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Home My WebLink About40597-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)765-1802 Planning Board approval_ FAX: (631)765-9502 11 iSurvey - SoutholdTown.NorthFork.net PERMIT NO. 14-- Check _ Form -- Septic For _.. N.Y.S.D.E.C....�...._....... Trustees. C.O.Application ..� Single&Permit Examined__,,,, 20 Flood Separate VAR 3 Storm-Water Assessment Form 0 "" Contact: Approved �-� 20A Disapproved a/c,_........ Phcne• v ��a "�"��" . _.. ... Expirationmmi, 20F ....._ 1 i po eet r APPLICATION BUILDING PERMIT Date —,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. 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 pen-nit 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 Build ing;Lone 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 appheant 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) (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,—rill 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 will be done: House Number _ Street Hamlet County Tax Map No. 1000 Section Block Lot _ Subdivision Filed Map No. Lat 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existinguse and occupancy _� . ► c��0..s� -�c� � d� c_� (-"Ale plc) p y �..� b. Intended use and occupancy 3. Nature of work(check which applicable):New Building Addition �' fkit ration Repair Removal Demolition Other Work _. ..... (Description) 4. Estimated Cost r w u �` be paid on filing this application) 5. If dwelling,number of dwelling units br,�f lliir" t its on each floor If garage, number of cars 6. If business,commercial or mixed occupancy,spea of each type of use. "G 0dn0 __ 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 construction:Front Rear Depth 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 12.Does proposed construction violate any zoning law,ordinance or regulation?YES NO 13.Will lot be re-graded?YES NO VjWill excess fill be removed from premises?YES NO-V/ 14.Names of Owner of premises Address Phone Nq. 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 "'e'� * IF YES,SOUTHOLD T(7V+N TRUSTEES&D.E.C.PERMITS MAY BE/REQUIRED. b.Is this property within 300 feet of tidal w=etland?* 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 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) S: COUNTY OF tO� 1 , being duly sworn,deposes and says that(s)he is the applicant (Name of individua'9 signing contract)above named, (S)He is the n,:iz (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 day of (a.y- h 2.0 �. C L.DWYER NOTARY PUBLIC,STATE OF NEW Yoll a r UXA No.OIDW63069M3A Notary PubliQUALIFIED IN SUPFM COO &nature of Applicant COM ISSMEXPIRESJUNE30,� Scott A. Russell , M �; ray �� SUPERVISOR " IM[ACNAG]ENUENT SOU OLD TOWN HALL-P.d.Box 1179 0 53095 Main Road-SOU OLD,NEW YORK 11971 ;'yr CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( O BE COMPLETED BY THE APPLICANT ) DOFF THIS PROJECT INVOLVE ANY OF THE ]FOLLOWING: (CHECK ALL THAT APPLY) Ye, e No A. Clearing, grubbing, grading or stripping land which affects more than 5,000 square feet of groundsurface. B. Excavation or filling involving ore than 200 cubic yards of material within any parcel or any contiguous area. C. Site preparation on slopes which exceed10 feet vertical rise to 100 feet of horizontal distance. D. Site r aration within feet of wetlands, beach, bluff or coastal erosion hazard area. Site i within one -year loo i depicted on l "IRM Tap .of-any watercourse. 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, IfSignature, Contact Information, ate & County T Map Number! Chapter 236 does not apply o youproject. ._ .. .If answered to one or more of a above, please submit Two copies of a toren aterManagement Control Plan and a completed Check List Form to the Building Department with your Building Permit Application. S.C.T. . #: 1000 bate. Contractor',Other} Dulrict Agent.APPLICANT: (PropertyOwner � �. a NAME: .�� eslan rla r:�ti� .... m._ ..� Section Block Lot �� .� � ".,�" .m.., n.x>� ➢ ��H'"t 1:'ii i(��L�1 ^�e,a 11'1°.hp `t�x�x"4`01.IIwN Contact information: :"d i Gr axa"a�r Reviewed By- � . L -�lµ. 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