HomeMy WebLinkAbout50726-Z TOWN OF SOUTHOLD
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#: 50726
Date: 5/22/20......4......._............................._..
Permission is hereby granted to:
Whelan Robert
_. ..
4782 Ole Jule Ln
POBOX 0._..._ ..... .. .... _.. _ ....... _.............. ..._... . .. .... ......
Mattituck, NY 11952
To: Install window replacements to a single-family dwelling as applied for per
manufacturers specifications.
At premises located at:
4782 Ole Jule Ln. Mattituck
SCTM # 473889
Sec/Block/Lot# 122.4-41
Pursuant to application dated 4/15/2024 and approved by the Building Inspector.
To expire on 11/21/2025.
Fees:
SINGLE FAMILY DWELLING-ADDITION OR ALTERATION $250.00
CERTIFICATE OF OCCUPANCY $100.00
....................................................
Total: $350.00
Building Inspector
Pict
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 li t1a ;//r w ogtl�1o1dt ��u,�.1 g
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only
rP
PERMIT NO,. 50-7a �e Building Inspector:,...—..--",
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.
Date:
OWNER(S)OF PROPERTY:
Name: �,+ h' SCTM # 1000-
Project Address: ,lZ �G�'' yGIL�L/t�, ,r' /V/
Phone#: Email: zi-)h&1qn h eq olQ%l enwl
Mailing Address: 1��� QL���i� L�, / l�C�� /✓ .
CONTACT PERSON:
Name:
Mailing Address: s
Phone#: Email:
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name:
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
Other 1 A; - / .ram $
Will the lot be re-graded? ❑Yes I gNo Will excess fill be removed from premises? DYe ❑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? ❑YesNo 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 y(print name �" �.� ❑Authorized Agent Clwner
Signature of Applicant: Date:
STATE OF NEW YORK)
SS:
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 K
(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 1 , 20IS
Notary Public DIXIEGUNTER
NOTARY PUBLIC-STATE OF NEW YORK
No. 01 GU6093375
PROPERTY OWNER AUTHORIZATION Quollfied in Suffolk County
(Where the applicant is not the owner) My Commission Expires June oz, 28t10
Im 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
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TOWN OF SOUTHOLD
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1230 TRAVELER STREET
SOUTHOLDy AY. 11971