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Home My WebLink About1000-17.-6-10 RECEIVED11 FOR INTERNAL USE UNLY 0( 1 019 SITE PLAN USE fie:) rBu . ., � _ _ _ A �..M ._ .,,..._.. _.. .....,,,,-.,.J Initial Determination Date: � Date Sent: � Project-Name.- • Project Address:_...,�....m Suffolk County Tax Map : - o. •1g00=--C=�L__ _ . ��Zoning District: „ Request, (Note- Plication and Wsu �._w_..,,,� — _�� -proposed use or uses should be submitted.) PPorting documentation as to initial Determination as to whether use is permitted: Initial Determ.ina-tion as to whether site plan is e Uired: S14e �A r) rea V/ Si tureo Bui"Iding Irsetor�_, Planning Department (P.D.) RefeFral: _ P D. Date Received- 10 Date of Comment: I L i% LX-OP Signature of Planning pt.-Staff Reviewer Final D tt rl"fiinnfi n Date: / Decision: TOWN OF SOUTHOLD BUILDING PERIv1IT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD,NY 11971 (3sets of Building Plans TEL: (631)765-1802 Planning Board approval FAX:(631)765-9502 Southoldtownny.gov PERMIT NO. Check 'S,-ptic Form N,,Y.S.D.E.C. xustees CD Application ocd Perms Examined 20 :gle&Separate ass Identification Form rm-Water Assessrent Form � OCT 1 5 2019 Con#ac#: ff�''�� Approved 20 Mail to:l�wsL,!N\, ,\ Disapproved ale Phone: Expiration 120 Building Inspector APPLICATION FOR BUILDING PERMIT q Dated 20 ! 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.Piot 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.Eve.r building permit shall expire if t-he work authorized has not commenced within 12 months ager the date of issuance or has not been completed within iS months fro>n 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 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 for necessary inspections. (Signature of applicant or name,if a corporation) Wailing address of applicant) State whether applicant is or,Lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Name of owner of premises roek- ,\- 1� ajje (As oniflic tax roll or latest deed) If applicant is a corporation,signature of duly authorized officer (Name and title of corporate office) Builders License No. � Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposeA work will be done: 6 6<\- House Number Street { Hamlet County Tax Map No. 1000 Section �,+�rT Blocic `1=1 Lot Subdivision Filed Map No. Lot 2. State existing use and occupancy of premises and iptended,use and cup ncy of roI o ed construction: a. Existing use and occupancy } [Vl y b. Intended use and occupancy 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work C -C�� / (De tion) 4. Estimated Cost l�' z 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 ` I 130 6. If business,commercial or mixed occupancy,specify nature and extent of each type of use. 7. Dimensions of existing structures,if any:Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction:Front Vq— Rear 1,' Depth ✓- Height \�1 p ac Number of Stories \ p 4. Size of lot:Front bl� Rear leo Depth <;IZ) 10.Date of Purchase Name of Former Owner 11.Zone or use district in which premises are situated 12. Does proposed construction violate any _r zoning law,ordinance or regulation?YES—NO 13.Will lot be re-graded?YES NO"�Vill excess fill be removed from premises?YES NCV::�:) 14.Names of Owner of premises &� t Addres s � - Phone No.It Name of Arcl itect y�-te Grp Addres Phone No� t- ^'LQ Name of Contracto to-)iL�14�� Address`k v*?, Phone No.'�3a - 15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO *IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BE REQUIRED. b.Is this property within 300 feet of a tidal wetland?*YES NTO�C` *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. 1 S.Are there any covenants and restrictions with respect to this property?*YES NO *IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF . (, being duly swom,deposes and says that(s)he is the applicant (Name of individual signing�ontract)above named, (S)He is the Qtd��r (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 the application filed therewith. Sworn tn before me this day of 20' R fWYER NOTARY PUBLIC, S A EYL D OF NEW Y , `Na701 D W63o6900 Notary Publ QUALIFIED IN SUFFOLK COUNTY Sign- re of Applic .` COMMISSION EXPIRES JUNE 30,2Q4