HomeMy WebLinkAbout52051-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#: 52051 Date: 07/01/2025
Permission is hereby granted to:.
Gregory Olsen
PO BOX 158
Laurel, NY 11948
To:
Legalize as-built wood stove at existing single family dwelling as applied for.
Additional certification may be required.
Premises Located at:
6645 Great Peconic Bay Blvd, Laurel, NY 11948
SCTM# 126.-10-20
Pursuant to application dated 05/29/2025 and approved by the Building Inspector.
To expire on 07/01/2027.
Contractors:
Required Inspections:
Fees:
As Built Alteration $500.00
CO Single Family Dwelling-Addition /Alteration $100.00
Tota I $600.00
Building Inspector
� w ra 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 htios://www.southoldtownnv,fzov
Date Received
APPLICATION FOR BUILDING PERMIT
p For Office Use Only
PERM IT N0. Building Inspector;, M AY 2
Applications and forms must be filled out in their entirety. Incomplete Building Department
applications will not be accepted. Where the Applicant is not the owner,an Town of Southold
Owners Authorization form(Page 2)shall be completed.
Date:
OWNER(S)OF PROPERTY:
Name: � - P-Y �, �S cCf SCTM # 1000- ..
Project Address: 4 6 q s- (3
Phone#: (23 / d 3 G 9 Y,;I- Email: A),`W ocsC'-Z' Ver2(-�) 'Mel (, co �44
Mailing Address: N C� �JOI� ( 7 , (l c�,�a-
CONTACT PERSON:
Name: e AY p ' C)I
Mailing Address: P, 0� (3 p'(' / S 8- �xc> v Ae( At y, /I G Y-
Phone #: J��rJ� 3 Email:
wocxoe-, cep
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name:
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
❑Other ovcg 0o-- $
Will the lot be re-graded? ❑Yes ONO Will excess fill be removed from premises? Dyes El No
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PROPERTY INFORMATION
Existing use of property: /��s ���N ��u) Intended use of property:
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? Eyes ❑No IF YES, PROVIDE A COPY.
❑ Check Box Aft r d g.,. Ile pwner/contractor/design professional Is responsible for all drainage and storm water issues as provided by
Chapter 236 o�h E � 4 15 HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building zone
Ordinance ofthe T otSoutho„ ,SuNk County,New York and other applicable Laws,ordinances or Regulations,for the construction of buildings,
addit ons 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
q
as a Bass"A misdemeanor pursuarrt to'Section 210.45 of the New
pun! , York State penal taw.
Application Submitted By(pri name): ff_�r2LP /� LEI SFtd) ❑Authorized Agent ElOwner
Date:. /Qj�
Signature of Applicant: �, /,
CONNIE D.BUNCH /
STATE OF NEW YORK) Notary Public,State of New Yorlc
No.01BU6185050
SS: Qualified in Suffolk County
COUNTY OF )
Commission Expires April 14, 20(
being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing 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.
Sworn before me this
dbyofM , 20
Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
I, residing at
do hereby authorize to apply on
my behalf to the Town of Southold Building Department for approval as described herein.
Owner's Signature Date
Print Owner's Name
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