HomeMy WebLinkAbout40117-Z TOWN OF SOUTHOI.D BUILDING PERMIT APPLICATION CHECKLIST
BUILDING DEPARTMENT Do you have,otpee4,the fallowing,before applying?
TO'W N HALL . Boar4 of Health
., ,..2 • - ,,
SOUTHOLD,NV 11971 ;, - ' 4 sets of Building Pkins
TEL: (631)7654802 ", , , .
' " '''' ''''' ,1",o//ty-
,„,.. ., , Planning Ppard approval
FAX: (631)765-9502 " ' Survey
SoutholdTown.NorthFotkitA PERMIT O. ) - ' ' e r Chrcek
Septic Forrn
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N.Y.S.D.E.C.
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1,°:X%A1111 red •"---/ ...._ _-, / C.O.Application
Flood Ptrtni;
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Single&Separate
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....----- Storm-Water AsseSsment Form
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Disapproved at ,r / Phone:
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7 Building Inspector
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' lrkPPLICATION FORBUILDIKG PERIVIIT
i , ',"LJ MSTRUCTIONS / ,___.
FEB 1 3 2010 ,,,,,..._, \
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a„71-(is aPPili;crIict_NidST-I."--rcniletely filled in by typewriter or Mink and submitted to the Building Inspector vd3.11?...4
sets ot1;74ansTacClIfFite plot plan to scale.Fee according to.soliedu/e.
,
La.Plotplan showing location of lot and of buildings on premises,.relationship to adjoining premises or public streets or
areas,andl,vater.vays.
c„The work covered by this application may net lie cortiinerided before issuance of Buildiu Permit,
d.Upon approval of this application,the Building inspector WitIlsstie a Building Permit to the appiicara,Siialt a permit.
sN-., i be kepi on the premises available for trispecrionithroughout,ther.Work.
No buiiding shall he occupied or used in whole or iii'paTt'fbr.any purpose'what so ever until the Building inspector
'.'ssi,e.a.a Ceriifreate OfoC,upancy. , ..l',1- \-
I3v,or).'buildir.g permit shall expire if Me work kitheiri;ed,has„not corrimeilced**Ri2 rhopps,after the date of
;35c:az:,,,i,or has not be-en completed within FS rffenth'SrOE fuel I date.;if nO'iching Eine4c1Me-iits:',6-:'other regulations affecting the
7)..7c7,,-;i77,,i'have been enacted in the interim,the BuildL-iginspector may authorize,in writing,the extension of the permit,for an
addition six months.Thereafter,a new permit shall be required.
APPLICATION)S HEREBY MADE to'the Building Dep3.541entifof the issuance of a Building Permit p!assuaiit to the
Buiidirg Zone Ordinance of the Town of Southold,Suffolk Cea.City:MiW l'icirk,''aild ether applicable Laws.Ordinances Or
Re f4uatf.ons,for the construction of buildings,additions,or attearittio„ris or fOrreIMoval or iiIemailition as herein described.The
applicant agrees to comply with all applicable laws,'ordinances,building colde,thou.sirig•code,and regulations,,inci to adroit
authorized inspectors on premises and in building for necessary inspections.
(Signature of applicant or name,ifs corporation)
(Mailing address of applicant)
„,-.7.--•
State whether applicant is owner,lessee,a gen.,architect,5., rneer,general contractor,electrician,plumber or builder
. .
_......_.
Name of owner of premises
— '-— (As oil the tax toll or iateet ,LTA)
If applicant is a corporation,signature of duly authorized officer
(Name and title of corporate officer)
Builders License No.
Plumbers License:N .o.
Electricians License No. ,
C)rhier Trade's License No.
i_ 3on oCiand on ycllid,-;propsed '„,wk;Nil]he dune:
17.--T---ie 444
House Number Street / •C`i"'I'li,fili(44-'10
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J. ifeall to 5/0,.„.ioic.Ah3 vrai,-I
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.: i' 0:1Y4„,,,,,eltra oil . „„„,,a_.„‘z-.- -) , (
County Tax Map No. 1000 Section a.„) i Block ,orrworagA•.K4aie r-r:i T,v.A.,,1ecdt
___,. 01 r,,,,,:.1.,,,,?...,...ri,7,-./7 ilomttIrmr)::
Subdivision Filed Map No. Lot
2. State existing use and occupancy of premiss and uuenged use and occupancy of proposed coriiitetion.
a. Existing use and occupancy -f//,./ /
b. Intended use and occupancy i° 741e-
3. Nature of work(check which aptilicableX New Building 'ar.A1,1on
Repair Removal .--17-7;i-T1... "that Work
(Description)
4. Estimated Cost Fee
(To be paid on filing this‘application)
5. If dwelling,number of dwelling units Number of dwelling units on each floer
If garage, number of cars
6. If business.conunercits1,6ntnixed occupancy,specify nature and extent of each type of use.
7. Dimensions 6+e'ixisting stEktures,tt any:Front Rear Depth
HeIgM , ,-° 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 ,,,,,_,Reat Depth
Height Nurobb_r of StorieS
Ure 'r&(1
9. Sizeuf lot:Front! Rea/ Depth
10.Date of Purchase Name of Fenner Owner
11.Zone or use district in which premises are situated )f.,
12.Does proposed construction violateanzoning jawortinattce or regulation?YES NO
13.Will lot be re- 0 .ded?YES NO WiI1.excss fil.libe.removedifrom premises?YES )(NO
14.Names of Owner of premises (2et,..k4tgyz 71144dciressPhone No.//7
3
Name of Architect 56.17/1„trAve. Address - Phone No •;;„,
Name of Contractor Address Phone Na.
15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetld?"YES NOY
*IF YES,SOUTHOLD TO\Vi TRUSTELFS Q1,..HRED.
b.Is this property 300 feet of,a tidal wetland?4'YES NC
*IF YES,DEC.PERMIT$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 PO 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.?C/ic ,,V
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-Lbeirfs.tiouly S GM,deposes arta.isa}Zs,that(s)he is the applicant
(Name of !dual signing contract)above zurne-,
(S)He is the
(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.
s - ` efore
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day ot • ' -`e 20
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Notary publicNowly plosc,ittr: Nov Yolk
Signature 4c:ic
No.01E1101U,0610 "
Goa,: tn Ovum,'0,1
Cormiliszlon Erptros*1114,2_0'
Form No.6
TO OF SOU OLD
BUILDING DEP• 'TMENT
TOWN LL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be filled in by typewriter or ink and submitted to the Building Department with the following:
A. For new building or new use:
1. Final survey of property with accurate location of all buildings,property lines,streets,and unusual natural or
topo i •phic features.
2. Final Approval from Health Dept.of water supply and sewerage-disposal(S-9 form).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1%lead.
5. Commercial building,industrial building,multiple residences and similar buildings and installations,a certificate
of Code Compliance from architect or engineer responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
B. For existing buildings(prior to April 9,1957)non-conforming uses,or buildings and"pre-existing"land uses:
1. Accurate survey of property showing all property lines,streets,building and unusual natural or topo phic
features.
2. A properly completed application and consent to inspect signed by the applicant.If a Certificate of Occupancy is
denied,the Building Inspector shall state the reasons therefor in writing to the applicant.
C. Fees
1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00,
Swimming •141$50.00,Accessory building$50.00,Additions to accessory building$50.00,Businesses$50.00.
2. Certificate of Occui.•cy on Pre-existing Building- $100.00
3. Copy of Ce •cate of Occupancy-$.25
4. Updated Certificate of Occu•.1 cy- $50.00
5. Temporary Ce •cate of Occupancy-Residential$15.00,Commercial$15.00
.
New Construction: Old pr Pre-existing Building: (check one)
7 cif D
Location of Property: ..4,1ww,`I /4 /-1-7A.) / .t9 r:/4. t— "'ft-*9-1 0.,(11
House No. Street 1
H. • et
Owner or Owners of Property: 40,eGX1-r 4i 7-- ekorc
Suffolk County Tax Map No 1000,Section 3 1 Block 0 b 1,0t
Subdivision Filed Map. Lot:
---
Permit No. LI Date of Permit Applicant:
Health Dept.Approval: Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate Final Certificate: (check one)
Fee Submitted:$
/-;
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Scott A. Russell S7FORMWA\, FER
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SUPERVISOR 7, ( —, ---) I• IVI AC NAG EIVILEN1F
SOUTHOLD TOWN HALL P.O.Box 1379
53095 Main Road-SOUTHOLD,NEW your< n971CS ',.f.;*,..,'----.-. 6' . Town of Southold
FEB 18 2015
ER 236 - STO ' IWATER IV A AGE I NT WO ' S ET
(TO BE CONIPI E FED BY THE APPLICANT)
ES S PRO I OL ' OF FO *WING:
(ClIEOC ALL THAT APPLY)
DIN A. 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.
EI pi 1 SiLe_ptepiaLauchrulisicpes whiclifi - 1 1 feet yes'1 i cal rise to
100 feet of horizontal distance_
n 0 D. Site preparation within 100 feet of wetlands, beach, bluff or coastal
! - erosion hazard area.
i D ffil E. Site preparation within the one-hundred-year floodplain as depicted
on F1' Map of any watercourse. . .
;EI F. Installation of new or resurfaced i- a-rvious surfaces of 1,000 square
i 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,
II
Si ature, Contact Information, Date & County Talc 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.
S_CT.M. 4: 1000 Dratc'
APPLICANT: (Property Owner,EP Trzp-Piufr--remre I,Agcrel,Conk-actor,.Merl mukt 1
NAME /11(Al *# P \C-11-4 CIP"/M414?-.7-
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Conran 1111am-trek lore 7351 5/ei
Reviewed Sy:
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