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TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
,1 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 #: 50302 Date: 2/6/202
Permission is hereby granted to:.
Graves, Jason
550 Fasbender Ave
Peconic, NY 11958
To: legalize "as built" HVAC unit as applied for.
At premises located at:
555 Fasbender Ave, Peconic
SCTM # 473889
Sec/Block/Lot# 67.-64.1
Pursuant to application dated 1/11/2024 and approved by the Building Inspector.
To expire on 8/7/2025.
Fees:
AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $500.00
ELECTRIC $200.00
CERTIFICATE OF OCCUPANCY $100.00
Total: $800.00
Building Inspector
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+ �� v «�u TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
, r Telephone(631) 765-1802 Fax (631) 765-9502 h!Vv,//www.southoldtownjiy.&Yov
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only
PERMIT NO. � � Building Inspector: 'J P-k���''a � � 9 24
Applications and forms must be filled out in their entirety.Incomplete .
applications will not be accepted. Where the Applicant is not the owner,an
Owner's Authorizationform(Page 2)shall be completed.
Date:
OWNER(S)OF PROPERTY: -
Name: SCTM# 1000-
Project Address: Z—W 7-a'N /1a rccov9 c lq
Phone#: G Email: \tjS C0
Mailing Address ' 0 LL(?
CONTACT PERSON:
Name;
CU 1� `�►
Mailing Address:
Phone#: - ��� Email: WY,4C9 .
DESIGN PROFESSIONAL INFORMATION:
Name;
Mailing Address:
Phone#: Email:.
CONTRACTOR INFORMATION:
Name
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Strutt re ❑Addition gllAit r ti n ❑ epair ❑ em l ti Estimated Cost of Project:
to
Will the lot be re-graded? Dyes El No Will excess fil7be—rrmdved from premises? Dyes ❑No
1
PROPERTY INFORMATION
Existing use of property: Intended use of property:
Zone or use district in which premises is situated:. Are there any covenants and restrictions with respect to
this property? ❑Yes El 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 on 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(prin name): � i S ❑Authorize Agent &Owner
Signature of Applicant: --D'at'. Q % mNNIE D.BUNCH
Notary Public,State of New York
STATE OF NEW YORK) No.01BU6185050
Qualified in Suffolk County +/
SS: Commission Expires April 14,2 7
COUNTY OF )
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
l�-, gym.
��)day of 6 0!2L , 0
Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
I, residing at
_do hereby authorize to apply on
my behalf to the Town of Southold Building Department for approval as described herein.
Owner's Signature Date
Print Owner's Name
2
� BUILDING DEPARTMENT- Electrical Inspector
TOWN OF SOUTHOLD
Town Hall Annex- 54375 Main Road - PO Box 1179
Southold, New York 11971-0959
Telephone (631) 765-1802 - FAX (631) 765-9502
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APPLICATION FOR ELECTRICAL INSPECTION
ELECTRICIAN INFORMATION (All Information Required) Date: C)p�
Company Name: L1N-%tJ 2,
Electrician's Name:
License No.: Elec. email:
Elec. Phone No; � - I request an email copy of Certificate of Compliance
Elec. Address.:
JOB SITE INFORMATION (All Information Required)
Name: Y- ow`�,�
Address: `
Cross Street:
Phone No..
BIdg.Permit#: email:
Tax Map District: 1000 Section: V1 Block: Lot: , I
BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly):
J�v H-S Ls 4/,/ IL-
Square Footage:
Circle All That Apply:
Is job ready for inspection?: El YES 0 NO E]Rough In El Final
Do you need a Temp Certificate?: El YES[_] NO Issued On
Temp Information: (All information required)
Service Size F-11 Ph E]3 Ph Size: A # Meters Old Meter#
❑New Service❑Fire Reconnect❑Flood Reconnect❑Service Reconnect❑Underground❑Overhead
# Underground Laterals 1 H Frame Pole Work done on Service? Y N
Additional Information:
PAYMENT DUE WITH APPLICATION