HomeMy WebLinkAbout50691-Z 'a TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
r° 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 #: 50691 Date: 5/16/2024
Permission is hereby granted to:
Roman, Mary
PO BOX 655
Orient, NY 11957
To: legalize "as built" heat pump installation to existing single-family dwelling as applied
for.
At premises located at:
740 Po uatuck Ln, Orient
SCTM # 473889
Sec/Block/Lot# 27.-3-4.5
Pursuant to application dated 4/5/2024 and approved by the Building Inspector.
To expire on 11/15/2025.
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
s
i y Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
Telephone (631) 765-1802 Fax (631) 765-9502 - ./1w^Nw. of tholdtowiii . o
Date Received
APPLICATION FOR BUILDING PERMIT
Q U E
For Office Use Only b G
PERMIT NO. Building Inspector: � qAPR 5 ,
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. I.
Date:
OWNER(S)OF PROPERTY:
Name: �,T(` _c�► C1 �e�► i vt ba,.► SCTM#1000-
Project Address:
Phone#: of i — Vl ( Email: " ►�w�
Mailing Address: S S
1 �W
CONTACT PERSON:
Name: 4,ve
Mailing Address:
Phone#: Email:
DESIGN PROFESSIONAL INFORMATION:
Name: N �f
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name: I<a V �''� - 1 1
Mailing Address: l �z /"� �� •i c ( �
l� � ' — —]Q'l -- cS cS Email:
Phone# `�
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure
r� ❑Addition ❑Alteration ❑repair ❑Dm eolition Estimated Cost of Project:
11
�'6ther � � �� , '`
Will the lot be re-graded? ❑Yes 5,1C Will excess fill be removed from premises? Dyes li�
1
u.
PROPERTY INFORMATION
Existing use of property: `-,t/ Intended use of property: (--S j-e V, +7
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
TO%A- V1 Sok+-k" I j this property? ❑Yes [moo 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 Lim,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 210.4S of the New York State Penal Law.
Application Submitted By(print name): ` -J 6 Vvt t ❑Authorized Agent QOminer
Signature of Applicant: Date: L
STATE OF NEW YORK)
SS:
COUNTY OF )
M(a being duly sworn, deposes and says that(s)he is the applicant
(Name cf in vidual 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 kno ed a and belief; and
that the work will be performed in the manner set forth in the application file therewith.
Sworn before me this
i
Sday of , 20
NA NA FRANKE
tar ,p,41�llSU ,STATE OF NEW YORK
i may' jon No.05FR6288691
Ouali in Suffolk C b 09, 0
PROPER T" OWNER AUTHORIZATION my commissionE'P"esseptem
(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
1fQ r BUILDING DEPARTMENT- Electrical Inspector
►� ' " r TOWN OF SOUTHOLD
' Town Hall Annex - 54375 Main Road - PO Box 1179
Zft„a Southold, New York 11971-0959
Telephone (631) 765-1802 - FAX (631) 765-9502
, . "amesh sootholdtownn ov— seand@southoldtgAnny.gov
APPLICATION FOR ELECTRICAL INSPECTION
ELECTRICIAN INFORMATION (All Information Required) Date: Li �2o
Company Name: K - e- E (-e c 6-0, v
Electrician's Name: e #J"L , IF n ; Q r a
License No.: Al E - :?6 S 3 3 Elec. email: (Ice
EIec. Phone No: 2 p ❑1 request an email copy of Certificate of Compliance
Elec. Address.: �d wt_as .s
JOB SITE INFORMATION (All Information Required)
Name:
Address: —7 11
Cross Street: ( ;
Phone No.:
Bldg.Permit #: Y� _ email: (r,rov►,uviw•J vna,
Tax Map District: 1000 Section: Block: Lot: ; S
BRIEF DESCRIPTION OF WORK, INCLUDE SQUARE FOOTAGE (Please Print Clearly):
Square Footage.
Circle All That Apply: ,.,
Is job ready for inspection?: �JIYES NO Rough In Final
Do you need a Temp Certificate?: YES O Issued On
Temp Information: (All information required)
Service Size 1 Ph I3 Ph Size: A # Meters Old Meter#
❑New Service❑Fire Reconnect[:]Flood Reconnect❑Service Reconnect❑Underground❑Overhead
# Underground Laterals 1 H Frame n Pole Work done on Service? Ll Y N
Additional Information:
PAYMENT DUE WITH APPLICATION
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RECAUCION
Antes de tener acceso a !os
dispositivos terminates, todos
los circuitos de alimentacian
debea ser interrumpidos.
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