of property:residential
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
Southold-R40 this property? ❑Yes ta-A No IF YES, PROVIDE A COPY.
®1 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 Class A misdemeanor pursuantto Section 210.4S of the New York State Penal Law.
Application Submitted By(print name):Henry Sommer ❑Authorized Agent ROwner
Signature of Applicant: " r ; Date: ; / 1A C;.2 '2
STATE OF NEW YORK)
SS:
COUNTY OF f? +[0 4 L )
Zr-e 62/'y S—O/2t It, ey- being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
(S)he is the ",2 / e ;I'
(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
I day of � ��c 20
Notary Public
FIROPERTY OWMmR ALJTH- I '"11LINDA B.SCHOLL
Notary Public,State of New York
(Where the applicant is not the owner) No.3OA858259
Qualified in Suffolk County
Commission Exnires May,S,i02S—,
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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