HomeMy WebLinkAbout50503-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
14
TOWN CLERK'S OFFICE
SOUTHOLD, NY
r
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 #: 50503 Date: 4/2/2024
Permission is hereby granted to:
Millard Amory
435 E 57th St Apt 4C
New York, NY 10022
To: legalize "as built" alterations to existing single-family dwelling as applied for.
Additional certification may be required.
At premises located at:
495 Maple Ln, Orient
SCTM # 473889
Sec/Block/Lot# 17.-2-3.1
Pursuant to application dated 2/22/2024 and approved by the Building Inspector.
To expire on 10/2/2025.
Fees:
AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $500.00
CO -ALTERATION TO DWELLING $100.00
Total: $600.00
Building Inspector
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
Date Recelved
E C E WE
For office Use Only
PERMIT NO. (/�W Building Inspector._ WW �yI��qq
0 pi P V.2 �
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 Authorization form(Page 2)shall be completed. Town op Q;rouft'a o l
Date
OWNER(S)OF PROPERTY:
Name: 4 A tNAC/11 SCtM# 1000-
Project Address: 1 � lil
OLSrl
Phone#: 'L — Email:
Mailing Address: 1 C)y1z;�\kl 0 /
CONTACT PERSON:
Name: 0
Mailing Address:
Phone#: JEmail:
DESIGN PROFESSIONAL INFORMATION:
Name: Qc
Mailing Address: ?-0 O�
Phone#: SD ka —,--I Email:
CONTRACTOR INFORMATION:
Name: 7 1
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
p D oli ion Estimated Cost of Project:
❑OtheStr tyre C ditto ❑Altera�io ❑Re air = ,0
Will the lot lee re-graded? ❑YesNo Will excess fill be removed from premises? ❑Yes No
1
PROPERTY INFORMATION
Existing use of property:," Intende..........................d use of property:
t sw Q(�61-YA-14
tr-
Zone or use district in which pre ses is situated: Are there any covens is and restrictions with respect to
iA this property? DYesANo IF YES, PROVIDE A COPY..
The owner/contr ctor/de n professsion l respa sibi'e for all drainage nd orm grater :su preWWA by
chapter 236 of the Tom Code. 4PLiCATION 15'HEREBY MADE to the Building Deparbrient for the Issuance al a Building Permit pursuant to the Building Zone
Ordinance of the Towaa of Souathoid,iuffoilu,County,Ner 'Vorh and other applicable laws,Ordinances or pe ulatlons.,for the construction of buildings,
additions,alterations or for removal or demolition as herein described.The applicant ogees to comply vWth all applicable lags,ordloanes,buittling,core,.
bousing 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 taw.
Application Submitted By(print name): ❑Authorized Agent owner
Signature of Applicant: 4/1
;.01 Date:
STATE OF NEW YORK) UU
COUNTY OF
A ' being duly sworn deposes and says that (s)he is the applicant
(Name of, dividuai signing contract)above named,
(S)he is the /l
(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 there th,
Sworn before me this
day of �. � �,..,
N dry a lic NDYA.ST PON
ataty piltllic,State of Nv: Y'Drk
Mf
guali ed in SO4 cocnty�
lriiis�lsr�i:itiEii�uileS,iail.6,2�i__
(Where the applicant is not the owner)
h 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
SURVEY OF PROPERTY
AT ORIENT
TOWN OF SOUTHOLD
SUFFOLK COUNTY, MY
1000--17-02-3.1
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AUGUST 22, 2003
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ELEVA77ONS REFERENCED TO AN ASSUMED DATUM.
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