HomeMy WebLinkAbout1000-141.-4-5 C. IV FOR INTERNAL USE uNt Y
MAR 1 ! 2021.
S lT E PLAN L1 S E _D ET E [N fT[O
Naar°in7 nig Board
Initial Deter[ ination
Date Sent:
Date:
Project Name: ... _. .
project Address: i` �.. .. .. ��
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Zoning
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Suffolk County Tax Map"No.:� I
}/ a -
R a~est .
..
do ,ur en as to
~ of Buil(
Permit Application and suPP
otting � tatiort
(Note: Copy
proposed use or uses should be submitted- Y/
` anon as to whether use is permittcd: ... ....�.- -�
-[nif[al Determtn
. •a[ Determination as to whether site plait is regUl� „'d:_. . _...
a n�ti
w - Signatu� Wing Inspector
Referral:..-----~
Qianning Department (P.D.)
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12
l _ Date of COUTI
p D.Hate Received: _-
cn 1o"
entsrt � .w vtD - r 5
Comm
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eviewer
Signature 0-1 lining f• Sfaff R
nnal Deterr lt"t Jon �
Date:=
_ R .t. ... a I n_qn . tn'
ofo TOWN ' . —B i` E T °SGT" e
Town Hai Annex.�'�'371 : r(R Road
P.0.Box, t f 7/9 Soulmom,,,NY, It 971-0959
Te�e�ncozYe(6317I IWZ Fax(63 It 75-4
APP �� g;;w y sem'
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For Office Use Only
PERMIT NO. Building Inspector:......ww
.,B 2 3 2021
Applications and forms must be fi'f(ed out in their entirety.(ncomp(ete
applications will not be accepted. Where the Applicant is not the owner,an
Owner's Authorization form(Page 2)shall be completed.
Date:2-24-21
OWNER(S)OF PROPERTY:
X Name: '7,E-T-e� yL V,.A j�f C 0 SCTM#1000-14-1-4-
Project
41 -Project Address:140 Pike Street, Mattituck NY, 1195
Phone#: ?)?� Z Z 1 0 0 1 QC� Em if: M V\-,l C@ IM A i I. C U r ✓(
k
Mailing Address: 14 S 5 C}-M L RO V
CONTACT PERSON:
Name. �-F—C � yVt PrVZ- C
Mailing Address: q 5 5 SCtbO L.-HO U S-E 0-040 Cv-f C}W G-v �F, ll ( I ( C1 3$
Phone#:332-210-0149 Email:marcoartnyc@gmaii.com
DEMN Ol L INFORMATION:
Name:Nicholas Mazzaferro,PE
Mailing Address:PO BOX 57, Greenport, NY, 11944
Phone#:516-457-5596 Email:nickmazzaferro@verizon.net
CONTRACTOR INFORMATION:
Name:TBD
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
ONew Structure ❑Addition *Alteration ❑Repair l]Demolition Estimated Cost of Project:
❑Other $10,000
Will the lot be re-graded? OYes _ No Will excess fill be removed from premises? QYes W No
1
PROPERTY INFORMATION
Existing use of property:pay Spa Intended use of property:Restaurant
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
H B - Mattituck this property? ❑Yes No IF YES,PROVIDE A COPY.
..... , �,-:,reg �_ ai re Gefor an
Z3fi c*theTbm rr-&- AMICATM!S HUMY ARAM to dw Buming Degpar7o"mt far the Isnamce of a Perna t pursuantto the BuffidftZmte
Onfoance of3heTiwn of SauftK Sttfolk,County,K,4--w Yank and other appficable Lagm Ord` .s or Repboom,forttte consbuction of b i
addftk,sn%afteradm or for rerswral or rod ort as herein dem The aMkent aWees t D cue+arils a➢appotWe taws,ar code,
sing rhe mW and to adrok audumbed yrs on premdses and in bujItHads)for neawwy knpeakm Fabe St t.rade dein are
pun*Awhie as a Mms.A moidemanor prrviant to Section 2ML45 of the New Yash State Penai taw.
Application Submitted By(Print name)-- 't—T te 44* -( 6 ❑Authorized Agent ROwner
Signature of Applica : Date:rp N) z 3 2 apt
STATE OF NEW YORK)
S :
COUNTY OFSLAJ01�,,_.— f e�eg- 'M )
C being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract) above named,
(S)he is the ~f' °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 file therewith. LYNDSEY BARKER
NOTARY PUBLIC,STATE OF NEW YORK
Sworn before me this No. 01 BA6156676
ualified in Suffolk County
�3 day of �� ( �i�ssiorw Expires November 27,20
Notary Public
.,„ ,,,,,,,,,,.,,,,, ,,,,,,,,, ,,.,,,,,,,,,,,,,„ ....,...
(Where the applicant is not the owner)
I, a 's Z 41t residing at o
do hereby authorize Pe 7c i to apply on
mynntheTown of Southold Building Department for approval as described herein.
zz
Owner's gnature Date
_
Prlfll OVVilePr.�Nd(fle
2