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20
TERMINATIO hi
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SITE PLAN USNannlng 5.0
[nifia[ Detet`miinafion f a.�I o2U
te Sent:
Da —
Date: �
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Project{Marne: � . �.�
project ddress. _.�
Tax Map No.:1 C 0
3zoning District :�.... ._ _.. .
Stfffotk County ._
[kation and ......�.�..�.��� __�_
ReqLfest
pfi supporting docurr�e1station"as to
([�tot�y of Building Permit App
proposed use or uses should beubrititted_)
" is �ern"titted:
-Initial Deterniinafion as to whether use [”
[•D eterm
ination as to whether site plan is reciured*._ -�
1 riga `
(4 ector
�+
--� � Signature o. Building [rIS4
" ent (P.D.-) Refei�ra[:, ..,..,�...u��------� �
Punning Departn► f �C
P.D.flats Received: -Date of Cot,�1�"'ne�`it=�.�.�-�--.---�---�-
l t
n"�rrtnts: ��,N-Ir,6
Co �i
tWA
conk-
Sig an Lure ofi P1a Deptpt._Staff Reviewer
Final Det6tIllinatJon
Date:=
Decision=_ w_.... _. ._..._._.._w.k .m.._ .,._.__.... _.,_._. ... .___.__ .. .. — _ __
nf RtiilcfinaLnGnPcta�
It ks 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 httt)s://www.southoldtoMLnny.g.oy
Date Received
APPLICATION FOR BUILDING PERMIT
' � � M5 I
�V
For Office Use Only r'
PERMIT, NO. Building Inspector.
DEC - 4 2020
Date:
O PO�»ERT�r�
Name.Or1 11ient Point scT
#i000
M
Phys N al Addresses "Old Main Road , Orient Point , NY 11.957
Email:pvasyahoo.
com
Phone# 516 721 1605 Em„ ilas77 _
Mailir g Address:11 Hilltop Drive, Bayville NY 11709
CC�Nw�C N"221»
asilas
rr, :Peter V
Mailing Address:11 Hilltop'Drive Bayville , NY 11709
Phone#:516 628 2296 Email:pvasilas77@yahoo.com
DESICaiN P +l I SMNAL INFOI N1 Tl!G N
„z
Name:
Mai.
ling Address: `
Phon�#: Email:
CONN1ACTOFt INNORNITNON:
Name:
Mailing Address:
Klorw #: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑Ner r Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
130tI erTemporary greenhouse w dirt floor $2,000•
Will the lot be re-graded? ❑Yes RNo Will excess fill be removed from premises? ❑Yes RNo
C
1
PROPI IM FORMATION
Existing use of property:Farming Intended use of property:Farming
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? ❑Yes R'No IF YES, PROVIDE A COPY.
❑ 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. APPUCATION 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 taws,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
p liable , la i, .rtlisdemeartorRM!sud�4t4:�?�dd. „f StatrcP
WIS
I
Application Submitted By(print name): ` ❑Authorized Agent @Owner
_w.. , ....n....a. .. ...._ ., e�,... .. ...,.....,,e m.._. ... .._ _ _.
Signature of Applicant. 57 �— Date:
STATE OF NEW YORK)
SS:
COUNTY OF
i
yos I /q J being duly sworn,'deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the nOUn`e�
(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 filet rewit'
Sworn before mire this
�19 day of /`d�f:"M6tS'1� 20
lob im otary Public
MICHAEL K BEME
Notary Public,5tattr ofNew York
NO.016E6097425
MYCommission` 1 pfr�as Auy�ill. 1 ERTY OWNER AUTHORIZATION
ere 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