HomeMy WebLinkAboutMattituck F.D. BPA form TOWN OF SOUTHOLD BUILDING PERMIT APPPCATION CHECKLIST
BURMING DEPARTMENT Do you have or need the following,before applying?
TOWN HALL Board ofHealth
LD,NY 11971 4 sets of Building Plaas
SOUTHO76 NY 11 pWming Board `ova
TEL: HO
FAX:(631)765-9502 Survey
SoutholdTownNorthFork net PERNIIT NO. Check
-
Septic Form
N.Y.S.DJ&C.
Trustees
Flood Permit
Examines 20L__ Storm-WaterAssessment Form
Contact: Attorney for Applicant:
Approved .20 Mail to:Re,Nielsen,Huber&Coughlin,LLP
36 N.New York Ave.,Huntington,NY 11743
Disapproved alc
Phone: 631425-4100
Expiration .20 -
F Building Inspector
APPLICATION FOR BUILDING PERMIT
Date ,20
INSTRUCTIONS
a.This application MUST be completely filled in by typewriter or in ink and submitted to 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 adjoining premises or public strects or
arras,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.
£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,housing code,and regulations,and to admit
authorized inspectors on premises and in building for necessary inspections.
Mattituck Fire District
(Signature of applicant or name,if a corporation)
P.O.Box 666,Pike Street,Mattituck,NY 11952
(Mailing address of applicant)
State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder
Owner
Name of owner of premises Mattituck Fire District
(As on the tax roll or latest deed)
If applicant is o tion,si ture of duly authorized officer
By ✓��
(Name itle ofcorporate officer) amm-FdA
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:
1000 Pike Street Mattituck
House Number Street Hamlet
County Tax Map No.1000 Section 140 MOVW.A YAM3 Lot 11.1
Subdivision C TRAWN Lot
vinuoa 31101lue n1 beftaou0
_0S.SS yluL 49ruga3 n01181mmO7 yM
2. State exi5img use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy Fire District/Department use,including communications facility
b. Intended use and occupancy Same as above with upgraded communications facility
3. Nature of work(check which applicable):New Building_ _ Addition Alteration
Repair Removal Demolition Other Work Re)lace,existing wooden pole with
120'cop mumications umpole and install antennas thereon,all as depicted is the plans (Description)
MEW&T,
(To be paid an filing this application)
5. If dwelling,number of dwelling Units n/a Number of dwelling Units on each floor
If garage,number of cars I Fire District/Department
6. If business,commercial or mixed occupancy,specify nature and extent of each type of use use,including
facility
th (a9
7. Dimensions of existing structures,if our. g�J�a" Rear I$5 a Dep
Height I `� Number of Stories*��g 5 wooden pole
Dimensions of some structure with alterations or additions:Front Rear
Depth Height Number of Stories
8. Dimensions of entire new construction:Front Rear Depth
Height Number of Stories*Pr°posed 120';;;;cmur"`ahons umtpole
9. Size of lot:Front Rear?U3 SQA* Depth
10.Date of Purchase Name of Former Owner
11.Zone or use district in which premises are situated HB-Hamlet Business
12.Does proposed construction violate any zoning law,ordinance or regulation?YES_NO X
13.Will lot be re-graded?YES—NQ_g Will excess fill be removed from premises?YES NOS
PO Box 666
lvlattituckFireDishictAddressMattitack,NY11952 Phone No.631-298-8833
14.Names of Owner of premises Phone No
Name of Architect Address
Name of Contractor Address Phone No.
15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?'YES NO X
*IF YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BE REQUIRED.
b.Is this property within 300 feet of a tidal wetland?*YES NOS_
*IF YES,D.E.C.PERMITS MAY BE REQUIRED.
16.Provide survey,to scale,with accurate foundation plan and distances to properly 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 properly?*YES NO_C
*IF YES,PROVIDE A COPY.
STATE OF NEW YORK)
SS:
COUNTY OFStL l
'10%%n C_ .%0n being duly swots,deposes.and says that(4he is the applicant
(Name of individual signing contract)above named,
�)He is the 2C_ '
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 fire 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
60r% of *tW 2013 M ' k-w District
F By
Notary Public r A.1MgAON Signature of Applicant
NOTARY FWt1P-"SrAM OF NEW
No.01 WI6256377
awNmW in Sullo*tou"V
My COMMMM"Espke$MY 22.2011
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