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Home My WebLink About40386-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 o'f Building Plans_.. TEL: (631)765-1802 Planning Board approval FAX: (631)765-9502Surve-4L 'y Southo[dTown.NorthFork.net PERMIT NO. D Check Septic Form N.Y.S.D.E.C—— Trustees C.O.Application..........m. Flood Permit Examined t 20 Single&Scp`ari�e--'- Storm-Water Assessment Form_. Contact: A,ppro%,ed 20.............. Mail to Disappravtd a,/c_ Phone: ExpirmiOTI APPLICATION FOR BUILDING PERMIT J Date 120 INSTRUCTIONS a:This applicatioff-,"= e 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 Perinit. d.Upon approval of this application,the Building Inspector will issue a Building Perinit to the applicant.Such a permit shat I be kept on the premises available for inspection throughout the work. e.No building shall be occLipied'dr 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 hasjiot commenced within 12 months after the date of issuance or ha's 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 Inspectonmay 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 134ii ldi rig Zcne Ordinance apt the Town of Southold,Suffolk Cc I unty,New York,and other applicable Laws,Ordinances or 1te,,uhaaiuns.for he construction of buildings,addi6ons,or alterations or for removal or demolition as herein described.The applicant agrees to com"ply with all applicable kaws,ordiniances,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) (MalBlng address of applicant) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder I.e Name of owner of premises -MoTdIcle"I Ad rk,i (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 prcvsed work will be done: House.Number Street Hamlet k, County Tax Map No. 1000 Section— ..... .. ..... Lot Subdivision Filed Map No. Lot 2. State existing use and oc6upancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy 'Am,t c r 1 b. Intended use and occupant} to 3. Nature of work(check which applicable):New Bulldin ✓ Addition Alteration Repair Removal Demolition Other 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 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 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 con struotiom,Front. ear� depth Height Number of Stories 9. Size of lot:Front Rearg t �.,,,,u Depth 10.Date of Purchase Name of F,oriftet Owner 11.Zone or use district in Which premises are situated" 1.2.Does proposed construction violate any zoning'law,'ordirianoe at°Terilation?YES NO n l : 13. Will tat be re-graded?YES NO Will excess f111 be sa pmcaved,from:premises?,YES—NO___ 14.Names of Owner of premisesf�!ncT .FC51i Acidness F"hone Na. 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 ti,frdshwates wetland?*YES NO ✓� * IF YES,SOUTHOLD`I`O'vi`N TRUSTEES&D.E,Z,P kkT'S'MAY I F REQUIRED. dl1 ED. b.Is this property Within 300 feet of a tidal wetland? * 4 E NO *IF YES,D.E.C.PERMITS MAYBE REQUIRED. 16.Provide survey,to scale,with accurate foundation plan and distances to property lines. 17.If elevation at any point on property i's 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) SS: COUNTY OF ) beim 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. Syvorn to b fore me °o mm: r dal'of' r: s l kla,l 2014:�- CONNIE D. Notary Public NO,01BU 1 Signature of Applicant Qu~InSLiffbik C Comm l Expo A0114, �C-'(�)]KN[WA` I 1 Scott _ ar > 7 Z SUPERVISOR soli OLD TOWN BALL-P_o.Box 1179 53095 Main Road-SOUTH OLD,NEWYORK11 � � Town of SouthoZd SHEET ( TO BE COMPLETED BY THE APPLICANT) DOES S PROJECT RWOLVIE At4Y OF INE FOLLOWING: 'Yes �� t r APPLY) El _ Clearing, grubbing, i stripping f land whichaffects more s t r _ " ., Excavation ill involving re than 200 cubic yards of materialu within any pac or any contiguousarea. El El _ Site preparationslopes is feet vertical rise to 100 f feet of horizontaldistance- Lj Site i within t s, o f or coastal ei _ DO ., Site preparationi one-hundred-year floodplain as- depicted on-FIRM. ...Map . _f._ -- . w terc.._._rs._.. . . Installation _- --e_-___r resurfaced imp, er a surfaces of 1, s uar feet or more, unless priorv for ate* Management Control Plan was received by the Town and the proposalincludes in-kind replacement of impervious ces. If you answered NO to all of the questions above, ! Complete the Applicant section below with your]Name, Signature, Contact Information, Date & County Tax MapNumber! Chapter 236 does not apply to your project- If you answered M to one or more of the above please submitTwo copies of a Sto -water Management p g eni Cantrol Plan and a completed Check list Form to the Building Department with your Building Permit Application_ APPUC AT. (Prt pur y Owner,Design Professional.Agent,Convracmr„Other) S.C.T-M_ 1 000 NAME ....... Secaion I�Yac k i.ok _., yY�,u u;.Yk nn.. ✓ �"'�x V,%J�. °1.tlr RevYewed ley- a w 1�r'�dj ess l 1._ocanon of C'onstruc hon Work: w.....— _. _... frju �urp<t:n uo�i� �uoa,ilp��otw f��mrui�i PAWa�,c'c'uie� C,'akniwP I'A;un I cap Hr'ytc6e¢;6 ' " .. �✓,,, '"�. r"00)",V ,✓, e 44 r All x Ad " wilk zw�r w M r, h �mv.. w• " w it, �„ m a 0 GO g ti