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Home My WebLink About40603-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 Survey ......._. SoutholdTown.NorthFork.net PERMIT NO. /°L603- — Check Septic Form N.Y.S.D.E.C. Trustees ppiicatuon Flagd Permitw,,,, Examined— 20 5ioile&Separate _.... ...... Storm-Water Assessment Form m Approved 20 � �_""'.". �4 Mail tw Disapproved af' Phone: Expiration r Expiration , L2, `nazi ing pector APPLICATION FOR A'�;'°y �. 6 ''` � R BUIL PERMIT i.. "i1NG DEQ.. Date . (. ". Y 20 'I~J6L)U"1`HOL 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 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,hWatu..re ic,codeand regulations,and to admit p p and in building for necessary inspections. authorized inspectors ors on remises ".l ; licant orname,if a corporation) t d _ t.l;d) S"Zwmt VC PiAhubv\..k,iti�. r ., r i (Mailing address of applicant) Ste�a��hethr delta ats?;is owne�;�lessee,agent,architect,engineer,general contractor,electrician,plumber or builder ,aa,' ,. Ndineol'ovv4Tof remises i iNSG=:G 44\ � ti -v t _ u 0raa,,i p i (As on the tax roll or latest deed) ISA pplic sit is a:.cozpoyationp s. nktya,e ofduly authorized officer (10 7e hand title��c� � at rho e'r) i flit iA 11 Plumbers License No. Iy „ ro Electricians License No ypp I@ {ry Other Trades License No. "fi t 1�b1 Ad which proposed work will be done: i ., 1. Location of land on.� ,"a lo House Number Street Hamlet County Tax Map No. 1000 Section i 1.2- Block � Lot �� Subdivision Filed Map No. _Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy P-e,5 &,j-i-1 AL_ b. Intended use and occupancy iZ e 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition -Other Work Poo L. 1=GNB: (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 Stoties,— 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 X 13. Will lot be re-graded?YES—NO Will excess fill be removed from premises?YES NO 14.Names of Owner of premises Address Phone No, Name of Architect Address Phone No Name of Contractor WJL �,O(OkAOAddress Phone No. i e-?Z 3zBc, 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 X 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) SS: COUNTY OF 1-144yr-ptea S'M�AK_beingo I only sworn,deposes and says that(s)he is the applicant (Name of hidYviduasi �'ng contract)above named, (S)He is the tq&'P-' (Contractor,Agent,Corporate Officer,etc.) of said owner or owners,and is duly authorized to perform or have per-formed 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. SHASHANTiMARINE Swors n e this Notary Pub4c,State of New York ,�.to before r No.o i NA6198804 da v of 0,4z��N\ 20\\,0 ouglied in Bron)c�o.,,,n,%,,-t Commission Expire a 4 Notary Public V Signature of Applicant SUFFOLK COUNTY, 14Y FOLK UM tIV C N �. F N 7 i r �*� ✓ Y/ % d+ ^I p 's � hk �� f Y yl\yNN � '1 a r'P PA9 W AREA P~rCr' e -9)44 SF or 0,1W Acre JOHIN C.E . 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