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Home My WebLink About39941-ZTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 Southold Town.NorthFork.net Examined -71r 20_ �Pproved '20 Disapproved a/c PERMIT N. LXpiration-,t 20_q APPLICATION FOR BUILDING PERMITAPPLICATION CHECKLIST Do you have or need the fbllowing, before applying? Board of Health, �Lls ofBuilding Plans plamung Board approval Check Septic Form N.Y.S.D,F.C,_ �.� 7�j6 ,�A pol Tm Food Permit Single & Separate- ............ -t �Zll .S�o iter Assessment Form - NIA -w�Ej (f -:�g- '20 45-- 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 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 c9dg-....axW regula.Eons, and to admit authorized inspectors on premises and in building for necessary inspections. -"-"Mnatureof applicant or name, if a corporation) #1) /0 7�v rDI , (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises (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. ......... Plumbers License No. Electricians License No. Other Trade's License No. — 1 . Location of land on which proposed work W, I be dope: 4 Jal'Y,-X, -Kc /Cl/ House Number stKeet County Tax Map No. 1000 Section BlockLL—L . .... ivision Filed Map No. mm of State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy 5-111 b. Intended use and Occupancy � � M Nature of work (check which applicabl ew B u il � Addition Alteration Repair Removal inolition Other Work (Description) 1. Estimated Cost Fee (To be paid on filing this application) i. If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars i. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front I ,� Rear Depth Height 12 Number of Stories-,,-,,,__ 3. Dimensions of entire new construction: Front Rear Depili Height L2 Number of Stories Size of lot: Front Rear ti 7 Depth 0. Date of Purchase Name of Former Owner �A C P\S [ 1. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation? YES_ NOX 13. Will lot be re -graded? YES® NO_—kWill excess fill be removed from premises? YES NOX 14. Names of Owner of premisesOA�_(��,A''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 IQ 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: ;OUNTY OF (f e i % being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, 'S)He is the Corporate Officer, etc.) A said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application-, :hat all statements contained in this application are true to the best of his knowledge and belief; and that the work will be Derformed in the manner set forth in the application filed therewith. S�qrn to before me th"� day of –)' — N L 20 --,----BETSY A. PERKINS Notary Pubfic NM Public, State of Now York Signature of Applicant No. 01 PE61 3M QuWffled In "olkCou�y Comm ion Expires July 18, Q. .... . Scott A., Russell STO]KIM[WATEK SUPERVISOR A A\\,NN A G I E IMI I E N T Sou OLD TOWN HALL - P. 0. Box 1179 53095 Main Road - SOUTHOLD, NEW YORK 11971 Town ofSouthold 1111111 11 lil I 1111 I i I (�ill Ingm-1 in E1. 1 0 - F.S 'I'HIS PROJECT IN 01.,VE ANY OF 'FHE FOL1,0WING: (CtIECK A..L THA'F APPLY) � No < Clearing, grubbing, grading or stripping of land which affects more 'than 5,000 square feet of ground surface. B. Excavation or filling involving more than 200 cubic yards of material within any parcel or any contiguous area. C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. Ej D. Site preparation within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. 5E. Site preparation within the one -hundred -year floodplain as depicted [Installation `6n FIRM Map of any watercourse. 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 11 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 Dcpartmcnt.with your Building Permit Application. NAME: Comact iidormatVm .... .... Property.Address Location of Construction Wcold 014 114t __ ., - - I A, 1::'ORM # SM CP .......FOS M A Y 2014 S.C.T.M. 1000 uatc. District Section Block R HIT )1 11 (A Reviewed By: Date:: Approved for processJng BtrildingPerafit. E71 Stormwater Management Control Plan Not Required. Stofaiwater Management Control Plan ns Required (Forward to Engjneer,rrg Departmeril for Review.) ... ru Na < 91) . tD D cr, , or) qua 0 0 CD 'W wav al""m "MMMMMIMMOAMMM,