HomeMy WebLinkAbout1000-69.-5-18.1FORINTERNALUSE ONLYI
SITE PLAN USE DETERMINATION
Initial Determination
Date: ~ /___L~, /
Project Name:
Project Address:
Date Sent:
Suffolk County Tax Map No.:1000- 1O~
3- - /8.) Zoning District:
Request: %~ ~,~;~.~ o~-~_~) /.~'~- c_~_.,,.~,~
(Note: Copy of Bud ng PerMt AppliCation and supposing ~cum~tation as to
proposed use or uses should be submi~ed.)
Initial Determination as to whether ~ is permitted:
Initial Determination as to whether site plan is required:
nature of Building Inspector
Planning Department (P.D.) Referral:
P.D. Date Received: .2 / /~ / d ~ Date of Comment:
-- ' Sk n' ' ' '" - ' ' '
Final Determination
Date: / /
Decision:
Signature of Building Inspector
2. State existing use and occupancy of premises and intended use and occupancy of proposed constriction:
· . ~' a. Existing use and occup~
b. Intended use and occupancy d~2/~q__
?
Nature of work (check which applicable): New Building
Repair Removal Demolition
Estimated Cost
If dwelling, number of dwelling units
If garage, number of cars
Addition
Other Work
Fee
Alteration
(Description)
(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 type of use. ~'xJ/~
7. Dimensions of existing structures, if any: Front Rear Depth
Height. Number of Stories
Dimensions of same structure with alterations or additions: Front
Depth. Height Number of Stories
8. Dimensions of entire new construction: Front ~ o Rear /,Zo Depth
Height. Number of Stories
9. Size of lot: Front ~9 ~/c~ Rear '~ J>~ .Depth
Rear
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 Will excess fill be removed from premises? YES NO
14. Names of Owner of premises
Name of Architect
Name of Contractor
Address Phone No.
Address Phone No
Address Phone 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 REQUIRED.
b. Is this property within 300 feet of a tidal wetland? * YES NO
* IF YES, D.E.C. PERMITS MAY BE REQUIRED.
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.
STATE OF NEW YORK)
CO TY oF
~&gd4.4 ...C ~,/~/~/~-~-'~"~. 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 knowledge and belief; and that the work will be
performed in the manner set forth in the application filed therewith.
0(
Notary Publi~ / ~
Signature of Applicant