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Home My WebLink About1000-109.-1-13.1 r d 6�. NIVI „ �.. ✓' *„ A ,. r%,. OL ol old, \ VN .M FOR INTERNAL USE ONLY SITE P LA N USE DETEI�.M�IATION Initial Dq erm natllan Date ! Project Name: l/ Project Address: 2-4 :1000- l0 9 -___1 Zoning=Zoning District: � Suffolk County Tax Map No. e. d 10 Request: W (Note: Copy of Bulldirwg Permit App licaflon and suppoding documentation as to proposed use or uses should be submitted.) Initial Determination as to whether use is permitted: as to whether site plan is required. Initial Determination of Bu .____.. _.m .. ... .... . .__... _.. _ . .... . ,mm ., µ, ilding Inspec or i !Z= Planning Department (P.D-) Referral: ,( Date of Comment; �---�-- /--�------- P.D. Date Received:=� v�—�-- Comments: � ► Signature of Planning ept.,S Reviewer final 1+ tern�Ina ian Date-__J /__ �nPctnr �innat<ire of Riiildina In ,TOWN OF SOUTHOLD BUILDIIs 3ERMIT 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 TEL: (631)765-1802 Planning Board approval FAX: (631)765-9502 Survey SoutholdTown.NorthFork.net PERMIT NO. Check Septic Form N.Y.S.D.E.C. Trustees Flood Permit Examined 20 Storm-Water Assessment Form Contact: Approved 20Mail to: Disapproved a/c Phone: Expiration .20— Building 2QBuilding Inspector APPLICATION FOR BUILDING PERMIT Date 120 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. e.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 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. J o h n 6er4t n 13u-,f de.I- Ji C-. (Signature of applicant or name,if a corporation) 1tf�' � (Mailing address of applicant) 1 Jq 71 State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Name of owner of premisesf =Gt r Iltnrtr (As o T e tax roll or latest deed) If applicant is a corporation,signature of duly autho 'zed officer 1 (Name and title of corporate officer) Builders License No. U, QqC, RT Plumbers License No. _ -yvct, -� flcrm f,., Electricians License No, I +r. Other Trade's License No. 1. Location of land on which proposed wok will be done: -Q y JCh t House Number Street Hamlet County Tax Map No. 1000 Sectio R 0 Block ` :bt Subdivision Filed Map No _ Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy syo(-L�e 'lloc i, b. Intended use and occupancy 'SA-DCL'c,e- \-3 C r r� 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition Other Work (Description) 4. Estimated Cost # 100 GO 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 6. If business,commercial or mixed occupancy,specify nature and extent of each type of use. 7. Dimensions of existing structures,if any:Front Lj 0 Rear LJ 0 Depth 66 r Height Q ' Number of Stories I Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction:Front 4o' Rear `f C) Depth (at) Height '=�Y` Number of Stories 1 9. Size of lot:Front l Rear $ 3 Depth t( } 10.Date of Purchase Name of Former Owner 11.Zone or use district in which premises are situated 12.Does proposed construction violate any zoning law,ordinance or regulation?YES NO 13.Will lot be re-graded?YES NO �Will excess fill be removed from premises?YES NOVI_ 14.Names of Owner ofpremisesl dL4ri 1hf)&A4Ad4 Address 0.&g.2 D2 4ucjc.Phone No. R r- to Name of Architect 0s is � Address SGS(stun l4- ti—Ii AOf Mone No 76 7— 1'071 Name of Contractorl,_)het ; l3w Id Address 11ci r Phone No. �ror tY 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, b. Is this property within 300 feet of a tidal wetland?*YES NO ' &QUIRED. *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? *YES NO * IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS. COUNTY OF t f'� being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the n I"mt (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 to before me this , (o day of 20 ti Not Pu $N ® Notary Public state ofxYo Signature of Applicant t4o.OiRU6020832 ouai`jFsac!in Suffolkaco 8,w commission Expi