HomeMy WebLinkAbout51124-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
w 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#: 51124 Date: 8/26/2024
Permission is hereby granted to:
Haase-Jr,Geor �e........�.�.. �. .................. ��� .._..............................._�...................... .
PO BOX 153
Southold,
NY 11971
To: Legalize an "as built" alteration to convert attic space to an office room in an existing
single-family dwelling as applied for. Additional certification may be required.
At premises located at:
tchogue 4785 Stillwater Ave,..............u......... _........................ .._�_��.�...................... �
SCTM # 473889
Sec/Block/Lot# 137.-3-10
Pursuant to application dated 7/_.......__,_ 0/2024 and approved by the Building Inspector.
m1_ _ _mmmmmmmmmmmmmm
To expire on 2/25/2026.
Fees:
AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $940.00
CO-ALTERATION TO DWELLING $100.00
Total: ...............................
_....$1,040.00
_..... ..... _ _............
Building Inspector
hP@ ,
TOWN OF SOUTHOLD —BUILDING DEPARTMENT
�C Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY It 971-0959
Telephone (631) 765-1802 Fax (631) 765-9502 htt:ps://www.soti'tholdtow,ii,iiyo�
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only r
PERMIT NO. 1 I v, Building Inspector;
Applications and forms must be filled out in their entirety.Incomplete BUILDING DEPT.
applications will not be accepted. Where the Applicant Is not the owner,an
Owner's Authorization form(Page 2)shall be completed. TOWN )F SOUTHOI
Date:July 1, 2024
OWNER(S)OF PROPERTY:
Name:George Haase SCTM# 1000-137.-3-10
Project Address:4785 Stillwater, Cutchogue
Phone#:201-925-2714 :1�Ell':ha:asejr@aol.com
Mailing Address:
CONTACT PERSON:
Name:Joan Chambers
Mailing Address:PO Box 49 Southold NY 11971
Phone#:631-294-4241 EmailJoanchambersl O@gmaii.com
DESIGN PROFESSIONAL INFORMATION:
Name:Lou Schwartz
Mailing Address:7 Ridgewood St, Bay Shore, NY 11706
Phone#:(631 ) 410-6838 Email:tiderunnereng@gmail.com
CONTRACTOR INFORMATION:
Name:as-built
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition WAlteration ❑Repair ❑Demolition Estimated Cost of Project:
❑Other
Will the lot be re-graded? ❑Yes QNo Will excess fill be removed from premises? ❑Yes @RNo
1
PROPERTY INFORMATION
Existing use of property: Intended use of roe Same
res(dentlal p p �►�
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
R-40 this property? ❑Yes No IF YES, PROVIDE A COPY.
19 Check Bolt 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. APPUCATION 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 210A5 of the New York State Penal Law.
Application Submitted By(print name):J oa n Chambers igAuthorized Agent ❑Owner
Signature of Applicant: Date:
CONNIE D.BUNCH
STATE OF NEW YORK Notary Public,State of New York
No.01 BU6185060
SS: QualifCOM issioled in n Expires uffolk County
AprilApril 14,20S�
COUNTY OFy, )
Joan Chambers being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
(S)he is the
Agent
(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
q
C_tL:L ay of C�I �M 20� t
Notary Public
PROPERTY OWNER. AUTHORIZATION
(Where the applicant is not the owner)
George F Haase jR residing at4785 Stillwater Ave
Cutchogue NY do hereby authorize Joan Chambers to apply on
my behalf to the'To of Southold Building Department for approval as described herein.
July 7 2024
wn se
erig'Signatur� Date
GetreMa Jr
g
Print Owner's Name
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