HomeMy WebLinkAbout39883-ZTOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
South oldTown.No rthFork.net
Exan'ined 20
Approved. 20
Disapproved
Expiration _1 ..w9, _, 20
PERMIT NO.
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
C.O. Application.....
Flood Permit _
Single & Separate _____ ........
Storm -Water Assessment Form
Contact:
Mail to: r
Building Ins ectot
FOR BUILDING PERMIT
w
�1
INSTRUCTIONS
Date„ 20 I i
a. This plic4lion MUST be completely fil I ,d in by typewriter or in ink and submitted to the Building Inspector with 4
sets of plans, ac urate `plat plts9rtocate l e according to schedule.
b. Plot pan showing iocation of lot and of buildings on premises, relationship to adjoining premises or public streets or
areas, an ware ---
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 pen -nit
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, housing code, and regulations, and to admit
authorized inspectors on premises and in building for necessary inspections.
(Signatu�f applicant if a corporation)
s'fi3'y ez h,. d J f CJrrt nfs--3
(Mailing address of applicant)
State whether applicantisowner, lessee, agent, architect, engineer, ` neral cont, electrician, plumber or builder
Name of owner of premises
��� t✓'urr>�,�✓
(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. 4179,-7-
Plumbers
139d7-Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which proposed work will be done:
House Number
Hamlet
pp t i2,1�,
County Tax Map No. 1000 Section Block 4 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
b. Intended use and occupancy
3. Nature of work (check which applicable)
Repair ____Removal
New Building Addition Alteration t,-/
. ..................
Demolition Other Work
(Description)
4. Estimated Cost— -Vou 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
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use.
7. Dimensions of existing structures, if any: Front.__._ Rear
Height Number of Stories
Depth
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 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 NO
14. Names of Owner of premises Address, Phone No.
Name of Architect Address --.Phone No
Name of Contractor 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,
18. Are there any covenants and restrictions with respect to this property? * YES NO.
* IF YES, PROVIDE A COPY.
STATE OF NEW YORK)
SS:
COUNTY OF_5)ff4k)
being duty sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
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
20_6�_
i
otary Public MACEY-L. DWYER Signature"
. .....
TAFRY PUBLIC, STATE OF NEW YORK
NO. 01 DWiM9W
QUALIFIED IN SUFFOLK COUNTY
COMMISSION EXPIRES JUNE 30, Zd&
SUPERVISOR
iii
SOUTHOLD TOWN HALL - P. O. Box 1179
53095 Main Road - SOUTHOLD, NEW YORK 11971
isrolm
1164, WV
41 a 11
M4 �, A&GIEPTIME
Town ofSouthold
DOES THIS RROJEC,1' INVOLVE ANY OF '1711E FOL LO.WING:
'Yes No - (CIFIECK ALL 'rHAT APPLY)
Clearing, grubbing, grading or stripping of land which affects more
than 5,000 square feet of ground surface.
Excavation or filling involving more than 200 cubic yards of material
/ within any parcel or any contiguous area.
F] []rC. Site preparation on slopes which exceed 10 feet vertical rise to
/100 feet of horizontal distance.
SrID. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
EI ET/E. Site preparation within the one -hundred -year floodplain as depicted
o, n FIRM Map of any watercourse.
Installation of new or resurfaced impervious surfaces of 1,000 square
feet or more, unless prior approval of a Stormwater Management
Control la was received by the Town and the proposal includes
in-kind replacement of impervious surfaces.
If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name,
Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project._
If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan
and a completed Check List Form to the Building Department with —your Building Permit Application.
u.(Profierty0wiier,Desi-.YiPofes-5ional,A-.erit, 1000 ➢Date�
P1 (o �-' I:- �:) Other) S.C.T.M. I District
NAME A, a a--
pw"I! ton Block Le:9
Contact Informatiorr. --,424t-, -71D Y?
Propc�r( ori of Construction Work:
. . ...........
1193-7
F'ORM " SMCP -- I -OS MAY 2014
d
Reviewed By ..... ....
Date:
Approved for processing Building Permit,
Storritwater Managernent. Control Plart Not Required,
Stormwater Management Control Plan is Requifed.,
Li(Forward to Erigmeenng Department for Review,)
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