HomeMy WebLinkAbout51129-Z f , 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#: 51129 Date: 08/28/2024
Permission is hereby granted to:
Elena Palencia
PO BOX 565
Peconic, NY
To:
Legalize an "as built" basement alteration to include an accessory apartment in an existing
single-family dwelling as applied for.
Premises Located at:
755 Oriole Dr, Southold
Section\Block\Lot # 55.-6-15.6
Pursuant to application dated 07/16/2024 and approved by the Building Inspector.
To expire on 02/27/2026.
Contractors:
Required Inspections:
Fees:
AS BUILT-SINGLE FAMILY ADDITION/ALTERATION $1,571.00
CERTIFICATE OF OCCUPANCY $100.00
Total $1,671.00
��� Building Inspector� �
:try TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
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Telephone (631) 765-1802 Fax (631) 765-9502 11tt1?S /WWw V SOUth01dtoW1M VQ
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APPLICATION FOR BUILDING PERMIT
For Office Use Only
PERMIT NO.-� I I � Building Inspector._
Applications and forms must be filled out in their entirety. Incomplete 1 ita "
applications will not be accepted. Where the Applicant is not the owner,an TOWN 8 "Mo
Owner's Authorization form(Page 2)shall be completed.
Date: 07/12/24
OWNER(S)OF PROPERTY:
Name: Elena Palencia SCTM# 1000-55-6-15.6
Project Address: 755 Oriole Drive, Southold, NY 11971
Phone#: 631-255-6212 Email: elenasea1234@gmail.com
Mailing Address: P.O. Box 565, Peconic, NY 11958
CONTACT PERSON:
Name: Mathew Smith
Mailing Address: PO Box 152, Mattituck, NY 11952
Phone#: 631 603 9092 Email: msmith@amparchitect.com
DESIGN PROFESSIONAL INFORMATION:
Name: Anthony Portilio
Mailing Address: PO Box 152, Mattituck, N.Y. 11952
Phone#: 631 603 9092 Email: aportillo@amparchitect.com
CONTRACTOR INFORMATION:
Name:
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
DOther Accessory Apartment Legalization
Will the lot be re-graded? ❑Yes ®No Will excess fill be removed from premises? ❑Yes ®No
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PROPERTY INFORMATION
Existing use of property: single Family Residence W/Accessory Apammnei Intended use of property: Single Family Residence W/Accessory Apartmnet
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
AHD this property? ❑Yes ®No 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 By(print name): AMP Architecture BAuthorized Agent ❑Owner
Signature of Applicant: Date: -7 It 6(2, LA
STATE OF NEW YORK)
0 �--�COUNTY O ,
U0�` _w being duly sworn, deposes and says that(s)he is the applicant
(Name of individual 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 knowledge and belief,and
that the work will be performed in the manner set forth in the application file therewith. A.
DARIBAI' A H.TANDY
Sworn before me this Notvy Public,State Of NeW'Vbrk
No. OITA6086 01
day of 1aQ
C 2Ci^ � ellfieod In Suffolkell
./s
Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
Elena Palencia 755 Oriole Drive, Southold, NY 11971
residing at ....... ..........
_
AMP Architecture
......w�do hereby authorize —to apply on
my behalf to the Torn of Southold Building Department for approval as described herein.
07/14/2024
Owner's Signature Date
Elena Palencia
Print Owner's Name
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