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FOR INTERNAL USE ONLY
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N USE DETERS{�, `� ON
Initial Determil atJ10"
- - - Date ----
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Date:,
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Project Name:
Project Address:
Suffolk County Tax Map No.:1000 Zoning District:
-
Request:
of Suilditg Permit Application and sup
porting p �e�� to
(Note: Copy
proposed use or uses should he submitted.)
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initial Determination as to Whether use is permitted:
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d.
Initial Determination as to whether site an is
Signature of Building Inpc
Planning Department(P.D.) Referral:
Date of Com meat=
P.D. Date Received:-------
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Comments; it s
teta
Signature of Planning Dep..- ie
F inai et r�i t do
Date: f
Decision:
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SAYIN&KOCANi,INC. 50-W214 52" APPLICATION CHECKLIST
PO B01;'514 -
CUTCHoQ-_DF,NY 11935 ^-7 need the following,before applying?
_ T ATE_. - 1-.
of Health
—,
of Building Plans
mg Board approval
qMx or
VSWele8
g
SUFFOLK COUNNff -O Form.
,, ��� 1 D.E.C.
tilEw_o "" pplication
1:02140S46Lei: 61 0022gS 6ii' OS12I Permit
&Separate
Saorm-Water Assessment Form
Contact:
Approved 20 Mail to:
Disapproved a/c
Phone:
Expiration _,20-
5Z 205Z
U Building Inspector
l SAY _] 2013 ICATION FOR BUILDING PERMIT
Date 7 _._20 -3
U INSTRUCTIONS �—
a. 11s 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 pen-nit 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)
(Mailing address of applicant)
State whether/applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder
Name of owner of premises on or-0--1
(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. �C�� j 2-1
1. Location of land on whic° roposed work will be done:
�-
House Number Street Hamlet
County Tax Map No. 1000 Section Block Lot