HomeMy WebLinkAbout51723-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#: 51723 Date: 03/11/2025
Permission is hereby granted to:
Dobi Inc
Attn: Southold Pharmacy
Southold, NY 11971
To:
construct alterations(interior demolition)to the existing building as applied for. Additional
permits/approvals will be required.
Premises Located at:
53855 Route 25, Southold, NY 11971
SCTM#61.-1-17
Pursuant to application dated 01/31/2025 and approved by the Building Inspector.
To expire on 03/11/2027.
Contractors:
Required Inspections:
DRAINAGE, FOOTING/REBAR, FOUNDATION 1ST, FOUNDATION 2ND, FRAMING/STRAPPING , PLUMBING ,
ELECTRICAL- ROUGH, FIRE RESISTANT PENETRATION , ELECTRICAL- FINAL, INSULATION, FIRESAFETY
INSPECTION , FIRE RESISTANT CONSTRUCTION , FINAL,
Fees:
Commercial-Alteration $300.00
CO Commercial- Addition/Alteration $100.00
Total S400.00
Building Inspector
Docusign Envelope ID:CF28F190-B214-4653-A90C-18E37D3E4090
TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
Telephone(631)765-1802 Fax(631) 765-9502 httLis://www.southoldtownny.gov
„r
Date Received
APPLICATION FOR BUILDING PERMIT b w LLJ
For Office Use Only f J A N 3 1 20125
C -
PERMIT NO. S -Z-3 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
Owners Authorization form(Page 2)shall be completed.
Date:1.30.25
OWNER(S)OF PROPERTY:
Name: Michelle S Metz SCTM#1000- 61.-1.-17
Project Address:53855 Rt 25 Southold, NY 11971
Phone#:631-766-7119 FE -mail mush! 2368@aol.com
Mailing Address: 1065 Leeward Drive Southold NY 11971 United States
CONTACT PERSON:
Name:KATHERINE SAMUELS
Mailing Address:25235 MAIN ROAD
Phone#:631-235-1177 Email:IG4TE@SAMUELSANDSTEELMAN.COM
DESIGN PROFESSIONAL INFORMATION:
Name:ABOVE
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name:tbd
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration ❑Repair Cj4Demolition Estimated Cost of Project:
❑Other $9A.W
Will the lot be re-graded? ❑Yes WNo Will excess fill be removed from premises? ❑Yes 5JNo
1
Docusign Envelope ID:CF28F1 90-B2144653-A90C-1 BE37D3E4090
PROPERTY INFORMATION
Existing use of property: Retail intended use of property: Retail
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
HB this property? ❑Yes®No IF YES,PROVIDE A COPY.
$] Check Box After Reading: The owner/contractor/design professional is responsible for an 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 Buli di ft zone
On 1ftmun of the Town of Southold,Suffolk County,New York and other applicable laws,Ordinances or Regulations,for the construction of buiklings,
additions,alterations or for removal or demolition as herein described.The applicant agrees to comply with an applicable laws,ordinances building code,
housing code and regulations and to admit autlwrized inspectors on premises and In building(s)for necessary inspectlans.False statements made herein are
punishable as a CLass A misdemeanor pursuant to Section 210AS of the New York State Penal Law.
Application Submitted By(print name): Katherine Jean Samuels ®Authorized Agent ❑Owner
Signature of Applicant: Date: 30th January 2025
RE
STATE OF K) Florida
SS:
COUNTY OF Miami-Dade 1
Katherine Jean Samuels being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)he is the Authouthoized 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. w RiSA BRANA
Notary Public-State of Florida
Sworn before me this `o"'n°si°""HH5M5%
moires on April 1Z2M
30th day of January 20 25
Commission Expires 04/12/2028 Risa Brana Notary Public
Notarized remotely online using communication technology via Proof.
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
Michelle S Metz residing at 1065 Leeward Drive Southold, NY 11971
I,
do hereby authorize Kate Samuels to apply on
S e
my 'e h Tr Southold Building Department for approval as described herein.
O UDC8os473- 1/28/25
Owner's Signature Date
Michelle S Metz
Print Owner's Name
2