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ADDRESS Southold NY, 11971
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I ANN OWNER: Old North Road Barn LLC
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TURCIC Southold, NY 11971
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Planning Department (P.D.) Referral:_—, / l 7
p.D.fla
to Received: �� � ��-- Date of Comm
0Z 2
ent:=�_---
Cornment
I ` .
Signature of Pl 11-l g Dept. Staff Reviewer
" nal Detrrtin Ion
Date:—/—/—
D ecis ion-.
ate: l fDecision: ..__.._. . _ __w_ ... .. ..
cno,_I.n.gnertnr_.._.
TOWN OF SOUTHOLD BUILDING 1 :MIT APPLICATION CHECKLIST
BUILDING DEPARTMENT Do you have or need the following,before applying?
TOWN HALL Board of Health
SOUTHOLD,NY 11971 4 sets of Building Plans Yes
TEL: (631)765-1802 Planning Board approval
FAX: (631)765-9502 Survey Yes
SoutholdTown.NorthFork.net PERMIT NO. Check
Septic Form
N.Y.S.D.E.C.
Trustees
� DD C.Q.Application YeS
�f Flood Permit NA
Examined 20 Single&Separate NA
NOV - B 2017 Storm-Water Assessment Form
Contact:
Approved 20 BIJ1= n']P Mail to:
t `
Disapproved a/c TONVN OFSO O Samuels&Steelman Architects
Phone: 531 734-6405
Expiration ,20
B i tn,w,inspector
APPLICATION FOR BUILDING PERMIT
Date November 2, .20 17
INSTRUCTIONS
a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4
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 Inspector 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 the Building Inspector
issues a Certificate of Occupancy.
f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of
issuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the
property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an
addition six months.Thereafter,a new permit shall be required.
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 r demolition as herein described.The
applicant agrees to comply with all applicable laws,ordinances,building code,hou ng code,ar11 4egulations,and to admit
authorized inspectors on premises and in building for necessary inspections.
ig of applicant or name,if a corporation)
2523 Main Road, Cutchogue, NY 11935
(Mailing address of applicant)
State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder
Architect
Name of owner of premises Rd Nnrth Rnaci Flare�( C
(As on the tax roll or latest deed)
If applicant is a corporation,signature of duly authorized officer
(Name and title of corporate officer)
Builders License No.
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which proposed will be d6me, -
5195 Old North Road Southold
House Number Street
County Tax Map No. 1000 Section 51 Block Lot ��
Subdivision Filed Map No. Lot
2. State existing use and occupancy of premises and intended use and occupaacv oreposed construction:
a. Existing use and occupancy EXISTING STORAGE BLDG. (A �
b. Intended use and occupancy 1NINE PRODUCTION gLr}O
3. Nature of work(check which applicable):New Building Addition X Alteration
Repair Removal Demolition Other Work-
(Description)
4. Estimated Cost 400,000 Fee
(To be paid on filing this application)
5. If dwelling,number of dwelling units 0 Number of dwelling units'on each floor -
lf garage, number of cars
6. If business,commercial or mixed occupancy,spec-nature and extent of each type of use. Wine Production
7. Dimensions of existing structures,if any:Front 101' Rear 101' Depth 90'
Height 23' Number of Stories one
Dimensions of same structure with alterations or additions: Front 131' Rear 131'
Depth 90' Height 23' Number of Stories one
8. Dimensions of entire new construction:Front - Rear Depth -
Height - Number of Stories
9. Size of lot:Front see site plan Rear Depth
10.Date of Purchase Name of Former Owner
11.Zone or use district in which premises are situated AC
12.Does proposed construction violate any zoning law,ordinance or regulation-YES NO X
13.Will lot be re-graded?YES NO X Will excess fill be removed from premises?YES NO x
14.Names of Owner of premises Old North Rd. Barn Address 5415 Old North Rd ' .
Name of Architect Nancy Steelman Address 25235 Main load Phone No (631)734-6405
Name of Contractor Address Phone No.
15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetlandl,,*YES NO X
*IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BE REQUIRED.
b.Is this property within 300 feet of a tidal wetland?*YES NOS
*IF YES,D.E.C.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,
18.Are there any covenants and restrictions with respect to this property?* E S NO X
*IF YES,PROVIDE A COPY.
STATE OF NEW YORK)
SS:
COUNTY OF Suffolk )
Nancy Steelman being duly sworn,deposes and says that(s)he is--he apvlicant
(Name of individual signing contract)above named,
(S)He is the Architect
(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 knowledge and belief_,and that the work will be
performed in the manner set forth in tf,a applicatID"lM SICK
Sworn to before me this NOTARY PUBLIC-STATE OF N ORK
day of20—�7 No.01M
u - Qualified in S [
NotaryPublic iSSi{ln Ftp e
mature of Applicant