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Home My WebLink About39926-ZTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.No rthFork. net BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health PERMIT2kc,- �w Examined 120 _I 4 �., i r � Approved.. 2( Disapproved a/c -------- ___, ._ _................................... _....... Expiration 20 uild,it w Inspector 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: .-e...e...........?..Sb.. T Phone: ?,-I - ¢7 APPLICATION FOR BUILDING PERMIT M S C I- CkJes J, Ser" i V_ t Co,•-., Date & ` Z-3 , 20_r .�_ 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 shat I 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. (Signature of applicant or name, if a corporation) po 7. _. (Mailing addresof applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner ofremises ,4 t ��r e� i .-, � " �p � � w � p� t ° l� . _S1, -Pep n � � P ( n 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. Plumbers License No. _ Electricians License NO. Other Trade's License No. CI . Location of lankon which proposed work will be done: House Number Street Hamlet Lot County Tax Map No. 1000 SectionB �_Z,,,� 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 7. c , .mss b. Intended use and occupancy t:e is= 3m ,SJ 3. Nature of work (check which applicable): New Building Addition_ Alteration Repair Removal Demolition Other Work (Description) 4. Estimated Cost Fee 5. (To be paid on filing this application) If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars ��mt 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. CS >.>? 25,� 2e t f 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories 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 l C'crd r., clt Address Phone No. G.31- ¢45 —4-4-3 a — 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 r[ P-�, ,0,g w, p I #ic , i m—_ being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the A � (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 this 5k h day of —lint 2015 r J Notary Public Signature of A ➢ic _. NOTARY PUBLIC, STATE OF NEW YORK g pp NO, 01 DW 900 QUALIFIED IN SUFFOLK COUNTY COMMISSION EXPIRES JUNE 30, Scott A., Russell SUPERVISOR SOUTHOLD TOWN HALL - P. O. Box 1179 53095 Main Road - SOUTHOLD, NEW YORK 11971 1 cslNo a 55TOKMI TFAVEEK 1\\4[A\\.IN\ A.G]EIMUENT Town of Southold DOES THIS PIkOJEC1.7 INVOLVE ANY OF THE FOLLOWING: (GIECK A1.1 111AT APPLY) ErA. 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 I within any parcel or any contiguous area. C' - Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. al). Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. I E. Site preparation within the one -hundred -year f loo lain as depicted on FIRM Map of any watercourse. F. Installation of new or resurfaced impervious surfaces of 1,000 square feet or more, unless prior approval of a for water Management Control Plan 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. I f 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. 1000 APPLICANT: (Property Owner-, Design Professional, .Agent, Contvzctorl Other) S.C.T.M. Districk I.q-2 . . L L NAME 1p Section Block Lot Comact finformanon. Pr2ELjLty Aqdress / Location of Construction Work - F�ORM " SM("P IOSMAY20M Reviewed By: . . ..... . Date: Approved for processing Building Permit. Sto—rrnwater Managernent Conlrot Plan Not Required, LSlormwatef Management Conlrol PlIan i,., ReqLivred. i (Fc)rwairdtol...'uigiii-iie(,.riiirgl)epartriierntioilleview.) d ocrvold tavwr oI— m w Y �co �� re nl uJ W XZvId xDfui.L.Lvw SNOLL 3i�� J W �a 6 L„ z LL z z 0 <C CL �y d W LLi LU CL 'v`r' hii w za' , a,r a ,i. d �[a Jus.. o on u° l 1 aF i r ._.i. .. 7- 0 W < Q �, 1 �a ro j c", LU UJ r 0 U z � W _- �- a� U4 �ry