HomeMy WebLinkAbout51720-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#: 51720 Date: 03/10/2025
Permission is hereby granted to:
Anne M Bellesheim
80 Huntington Ave
Scarsdale, NY 10583
To:
construct additions and alterations to existing single-family dwelling as applied for.
Premises Located at:
2130 Plum Island Ln, Orient, NY 11957
SCTM# 15.-5-30
Pursuant to application dated 01/30/2025 and approved by the Building Inspector.
To expire on 03/10/2027.
Contractors:
Required Inspections:
Fees:
Single Family Dwelling- Addition&Alteration $994.75
CO-RESIDENTIAL $100.00
F, Total $1,094.75
Building Inspector
TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY l 1971-0959
Telephone 631 765-1802 Fax 631 765-95021 ttt ://www.sotltho Idt:ONVI)n ��1ov
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Date Received
BUILDINGAPPLICATION FOR E T 1r;
r
For Office Use Only J A N 2 9 9
PERMIT NO. 5/ Building Inspector
Applications and forms must be filled out in their entirety.Incomplete
applications will not be accepted. Where the Applicant is not the owner,an
Owner's Authorization form(Page 2)shall be completed.
Date:1/29/2025
OWNER(S)OF PROPERTY:
Name:Anne & Gerard Bellesheim SUM#1000- C;,- — S — 3
Project Address:2130 Plum Island Lane, Orient, NY
---mail:
Phone#:1 (914) 714-5078 E
Mailing Address:..
CONTACT PERSON:
Name:Adam Volosik
Mailing Address:528 South Harbor Rd. Southold, NY 19171
Phone#:(631) 806-2537 Email:avolosikCa-)g mail.com
DESIGN PROFESSIONAL INFORMATION:
Name:Adam Volosik Architect
Mailing Address:528 South Harbor Rd. Southold, NY 19171
Phone#:(631) 806-2537 Email:avolosik�gmail.com
CONTRACTOR INFORMATION:
Name:To be determined
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure WAddition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
❑Other TBD
Will the lot be re-graded? *Yes ONO Will excess fill be removed from premises? *Yes ONO
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LVIIG VI 4JG YIJ tlU\.\111Y11111 ►/IGIIIIJGJ !J situated: 1R-40 Medim Density Residential this property? ❑Yes D�No IF YES, PROVIDE A COPY.
1 Y N ® -iek Box,After Reading: The owner/contractor/design professional Is responsible for off drainage and storm water issues as provided by
mapter 235 of the Toe.!.^.Ccde. AuptOn ON Ic NGRE9Y fU111VE to the faUUl,i!„"VeF=1+-n1ePt fnf the!19Sl8.„.Ce Of 2 9@-'!!dln$Permf►rpu1nuentte ne Ru fMng Zone t dM
ordinance of the Town of Southold,Suffolk,county,New York and other applicable taws,ordinances or Regulations,for the construction of buildings,
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housing code and regulations and to admit Whorhed inspectors on premises and in building(s)far necessary Inspections.Faise statements made hand are
punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law.
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Sg ture of rill nt: Date:
Cf)NNIE D.BUNCH
Notary Public,State of New York
STATE OF NEW YORK) No,OIBU6166060
SS: Qualified in Suffolk County
Commission Expires April 14,2_�
COUNTY OF
1
being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the
(Contractor,Ascent,Corporate Officer,etc.)
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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.
Swom before me this
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2 stay of � r��
Notary Public
-PROPERW OWNER AUTHORIZATION
(Where the applicant is not the owner)
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1, c rA e'sh,eA cv) residing at "Z190 FItIc\n )Slo,rc( Lyl
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do hereby authorize to apply on
my beh the To uthold Building Department for approval as described herein.
Owne S JignarEure imie
Print Owner's Name