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Home My WebLink About39924-ZTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown.NorthFork.net 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 LJ if Examined '20 AIN 2 5 Approved --__,-_ , 20-- Disapproved 0._Disapproved a/c a--------w-- Expirations,,µµµµ,__,,, 20_ Building Inspector Check Septic Form N.Y.S.D.E.C. Trustees........ C.O. Application Flood Permit Single & Separate Storm -Water Assessment Form_______ Contact: 11 Mail Phone: 9 4-% � C -U nn APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date (— Z 3 20/ S 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 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) MfCI,cPI 14, (Mailing address of a0plicarn) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises r d I n e ) f (As on the fax 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 N 1. Location of land o which proposed work will be done: House Number Street Hamlet County Tax Map No. 1000 Section 4 2— Block r 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 ^.r-0 ............ . . . ..... b. Intended use and occupancy C I— �Ik 3. Nature of work (check which applicable): New Building_Addition m Alteration Repair Removal Demolition Other Work, (Description) 4. Estimated Cost 5b 0 0 Fee (To be paid on filing this application) 5. If dwelling, number of dwelling units Nfter(' qdMng 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. ?I?- e 4-,- J — 7. Dimensions of existing -structures, if any: Front Rear ___Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front — Depth Height Number of Sta 8. Dimensions of entire new construction: Front RearDepth 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 Rear 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 A I C -,-di 1te -Address Phone No. (23 1- 44-5 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 IX • 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 X' * IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF3Qffi4 Wk I ��, te 1 being duly sworn, deposes and says that (s)he is the applicant Name of individual signing contract) above named, (S)He is the .--,4 Ss:�t 4 (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 5 d aY of __01) UC__ 20 15 Pubotary Signature Appof ��TRACEY L. DWYER NOT PUBLIC, STATE OF NEW YORK NO. OIDW63D6900 QUALIFIED IN SUFFOLK COUNTY COMMISSION EXPIRES JUNE 30,21LO, Scott A.'Russell SUPERVISOR E SOUTHOLD TOWN HALL - P. O. Box 1179 53095 Main Road - SOUTHOLD, NEW YORK 11971 "MT 11, A% -ilEPTUE 11� 1 Town of Southold CH"TERSTORMWATER MANAGEMENT WORK SHEET 0-M [a nrms (TO BE COMPLETED BY THE APPLICANT) DOES THIS ICP VOINE ANY OF 1'HE FO.LLOWING: (CHECK ALL THAT 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. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. Site preparation within the one -hundred -year f loodplain as depicted on 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 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. If � �ouans credYES 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. &C.T.M, 1000 Datc (Property owner, Et�-ign Professional, Agent, Contractor, Other) _F5 1�i I —I,_ t NANE� ------ Section 1p"'M N'T I �"'f 0 N I '4 Contact Informatiort PF22-rWork: Ly Address / Location of FORM 4 SMCP - I'OS MAY 2014 Reviewed lay °•` !3` Approved for processing Building Permit Stormwater Management Control Plan Not Required. ElStorrnwater Management Control Plan is Required. (Forward to Engmeeringe Department for Review.) a t4 "xDfU z xMk ream LLL VN z (1vold NrvqK LOg _4 a- vZv'lCl )iDfuijuvw mLU z C) Ln uj in F- w 1-4 wU) SNOliV`d] I IV a %D u.PZcr,,A