HomeMy WebLinkAbout39821-ZTOWN OF SOUTHOLD
PUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
SoutholdTown.NorthFork.net
Examined o , 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
PERMIT NO:. �.' 1. Check
Septic Form
.N,Y.S.D.E.C.
Trustees
C.O. Application
Flood Permit
Sirigle:&;Separate
NAY , �� �.'
Stonn-Water Assessment Form
Contact:
U -r Mail to:
cen� K
ch,
i on . -266!5
Disapproved
Disapproved ac '
Expiration r , 20_J/&
Building Inspector
APPLICATION FOR BUILDING PERMIT
'Date 20 /5'
INSTRUCTIONS
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 coiripleted within 1.8 months frdiwlsuch date. If no zoriiiig>am'endments'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.
T4t)4.5 Z--1>1
(Signature of applicant or name, if a corporation)
--PO :Bbx 9, " L;g /vy my35-
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
C'.c.0Z
Name of owner of premises -7_zj?eJZ;,'
(As on, the tax roll or latest deed)
If applicanrt is a coWEaliorp, suture of duly authorized officer
/(Name and title of corporate officer)
Builders License No. 7.-1
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which proposed work will be done:
House Number =.. Street ,Hamlet
County Tax Map No. 1000 Section Block . ,Z Lot
Subdivision Filed Map No. Lot, '
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing -.use- and occupancy
_4�` 1
b. Intended use and occupancy Z 57mzy-s, �wz,, % , 1 C.c 1'x�J1i/�';
3. Nature of work (check which 'applicable): New Building �-�th�r
on Alteration
Repair Removal DemolitionWW
(Description)
4. Estimated Cost sSUUy, ou Fee. 1600,66 t
(To`be `paid on filing this application)
5. If dwelling, number of dwelling units Nur lgr Af dw f ig units on each floor
If garage, ,number of cars
6. If business; commercial or mixed occupancy, specify nature and extent.of each type of use.
7. Dimensions of existing structures, if any: Fronts 66 '3 Rear 60 3" Depth, 2y
Height ,!F Number of Stories .. 2 -
Dimensions
Dimensions of same 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
9. Size of lot: Front Rear /7,,5- YY
10. Date of Purchase Name of Former Owner
11. Zone or use district in which premises are situated A''007 -.5d
12. Does proposed construction violate any zoning law, ordinance or regulation? YES , NO k
13. Will lot be re -graded? YES'X NO Will e,xcess fill be removed from premises? YES NO.
14. Names of Owner of,premisesQ,_ - aL Address % hone No.,aV-6 go
Name of Architect Address, Phone No
Name of ContractorCd4rv-� 24a6 c:�e Address r?v -t;�zw q` r4.�'hone No.
15 a. Is this property within 100 feet ofa tidal wetland or a freshwater wetland? *YES NO.
* IF YES; SOUTHO'LD TOWN TRUSTEES & D.E.C. PERMITS MAY BE -REQUIRED.
b. Is this property within 3'00 feet of a tidal wetland? *"YES NO
* IF YES, D.E.C. PERMITS MAY BE REQUIRED''.
16. Provide, survey, to*scale, with accuratefoundation 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 JC
* IF YES, PROVIDE A COPY.
STATE OF NEW YORK)
SS:
COUNTY OF )
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. .
Sworn o befor the this
a oQ Notary Publ;e, State of }'�:
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