HomeMy WebLinkAbout33925-ZFORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPkRTMENT
Town Hall
Southold, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
PERi, IT NO. 33925 Z Date MAY 15, 2008
Permission is hereby granted to:
LIZEWSKI
DEPOT LANE
CUTCHOGUE,NY 11935
for :
ALTERATIONS TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR
at premises located at 29205 MAIN RD CUTCHOGUE
County Tax ~ap No. 473889 Section 102 Block 0002 Lot No. 012.005
pursuant to application dated APRIL 25, 2008 and approved by the
Building Inspector to expire on __ __ __
Fee $ 200.00 NOVEMBER 15, 2009.·
ORIGINAL
Rev. 5/8/02
FOUNDATION (1ST)
FOUNDATION (2ND)
ROUGH FRAMING &
PLIYM~ING
IAN~SU"LATION PER N. Y.
STATE ENERGY CODE
FENAL
ADDITIONAL
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
SoutholdTown.NorthFork.net
PERMIT NO.
Examined ~~ ,20~'/
Approved ,20
BUILDING PERMIT APPLICATION CHECKLIST
Do you have or need the following, before applying'?
Board of Health
4 sets of Building Plans
Planning Board approval
Survey
Check
Septic Form
N.Y.S.D.E.C.
Trustees
Flood Permit
Storm-Water Assessment Form
Contact:
Mailto:
Phone:
Disapproved a/c
Expiration ,20
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
DateAI 'Z5 ,20
a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4
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, and 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 the Building Inspector
issues a Certificate of Occupancy.
f. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of
issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the
property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an
addition six months. Thereafter, a new permit shall be required.
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
Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein described. The
applicant agrees to comply with all applicable laws, ordinances, building code, ho)~ing code, and regulations, and to admit
authorized inspectors on premises and in building for necessary inspections.
(Signature of applicant or name, ifa c~rporation)
(Mailing address ofapphcant) ti ~ O ]
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Name of owner of premises /'~ v" '1-
(As on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer
(Name and title of corporate officer)
Builders License No. () tx] ~. ,,~
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land 9n which proposed work will be done: /
House Number Street
Hamlet
County Tax Map No. 1000 Section
Subdivision
Lot i2.
Lot
2. State existing use and occupancy ofpremise~ and intended use and occupancy of proposed construction:
a. Existing use and occupancy /r~ e 5'. ~ e~ gl '/,' "~ [
b. Intended use and occupancy ]~ ~. S t ~ ~- ti · ~ /
3. Nature of work (check which applicable): New Building Addition Alteration
Repair X~ Removal Demolition Other Work
Estimated Cost ~ 0 ~ ·
Fee
(Description)
(To be paid on filing this application)
Number of dwelling units on each floor
If dwelling, number of dwelling units
Ifgarage, numberofcars ~) ~'{ q.'t ~ ~3 l ~_ ~ ~_~.-,,_ ~ {.~. ~
If business, commercial or mixed occupancy, specify nature and extent of each type of use.
Dimensions of existing structures, if any: Front 5 7. 6 / Rear 12.' '7 Depth
Height '~ 0 Number of Stories
Dimensions of same structure with alterations or additions: Front /~/¢ (' [1. ~t { ~ .._ Rear
Depth /'C)/~' Height ([,) t/ (_, Number of Stories
8. Dimensions of entire new construction: Front Rear
Height Number of Stories
9. Sizeoflot:FrontJ2q- 7.5 Rear rd.70 Depth'2
Depth
10. Date of Purchase Name of Former Owner
11. 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__Will excess fill be removed from premises? YES__
14. NamesofOwnerofpremises /-; 7~g O5~ Address ~Va~ t~ PhoneNo.
NameofArchitect cl~qgg lhorx~tJ Address /~,'¥1/~l,d PhoneNo
NameofContractor l~li~dt_ Ocf~ Address /~;I/e~,//a ~tt PhoneNo.
l 5 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 ~,EQUIRED.
b. Is this property within 300 feet ora tidal wetland? * YES NO
* IF YES, D.E.C. PERMITS MAY BE REQUIRED.
/
72.-7' '7q4
16. Provide survey, to scale, with accurate foundation plan and distances to property lines.
17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey.
18. Are there any covenants and restrictions with respect to this property? * YES__ NO J
· IF YES, PROVIDE A COPY.
STATE OF NEW YORK)
SS:
COUNTY OF )
9 ~fl: ~. ~] ~ ;~._ being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing ~/ontract) above named,
(S)He is the /~[
(Contracto~ 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 knowledge and belief; and that the work will be
performed in the manner set forth in the application filed therewith.
Sworn to before me this
Notary ~blic
-'u['al'-pfl~drr :m :.~l~fil~'lloMs¢~ ,
,ss,on c'q~ms March l~,