HomeMy WebLinkAbout52221-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, NY
BUILDIING 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#: 52221 Date: 08/28/2025
Permission is hereby granted to:
Jonathan Fischer
75 Henry St
Brooklyn, NY 11201
To:
construct an accessory pergola as applied for.
Premises Located at:
10945 Sound Ave, Mattituck, NY 11952
SCTM# 141.-3-1.1
Pursuant to application dated 07/25/2025 and approved by the Building Inspector.
To expire on 08/28/2027.
Contractors:
Required Inspections:
Fees:
Accessory-New Structure $207.50
CO Accessory $100.00
Total 0'7.SQ
Building Inspector
'Off 8
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 litt s://ww ,soijthol(itownr,n . gory
9v uFl
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only E C E I lJ E
,ID
PERMIT NO. Building Inspector:
— L� — I
Applications and forms must be filled out in their entirety.Incomplete
applications will not be accepted. Where the Applicant Is not the owner,an Building Department
Owner's Authorization form(Page 2)shall be completed. Tomm Of ,0LIfl•0?d
Date:
OWNERS)OF PROPERTY:
Name: T o-44 h SCTM# 1000- .
Project Address: 0 9J,--- V Id � �Ve -�'�%i�cc � / 5-Z
Phone#: _ 23 Email: I G�`I 4AC,tA
Mailing Address:
CONTACT PERSON:
Name ,,—
Mailing Address: Fb. 'Rck Or eh
Phone#: 6-31_ Zql--5d470�5- Email: irbelcfrs- eeo— i°1lt! Cyr
DESIGN PROFESSIONAL INFORMATION:
Name:
�an'1� 1 (fcov'12
f`PQ. • i
Mailing Address: O �/S �4 Yl6) PeCeh Z
Phone#: ��/- �7 t�� •� Email: 4 `� i"t a d ,
CONTRACTOR INFORMATION:
Name: a4, Lf kod""
Mailing Address:
Phone#: ��— Z — �0 �� Email. 6 e;we i �.Co/!,
DESCRIPTION OF PROPOSED CONSTRUCTION
BNew Structure ❑Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:
❑Other '-
Will the lot be re-graded? Dyes [XNo Will excess fill be removed from premises? ❑Yes 12No
1
PROPERTY INFORMATION
Existing use of property: hPS,�eh.����> Intended use of property:
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? ❑Yes ❑No IF YES, PROVIDE A COPY.
❑ Check Box After Reading: The owner/contractor/design professional is responsible for a6 drainage and storm water issues as provided by
Chapter 236 of the Town Code. APPLICATION IS HEREBY NWDE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone
ordinance off4eA60n udf old"pup ,County,New York and'other applicable Laws,ordinances or Regulations,for the construction of buildings,
additions,plteratlrir�or err rr�or or dean olltionasherelp descrlbecl.The applicant agrees to comply with all applicable laws,ordinances,building code,
housing code and regulations and to admit au4dorrzed Inspectors on premises erld In building(s)for necessary Inspections.False statements made herein are
punishable as a Class A misdemeanor pursuantto Section 910AS of the New York State Penal law.
Application Submitted By(print name): Ecl"r.4 Py,�r- MAuthorized Agent ❑Owner
Signature of Applicant: `�rz Date: 71171-Z
STATE OF NEW YORK)
S:.
COUNTY OF � - )
�d K.4r A m 2r' 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
24--day
- -.day of uJA ZD
I Lary PU*—ft "ANY A CONRAl i
Notary Public,S121tr:Of New York
R,q,No.()1Ci 624 154
Duiffred in SUffcalk Co my
PROPERTY OWNER AUTHORIZATION com isslon Expires»luly 18"20
(Where the applicant. is not the owner)
I, U T/� ►- in'N s Gµ residing at (�°) t— Od.A ,j"TvD P ti
do hereby authorize to apply on
my behalf to the Town of Southold Building Department for approval as described herein..
1,Ai�, I I J—LLy -Z�p
Owner's Signature Date
Print Owner's Name
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