HomeMy WebLinkAbout37369-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
V 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#: 37369 Date: 7/17/201.2
Permission is hereby granted to:
Cook, Donna
PO BOX 207
Southold, NY 11971
To: 'As Built', Addition of an Accessory Structure;
Above Ground Pool, 12 ft. round, 3 ft. high, as applied for. G
�a
At premises located at:
25 Private Rd #12, (6900 Main Bayview Road), Southold
SCTM # 473889
Sec/Block/Lot# 78.-6-9.2
Pursuant to application dated 7/2/2012 and approved by the Building Inspector.
To expire on 1/16/2014.
Fees:
CO - SWIMMING POOL $50.00
SWIMMING POOLS -ABOVE-GROUND WITH REQUIRED FENCING $250.00
Total: $300.00
Bui ding Inspector
TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
Y 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
www.northfork.net/Southold/ PERMIT NO. Check
Septic Form
N.Y.S.D.E.C.
Trustees
Examined I3 20 Contact:
Approved 120 Mail to:
Disapproved a/c � /
p � Phone: [J �
Expiration ��' 20 / 7
Building Inspector
APPLICATION FOR BUILDING PERMIT
-ZINSDate —Z-
INSTRUCTIONS
TRUCTIONS
a.'This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3
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 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 r al or demolition as herein described.The
applicant agrees to comply with all applicable laws,ordinances,building code, using code,and regulations,and to admit
authorized inspectors on premises and in building for necessary inspections.
u
rgnature of applicant or name,if aration)
(Mailing address of applicant) 9
State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder
Name of owner of premises 0
(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.
1. LoatiW of land on which prgposed ta w k will b done: ((q-71
House umber Street H14 et
County Tax Map No. 10 Section o /0 Block 7 t Lot t
Subdivision A Filed Map No. Lot
2. State existing use and occupancy of premises }d intended}}}se and occupancy of posed construction:
a. Existing use and occupancy
b. Intended use and occupancy
3. Nature of work(check which applicable):New Building Addition teratio 2''J4
Repair Removal Demolition Other Work
it /�" (Description)
4. Estimated Cost ! ✓ 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, ecify nature and extent of each type of use.
7. Dimensions of existing structures,if any:Front\ Rear Depth
Height Number of Stories
Dimensions of same structure with alterations or additions:Pront Rear
Depth Height Number of Stories
8. Dimensions of entire new onstruction:Front R ar Depth
Height Number of Stories \
9. Size of lot:Front i \ Rear Depth
10.Date of Purchase.10 ame 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 NOW-
13.Will lot be re-graded?YES—NO!v Will excess fill.be removed from premises?YES_N09-
14.Names of Owner of premises Address Phone No.
Name of Architect Address Phone No
Name of Contractor Address Phone No.
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 REQUIRED.
b.Is this property within 300 feet of a tidal wetland?*YES NO
*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.
STATE OF NEW YORK)
COUNTY 03U �
Cg'2' Q �–(�(� being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)He is the 0 �
(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 t efore me this
day o�_p 11KA A C!
f 20
C,
Notary Public Signature of Applicant
VICKI T 'rw
Notary Public State of New York
edTSoo06oQualiif infflkCunty
Commission F-Vires July 28.20