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_EC FOR INTERNAL USE ONLY
PLAN USE DETERMINATION:
Planning Board `����
Initial Dettrenintior
_ Date Sent:_f=—
Date: U
5
Project Name:._�...._ '� ._.....�M
Project Address:.
Suffolk County Tax Map No..1000- /0—G41' �,- Zoning
District:
Request: -..
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p �
crtin
do�cr_e.�ntatio. n-,.a.s..�to
Dutldirig Permit Application and sup
(Note: Copy of . _... ._..___
proposed use or uses should be submitted.)
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upermitted:...-
Initial
1ni�tia�l D �
rmtnation as to Whetheruse is
.. . ...is required: w -
Determinati
on as to whether sti: plan
Signature of Building Inspector
Planning Department(P_ ) Q . "
o1 � Date of Comirient:—vCJ
P..D. Date Received:_,�,��_�-�-•�� -- -�
Comments: pp
5 ^5
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Iq °f Myl re of Planning Dept. " ff Reviewer
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ihai Dtrrninatica6
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RECEIVED
G FOR INTERNAL USE ONLY
1�,AJ G () 2'S �N "
_.....� oldn SITE PLAN 1�SE DETERN(INA
Planning Board
initial D tern inati01"
' / � c� _..� �- Date
Date.__ - _.. _µ.
. Project Name: — W 1� .�_.� _�..._ �.........��.._ _.._. ..�...._...�..�....��__...�..� .._.��--�--. ._re
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Project Address: �_-_. __. _ .--
7oiing District:
Suffolk County Tax Map N
.
� — supporting documentation as to
(Note: Copy
of B uilding Permit Application and supp g
-proposed use or uses should be submitted-)
ermined: G�
initial Determination as to whether use is p
.Initial Determination as to whether site plan is require :-
--*;;_'_
�.. ,_. _.._w_.. _.... ...._ ._..... .. ......._ Signatur of Building Inspector
Planning Department (P.D.) Referral:W—..-_.__. ''_"_"�
Q a
Q..D. Date Received: �•
Date of Comment:
Comments: �° S.
Sgna re of Planning Dept. off Reviewer
F al D te, inati l�
Date:
Decision:...._.-.......�.m.... ....... ... ..._ . ..... �.. . _.. .
of-innil irP...of Riiildina.w.I.n-qnPntnr w_
S�YW
VED
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FOR INTERNAL USE ONLY
ap G tZo
a a i rd
..._ ..._ Jo n SITE PLAN USE DETERMINATION
Planning Board
Initial et rmination
Date
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A "Project-Name:._-, �_�......... ._....�.__.�,.. ..�..wmm�,..�..�._�.. ..��..... .... .._..�._.�...��....�.. .__�
Project Address: ,, ..�.:._.�._..._.�..._.....�.._....��.��. �..��_..
. �_ �� 'Zoning Dist�ric(:, .., -�..
Suffolk County Tax Map
Request: _._ __
..�........_...... .. ...._._.........,_....__.�� ortin documentation as to�.w..,.�,.�.�.
' Application and supp g
��fBuilding Permit
(Note: Copy
proposed use or uses should be submitted.)
-Initial Determination as to whether use is p
Initial-Determination as to whether site plan is requird:
Signature�" f B '�� g In p.��.�.�
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Department (P.D.) Referral:_,.�....��_;.�----�.��----�.......'�_.�.......`.__.. . ... ..�.,�.�_..... _��
. -
Date or Comment:
P.D.. Date Received:
_—
Comments: _ .
Sire of Planning Dept .Staff Reviewer
final betel linaIt1oll
Date: w....__. �. ... _....�_ _.. _ ._
c;,innhirP c)f Ri ' lino Insnpotor
rDa �.. TOWN OF SOOT O1,D-F U11,.DING DEPARTMENT
}"owre I-la}1 Annex 54375 Nv1ain Road P. 0. Lox 1179 Southold NY } }97} t)c)59
Telephone (63}) 765-} 80? Fax (63} ) 765-9502 h7.1 .w,.E�w ---------e}L� rr� sp��
I:1a7 e Ret;e q e d
APPLICATION FOR BUILDING PERMIT ECEUVE
r�'
For 01fice Use ( r\
U N 2 0 2024
PERMIT NO. Building Inspecto ,
Applications and forms must be filled out in their entirety. Incomplete
applications will not be accepted. Where the Applicant is not the owner,an iFSOUrliell
Owner's Authorization form(Page 2)shall be completed.
m Date,_......... ... ( p..�.� .._ _.. _.... . ......_ __.. ..
OWNER(S)OF PROPERTY:
Name: ... � � ... SCTM# 1000- k�Qj-O3- S,41
���
Project Address: 2` �� L L� J 5 �C; a,+ C_
Phone#: Email:
"� t
5�.P 011,Z�.
Mailing Address �... `._._. ....... _. ...__....w__..,_........ -'�..... _ . _ ...
CONTACT PERSON:
Name:Brooke Epperson
Mailing Address:PO Box 152, Mattituck, NY 11952
63 ........._.�_.
Phone#: 1 603 9092 pp @ p Email:be erso am arctect.com
. _. ..___.._ n ..w.w. parch i ..w_._._...�.w.
DESIGN PROFESSIONAL INFORMATION:
Name:Anthony Portillo
Mailing Address:PO Box 152, Mattituck, N.Y. 11952
Phone#: 092 A�ma'il'.aportlllo@amparchltect com
_.. .. 631 W603 9........__._.._ ._ ... ...... w ._ _.. ..__...._..._ _...... ._. ............ww...._ .._._-
CONTRACTOR INFORMATION:
Name:
Mailing Address:, _
w.
Phone# Email;--- _.. .www_._._._._ww.............................................._
DESCRIPTION OF PROPOSED CONSTRUCTION
New Structure >dAddition -Alteration '--Repair -Demolition Estimated Cost of Project:
—'Other ._ ..... w..... �-��C�O
Will the lot be ra nr ailed? Yves G.. ....... _........ Wi�I exce.s ohll be removed ff"C"tlm pre rrfl ,i,.,s? 1 t's:�'" u y
.......w_.___..w.................._.....w.........mmm.�.._..._..w_..... �......ww._w .__....._...... .... ....................................._�_.....�.�_�_ ..wvv,w ......._. ...... ..._�_�_.....�.�_�.�..... ...M.M.�. ......__..._.__ .... .. .._..
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PROPERTY INFORMATION
Existing use of property: e,ctizv uTjP-atx� intended use of property:Ze,
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? ..... .._... _ ..._w.
.Yes J' n IF YES, PROVIDE A COPY,
w.w... ...
Chapter Check
Box
After Town Reading'
Code. APPLICATIONIS er .._, ...o signM r ..al i
The owner/contractorJdesign professional is responsible for all drainage and storm water issues as provided by
of
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 (print name): 1P 7\) .RAuthorized Agent ❑Owner
Signature of Applicant: Date:
STATE OF NEW YORK)
C SS:
COUNTY OF _)J C S k_ )
_ being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
(S)he is the........... ------ ._.......... ..........
. _.w........ _._.... __._�.. _�........ ..............
(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
� 1 day of _0__Q.. ........... ..._...._., 20
DAR , E AUFENANGER Notary is
NOTARY PUBLIC,STATE OF NEW YORK
Registration No. 01A00019644
Qualified in Suffolk County PROPERTY" AUTHORIZATION
Commission Expires January 9, 2028 (Where the applicant is not the owner)
residing at
_do hereby authorize ,,�� � �� M .. to apply on
my behalf to the Town of Southold Building Department for approval as described herein.
4
1 Owne .r Rnatu e date
Print Owner's Narne
2