HomeMy WebLinkAbout30666-ZFORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Hall
Southold, N.Y.
(THIS
BUILDING PERMIT
PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
· PkP~rrNb. 30666 z
Date SEPTEMBER 27, 2004
Permission is hereby granted to:
LUCILLE C LUFR3kNO
PO BOX 642
POINT LOOKOUT,NY 11569
for :
DEMOLITION OF SINGLE FAMILY DWELLING AS APPLIED FOR
at premises located at 610 LUPEN DR
County Tax Map No. 473889 Section 104 Block
pursuant to application dated SEPTEMBER 27, 2004
CUTCHOGUE
0001 Lot No. 003
and approved by the
Building Inspector to ex/~ire on MARCH
Fee $ 305.00
27, 2006.
ORIGINAL
Rev-. 5/8/02
TO~2'ff OF S O~3TI:IO~LD
TOVVN HALL
SOl. HOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
~T. no~for~neffSou~ld/
Exam~ed
Disapproved ~'c
iExpiration_ 20__
PERMIT NO.
BU!.LDENG PERMIT APPLICATION CI-I~CKLIST
Do you hw~-e or need the following, befo)-e apply/~g?
Board or'Health.
4 sets of Baflcl/ng Plans
Harming Board a?pro'~al
Survey
Ch~k:
S~fi¢ Form
N.Y'.s;D.E.C.
Trustees
Contact: -,. ~ "~.
Bull /nspector
Mail to:
APPLICATION FOR BUILDING PERMIT
Date
INSTRUCTIONS
,20 vp'
a. This application MUST be completely filled in by typewriter or in ink and subm/tted m the Building Inspector with 4
sets ofplans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan showing location of lot and of buildings on premises, relationship to.adjoLaing premises or public streets or
areas, and watem,ays.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector ~511 issue a Bui/ding Permit to the applicant. Such a permit
shall be kept on the premises ava/lable for inspection throughout the work.
e_ No building shali be occupied or used in whole or in part for any purpose what so ever until the Building Inspector
issues a Ce~lificate of Occupancy.
f. Ever)' building permit shall expire if the work authorized has not commenced within 12 months a~ter the date of
issuance or has not been completed within 1 $ months from such date. If no zot~g mnendments or other regulations affecting the
property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension o£the permit for a~
-:addition ~ix--m~-nth-s: Thereafter7 a new permit shaI1 be requ/red. ' '
APPLICATION IS HEREBY MADE _to the Building Department for the Lssuanc~ of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southpld, S'.uffolk CounW, New York, and other applicable Laws, Orc[mances or
Regulations, for the construction of buildings; additions, or alterations or for remoxml or demolition as herehi 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 for.necessary inspections. ,/rl.{/~'-,~/~Y/~,~-''' ,~~~/~C', '
(Signature ofapplicant or name, ifa corporation)
State whether applicant is owner, lessee, agent, arckitect, engineer, general contractor, e/ectrician, plurnber or builder
Name of owner of premises
If applicant is a corporation, signature of dui3' authorized officer
(Name and title of corporate officer)
Builders License No_
· Plumbers License No.
Electricians License No_
Other Trade's License No.
(As on the tax roll or latest deed
1. Location of land on which proposed wo~-k ~411 be done:
House N~b~ ~reet
H,'fmlct
County Tax Map No. 1000 Section
Subdivision
(Name)
Block ,o/
Filed Map No.
Lot .
· Lot
2. State existing use and occupancy of premises a~ inten/d,~d use and occupancy ofproposed construction:
a. Existing use and occupancy ,~. ~' ~/~.~_
b_ Intended use and occupancy
3. Nature of work (check which applicable): New Building
Repair Removal Demolition
4. Estimated Cost ~P,~, ~
5. If dwelling, number of dwelling units
If garage, number of cars
Addition ~ Alteration
Other Work
,~' (Description)
Fee
(To be paid on filing this application)
Number of dwelling units on each floor
6. If business, commercial or mixed occupancy, specify nature and extent of each t)?e of use.
7. Dimensions of existing structures, if any: From ~. ~r~
Height -/fi' ~ Number of Stories ~
Rear J~'~- d~ .Depth ~'J~- 40
Dimensions of same structure with alterations or additions: Front
Depth Height Number of Stodes
Rear
8. Dimensions of entire new construction: Front
Height Number of Stories
Rear Depth
9. Size of lot: Front d~-~'~ -r¢~">-'¢7 Rear Depth
10. Date of Purchase Name of Former Owner
1 I. Zone or use district in which premises are situated
12. Does proposed construction violate any zoning law, ordinance or regulation? YES__ NO
13. Will lot be re-graded? YES __ NO t/'Will excess fill be relnoved from premises? Y'ES NO
14. Names of Owner of premises "~"~"~7 ~e~'~Addt'ess ~"~ ~'~'-J"~ Phone No_.~/~
Name of Architect Address Phone No
Name of Contractor /~J~--~ ~../'~_c~/"~Address ~ ~7~--_-_-_-_-_-_-_-_~. ~-~one No.
15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES__NO __ * IF YES, SOUTHOLD TOWN TRUSTEES & D.E_C. PERMITS MAY BE REQUIlOdSD.
b. Is this property within 300 feet ofatidaI wetland? * YES__ NO q-~'
* IIc YES, D.E.C. PERMITS MAY BE REQUIRED.
16. Provide sumrey, to scale, with accurate foundation plan and distances to pmperOr lines.
17. If elevation at any point on property is at 10 feet or below, must provide topographical data on surcey.
STATE OF NEW YORK)
~ /?., , .SS:
(Name of in~('dual si~m~ing contract) above nm~,
(Con, actor, Agent, Co¢omte Office, etc.)
of said o~mer or o~-ners, and is duly authorized to perform or have performed the said work and to make and file this application;
that ali statements conta~ed in this application are tree to the best of his knowledge and belief; and that the work will be
performed ~ the manner set forth in the application filed therewith.
Sworn to before me this .4
· ,. ///-~/.~
/N~c~t aw Public
Si_maam~ Applicmzt