HomeMy WebLinkAbout39807-ZTOWN OF SOUTHOLD
BUILDING. DEPARTMENT
TOWN'HALL'' '
SOUTHOLD, NY 119.711
TEL: (631) 765-1802
FAX: (631) 765-9502
SoutholdTown.NorthFork.net
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PERMIT NO
J a v a } � �•
Approved 120
Disapproved a/c t
Expiration , 20
BUILDING PERMIT APPLICATION.CHECKLIST
D -Do
Baard 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:
Mail to: I`
?_ g'3 -- 22717
Phone: 16 -,;-
APPLICATION FOR BUILDING PERMIT
Date g-- \ , 20 1!;'
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. j
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of this application, tyle Building Inspector will issue a Building Permit to the applicant. Such a permit
shall be kept on the premis6&aR1able boy='-slid1ion throughout the work'."'��
e. No building shapabeocc pi ot!lisi llcnlwhole ovin part�for�rpoaa �i+liat so ever until the, ildil4gtInsp Etmt�'
issues a Certificate of Occupancy: r -o fe :���v5 :. 2�po o l >W++' s- D:
f. Every building permit shalLgx�Wirfit� eMqyks authorized has not cold to csesd in 12 months after the date of
issuance or has not been completed within 1months 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.v�
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 alt RhRr 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.
(Signature of applicant or name, if a corporation
90 1256 rAt i+t'1'vQCIN%4 11 q. S111-
6SI-2Ag - 7 -2 -Vo 431 -R 65 -11$-'7
ailing address of applicant)
M10 -1-S0-0% (51 &eMbsrs sArg1te�s -Cela
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Name of owner of premises r^ G44 `� I ^ Co\
(As on the tax roll or latest
If applicant is a corporation, signature of duly authorized officer
(Name and title of corporate officer)
Builders License NoD.> 0iI
Plumbers License 1�0.
Electricians License No.
Other Trade's License No.
%eN.rn
1. Location of land on which proposed w4rk4 i11 Vc4do�- r. -" ° f ^ =' j -j : e
House Number
County Tax Map No. 1000
Subdivision
Section 115- Block 1
1-1
Filed Map No.
FPS
Lot
Lot
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2. State existing use and occupancy of premisesand intended use and occupancy of proposed construction:
a. Existing use and occup cy St nett M.ly �w x`11 o n
b. Intended use and occupancy�.•�n>>.j S,2 !k
3. Nature of work` (check whichapplicable): New Building Addition Alteration iC
Repair Removal Demolition Other Work
�- (Description)
4. Estimated Cost 50, , 000 Fee
(To be paid on filing this application)
5. If dwelling, number of dwelling units Number of dwelling units on each floor
If garage, number of cars z-
7.
If business, commercial or mixed occupancy, specify nature and extent of each type of use.
T /f av 9 s.+' col'x'' 61,, Vii- .'
Ditnensions of existing structures, if any: Front Rear Depth
IjleagY�t Z�' a Number of Stories
Dimensions of same structure with, alterations or additions: Frorit Rear
Depth_ Height 0vim, besk torles,w
8. Dimensions of entire new construction: Front.rri?,a Depii 1 W4
Height Number of Stories C, d. ` ; ° 3} •�a ; `a'iri ; 3d Z.r
L . "
9. Size of lot:
10. Date of Purchase Name of Former. Owner
11. Zone or use district in which premises are situated4 �.
12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO
13. Will lot be re -graded?, YES,",,. NO �(., I Will excess f ll, be removed from premises? YES NO
14. Names of Owner of -remises Cui&,QOeNV-a Address 3900 m�},�.t;„ �,k Phone No.417"%'7 a-q+S&
Name of Architect �� .•-..;DSS Ka>K A,,.' Ad -dress hone No'Aft "76S - V'LZ
Name of Contractor NNq>C iC.�t4 Address ` };-t tk 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 3is at 10 feet or below, must provide topographical databn survey.
18. Are there any covenants and restrictions with respect to this property? * YES
* IF YES, PROVIDE A COPY.
STATE OF NEW YORK)
SS:
COUNTY OFStd F�6 IIC)
NO )r
t- *\ IC -V% --f- being duly sworn, deposes and says that (s)he is"the applicant
(Name of individual signing contract)'above nar qj. O
(S)He is the A C�
(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 to before me thi
I "D ._ day of 6)--q0-r't 2015
Notary Public
BARBARA H. TANDY
Notary Public, State Of New York
No. 01 TA6086001
Qualified In Suffolk County
Commission Expires 01/13/20 .
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