HomeMy WebLinkAbout50076-Z TOWN OF SOUTHOLD
r BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
� SOUTHOLD, NY
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES
WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS
UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)
Permit#: 50076 Date: 12/1/2023
Permission is hereby granted to:
Chambrun Claire
840 Pinewood Rd
Cutcho ue NY 11935
To: legalize "as built" alterations to existing single-family dwelling as applied for.
Additional certification may be required.
At premises located at:
840 Pinewood Rd, Cutcho ue
SCTM # 473889
Sec/Block/Lot# 110.-5-25
Pursuant to application dated 11/13/2023 and approved by the Building Inspector..
To expire on 6/1/2025.
Fees:
CO-ALTERATION TO DWELLING $100.00
AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $516.80
Total: $616.80
Building Inspector
Po.
art 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 htt s://www.southoldtownnv. o
APPLICATION FOR BUILDING PERMIT
For Office Use Only
PERMIT NO. Building Inspector:
Applhckions,,and formsmust be filled out in their entirety.Incomplete-
applications will not be accepted, '''here the AISpbcant'is,not the owner,an
OWrer's Authorizatiori form(Page 2)shall be completed:
Date: Z 3
OWNER(S)OF PROPERTY:
Name: i(�C h � C>✓fM �u I M# 1000-
d 1� �,
Project Address: SL4 n C �,„U �;, vr'(' Na I q J
Phone#: Email:.
r
Mailing Address: 3g S ckjc, Si (hi (,GcAr. �i`( 119 3r
CONTACT PERSON: r
Name:
Mailing Address: 3Do,t( S t ,. �,,� �� 1 Irl 37
Phone#: U 31 - 7 34 - Email:
DESIGN PROFESSIONAL INFORMATION:
Name: S`,.,4
Mailing Address: � 0 BOX .7 4c�G D(�
PhEELSi q'71 - 106S Email: �v•Tt/ r��l�l S'fe� ryiu �. Call
CONTRACTOR INFORMATION:
Name:
Mailing Address: r~`i' U,2,-4 IV( )JJ()1
4.
JJ ``
Phone!: �i a,� — S 7 a'& Email: HG�I.�,ui"I
n
DESCRIPTION OF PROPOSED CONSTRUCTION
[--]New Structure ❑Addition 4AIteration ❑Repair ❑Demolition Estimated Cost of Project:
[--]other $
Will the lot be re-graded? ❑Yes UrNo Will excess fill be removed from premises? ❑Yes eNo
1
A
PROPERTY INFORMATION
Existing use of property: res) (L ,hi Intended use of property: IleSi'det�Ic(
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? ❑Yes ❑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.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,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 an premises and in building(s)for necessary inspections.False statements made herein are
punishable as a Class A misdemeanor pursuant to Section`210.45 of the New York State Penal Law.
Application Submitted By(print name): Fjwcv6t �'`Lfr'' ZZU ❑Authorized Agent []Owner
Signature of Applicant: Date:
CONNIE D.BUNCH
Notary Public,State of New York
STATE OF NEW YORK) No. 01 BU6185050
SS: Cltalified in Suffolk County
COUNTY OF Commi slon Explres Aprll 14, 2(OD4
)
F(� G'%1-/-r,' zzo being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract) above named,
(S)he is the
(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.
Sworn before me this
day of 0 QVC4' ti 4-h , 20t):�)
Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
0 _ —
i, �... � t �° ,f � residing at 1 Gl .SI ft `� J
do hereby authorize �4��'r� �i���'' no to apply on
my behalf to the Town of Southold Building Department for approval as described herein.
t e
Owner's Ig nature date
s�
Print Owner's Name —
2
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CERTIFICATE OF LIABILITY INSURANCE
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT; If the certificate holder is an ADDITIONAL INSURED, the policyfles)must have ADDITIONAL INSURED provisions or be endorsed.
It SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this cenilmate docs not confer rights to the Certificate holder in lieu of such endorsement(s).
CONTACT
PRODUCER R KAUr FrsP Alra
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CERTIFICATE HOL IS LISTEDADDITIONAL INSURED
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF IHL ABOVE UkUGHIHL•"D T'OLICIE9 OE CANCELLED BEFORE
Suffolk County Department Of Labor, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Licensing & Consumer Affairs ACCORDANCE WITH THE POLICY PROVISIONS.
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Po BOX 6100 AUTHORIZEDREPRESEWATIVIE
Hauppauge, NY 11778
FC r.; s,grc;l;l;a,:LEL!
>1966®2015 ACORD CORPORATION. All rights reserveda
ACORD 25{2016f03) The ACORD name and logo are registered marks of ACORD
Suffolk County Dept.of
Labor,Licensing&Consumer Affairs
HOME IMPROVEMENT LICENSE
Name
EDWARD J GIARRIZZO
Business Name
This certifies that the
nearer is duly licensed EDG Renovations
:)y the County of suffolk
License Number:HI-67752
Rosalie Drago Issued: 01/06/2023
Commissioner Expires: 01/01/2025
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