HomeMy WebLinkAbout30372-Z FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Hall
Southold, N.Y.
BUILDING PERMIT V ` ' ` V V
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
PERMIT NO. 30372 Z Date JUNE 2 , 2004
Permission is hereby granted to :
MICHAEL J SCHMIDT
MATTITUCK,NY 11952
for
CONSTRUCTION OF A DECK ADDITION TO AN EXISTING ONE FAMILY DWELLING
AS APPLIED FOR. THIS PERMIT REPLACES BP#27387 .
at premises located at 195 SELAH LA MATTITUCK
County Tax Map No. 473889 Section 106 Block 0009 Lot No. 004 . 005
pursuant to application dated JUNE 2 , 2004 and approved by the
Building Inspector to expire on DECEMBER 2), 2005 .
Fee $ 150 . 00
th ized Si ure
ORIGINAL
Rev. 5/8/02
FIELD INSPECTION REPORT BATE : ._,_.�_;' COMriENTS
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FOUNDATION ( 1ST)
I
�pUNDATION (2ND) --__----�( 'r, ,"" ----_-----
II
I
II
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ROUGH FRAME & I �'
'PLUMBING G')
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INSULATION PER N. Y. ±$ H
STATE ENERGY J
CODE
I
FINAL
N
ADDITIONAL COMIENTS:
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765.1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INS CATION
[ ] FRAMING [ 'FINAL jak ,
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS: r"z .
Aof
DATE B INSPECTOR
I U wiv Ur oUu I nVLU t3UILI)INU rhKM11 APPLIC;AI'ION C;HECKLIS
BUILDING DE ARTMENT Do you have or need the following,before applying
TOWN HALL Board of Health
SOUTHOLD, 11971 3 sets of Building Plans /
TEL: 765-1802 Survey
__._PERMIT NO. Check
Septic Form
N.Y.S.D.E.C.
Trustees
Examined , 20 Contact:.
Approved , 20 0 1 Mail to:, 6,9E St w�v b7
Disapproved a/c /9S.1 LAµ U• �t./..,/7WAff4 A_ /
Phone: a
J
B ing Inspector
APPLICATION FOR BUILDING PERMIT
Date Adel[.. , 20_
INSTRUCTIONS
a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3
sets of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan showing location of lot and of buildings on*premises, relationship to adjoining premises or public streets or
areas, arld waterways.
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 will issue a Building Permit to the applicant. Such a permit
shall be kept on the premises available for inspection throughout'the work.
e. No building shall be occupied or used in whole or in part for any purpose what-so-ever until a Certificate of Occupan
is issued by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County,New York, and other applicable Laws, Ordinances or
Reations, for the construction of buildings,additions,or alterations or for removal or demolition as herein described.The
apant-agrees to comply with all applicable laws, ordinances,building code,housing code, and regulations, and to admit
aut)ICIized inspectors on premises and in building for necessary inspections.
(Si ture of applicant or name, if a corporation)
/QS.kLA// 1,g• .f %F771 vcE iCJy//QS'L
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Name of owner of premises 1Seyv.10 7-
(as
(as on fhe tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer
(Name and title of corporate officer)
Builders License No.
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which proposed work will be done:
Z O9 Al
House Number Street Hamlet ' *
County Tax Map No. 1000 Section /OCi DD Block '09- 00 --` Lot Do se; �Qp
Subdivision LcJC,s7 .4��/ .S't��di v�c a,�J Filed Map No. 96,19 Lot 3
(Name)
?. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy .` ,�E7t�7J,9/ -„pa
b. Intended use and occuparncyV
i. Nature of work (check which applicable): New Building ✓ Addition Alteration
Repair Removal Demolition Other Work -�
1. Estimated Cost (Description)
(y cc,le- Fee
.,
(to be paid on filing this application)
If dwelling; number of dwelling units / Number of dwelling units on each floor
If garage, number of cars z
If business,_commercial or mixed occupancy, specify nature and extent of each type of use.
Dimensions of existing structures, if any: Front L Rear so . Depth `30 . y
Height 'U^*_ Number of Stories Z
Dimensions of same structure with alterations or additions: Front z. Rear
Depth so. co HeighNumber of Stories z
Dimensions of entire new construction: Front /2 / Rear �2 Depth /L
Height /L Number of Stories_
Size of lot: Front /L/. 79 Rear i& & i5 Depth 7-7-7 . 9
0. Date of Purchase ,_Name of Former Owner 9- CAJAo7-
1. Zone or use district in which premises are situated
2. Does proposed construction violate any zoning law, ordinance or regulation:
3. Will lot be re-graded .vo Will excess fill be removed from premises: YES
4. Names of Owner of pre ises= Address �,,�
�9sL � Phone No. 6LSi
Name of Architect _Address Phone No
Name of Contractor Address Phone No.
5. Is this property within 10 feet of a tidal wetland? *YES NO
• IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED
6. Provide survey, to scale, with accurate foundation plan and distances to property lines.
7. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey.
TATE OF NEW YORK)
SS:
'OUNTY OFS�/�
.�iG/1A6 L J. 5'c,,,t 4.14 '7" being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
3)He is the ,.�,,,,,,�-,�L
(Contractor, Agent, Corporate Officer, etc.)
f said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;
iat all statements contained in this application are true to the best of his knowledge and belief; and that the work will be
-rformed in the manner set forth in the application filed therewith.
worn to before me this
day of 200
Notary Public gnature of Applicant
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