HomeMy WebLinkAbout40228-Z TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
BUILDING DEPARTMENT Do you have or need the following,before applying?
TOWN HALL Board of Health
SOUTHOLD,NY 11971 4 sets of Building Plans
TEL: (631)(631)765-1802 Planning Board approval
FAX:(631)765-9502 ..) , 1 98;7---- suncy yr--
SoutholdTown.NorthFork.net PERMIT NO. ' GOA< '4---- Check
Septic Form
N.Y.S.D.E.C.
Trustees
C.O.Application 7
FslionogdleP8cermseitparate
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Exarnined /(4/P ,20
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7) ------ Storm-
-- Water Assessment Form
Contact:
Approved ,20 ____ ,
_ e'-‘---- ' Mail to:
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Disapproved aic
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Building lnspe r
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A'1PLICATION FOR BUILDING PERMIT
1 I
Date /VZ3 ,20,
INSTRUCTIONS
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.
h.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 agliees 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.
(3.,,6)/7-4.4 al, L-ii)
(Signature of applicant or name,if a corporation)
' e._:/--/), i...e.F/Aft"
(Mailing address of applicant) ,/955
State whether applicant is owner, lessee,agent,architect,engineer,general contractor,electrician,plumber or builder
2Ile-74'2
Name of owner of premises /Z , ,JH.,,g..,z,.=.7(el , ..ZA r — rj.e3-yo
(As on the tax roll or latest deed)
If applica is a corpoy:ipn,s,ignasure of duly authorized officer
(Name and title of corporate officer)
Builders License No. Ar--/Z.#2//
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which proposed work will be done:
‘__; _____ ) S7 ./1I
House Number Street Hamlet
County Tax Map No. 1000 Section //),L, Block 0 9
f Lot •
Subdivision -liqe Filed Map No. 5ZSr--U Lot
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction,
a. Existing use and occupancy 5_67?..1,2,7,-
b. Intended use and occupancyz ..t7v./2.77
3. Nature of work(check which applicable):New Building Addi 11 Alteration
Repair Removal Demolition - ler
(Description)
4. Estimated Cost /5-;etio - 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 9 Rear Depth L__ •"fle...3i1)., 3/
Height 05— Number of Stories 2.
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
A
9. Size of lot:Front /Z/,5—`71 Rear ¶ I Depth .51c.)
10.Date of Purchase Name of Former Owner
11.Zone or use district in which premises are situated 5 iPc-Rf7-444,
12.Does proposed construction violate any zoning law,ordinance or regulation?YES NO-D(
13.Will lot be re-graded?YES NO Will excess fill be removed from premises?YES >(. NO
LOILI Avuet ev-u
14.Names of Owner of premises , r A.1,• L Address AP[A-r-4.1‘.-=Ay"-A...4_22D Phone No..524.-•1,'-c•-j•
Name of Architect Address Phone No
Name of Contractor Address•-:t.o.7,ar a..,./..r_"&r,,..ehone No. 7:?
15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO X
*IF YES, SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BE REQUIRED.
b.Is this property within 300 feet of a tidal wetland?*YES NCP
* 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)
COUNTY OF )
'
7707(AC being duly sworn,deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(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.
Sv.orn to before me
day,I' _A 2 0/
IN
it. •
Nola Y I)1iC mot HYDELL Signs tie of Applicant
NOTARY PUBLIC-STATE OF NEW YORK
NO.01HY6189695
QUALIFIED IN SUFFOLK COUNT'//-
COMMISSION EXPIRES 06/30/20r /CO
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Scott A. Russell ' ST 0 RM[WAT E R
SUPERVISOR 4 0 ( MANAGEMENT
SOUTHOLD TOWN HALL-P.a Box 1179 u
• 0 `,
53095 Main Road-SOUTHOLD,NEW YORK 11971 • cy.` Town of Southold
C PTER 236 - STOR ATER AGEMENT WO SHEET
( TO BE COMPLETED BY THE APPLICANT )
ISES I IS PROJECT I OL Y OF E FOLLOWING:
(CHECK ALL THAT APPLY)
Yes No .
El A. Clearing, grubbing, grading or stripping of land which affects more
than 5,000 square feet of ground surface.
091-3. Excavation or filling involving more than 200 cubic yards of material
/ within any parcel or any contiguous area.
Oac. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
Ej Er' D. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
11 07E. Site preparation within the one-hundred-year floodplain as depicted
cm-FIRM-Map of any watercourse:-
ro F. 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 you answered YES to one or more of the above, please submit Two copies of a Stormwater ManagementControlPlan
and a completed Check List Form to the Building Department with your Building Permit Application.
S.C.TIVL 1000 Date
APPLICANT- (Property Owner,Design Professional,Agent,Contractor,Other)
DL.str,t
NAMEeel4A4 24.2r.,21.- 4.7p _ AOL, /6)./ .,1)/z C
Sect ion Block Lot
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D ,I\:4.1 IA,P LI T 1.SE f Y\41
conLicr hirm15.1rilon JI'
ReYwYvrd By ez-n---/
Date:
)pr'-iii/ Aridless / Location of Construction Work: _ _ _ _ _ _ _
Approved for prof cr, ung Butfidung Prrnii
?t2e/44_ 71--1) SwrnTivaer Mandgernent Cunt ro Han Not Required
/*- SturnpNuter Krumsernen Conoco Han r,Requored
(f rwv,ard f nF[neerfrg, Depairmenu kr Review)
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