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Home My WebLink About40605-Z OWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST UILDING DEPARTMENT Do you have or need the following,before applying? OWN HALL Board of Health ___ OUTHOLD,NY 11971 4 sets of Building Plans,..._m EL: (631)765-1802 Planning Board approval. (631)765-9502 - Survey o ho dTowNo hFork.net PERMIT NO. Check Septic Form—.----- N.Y.S.D.E.C._...._..... Trustees C.O.Application, �,,,,_ Flood Permit xamined20 � I Single&Separate , 2016 ) Storm-Water Assessment Form,......_._— Contact: pproved2p'_v 'BTJ"ING DM. Mail to: _tJ ...........� lisapproved a/c....,__ TOWN OF SOUMOLD ..... Phone: xpir rtion 2d /b-1 glainklms for APPLICATION FOR BUILDING PERMIT Date_ +l .i _........_,20 INSTRUCTIONS a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 ets 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 real,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 hall 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 ssues a Certificate of Occupancy. f Every building permit shall expire if the work authorized has not commenced within 12 months after the date of ssuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the rroperty have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an iddition 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 3uilding 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 rpplicant agrees to comply v�ith all applicable laws,ordinances,building code,housing code,and regulations,and to admit ¢utlro6zed inspectors on premises and in building for necessary inspections. (Signature ��fa Si � 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 ,,,,,,, 1�e i (As on the tax roll or latest deed) If a iplicant s a corporation,si 7lst e of duly authorized officer (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. _ .... Other Trade's License No on of land on which roposed work will be done- House 1. Locate House Number Street Hamlet CountyTax Ma No. 1000 Section�� Block fP Lot f p —......... — Subdivision Filed Map No, Lot State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy b. Intended use and occupancy Nature of work(check which applicable):New Building i0111 Alteration Repair Removal Demolition ther Wor, (Descriptior) Estimated Cost 74"5"c paid on filing this application) If dwelling,number of dwelling units_ �wV�ii in each floor If garage, number of cars I 'A If business,commercial or mixed occupancy,specify.7Mt"(AWMft'X,Tep;of each type of use. Dimensions of existing structures,if any:Front � Vw Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories Dimensions of entire new construction:Front —Rear Depth Height Number of Stories Size of lot:Front —Rear —Depth Date of Purchase Name of Former Owner Zone or use district in which premises are situated Does proposed construction violate any zoning law,ordinance or regulation?YES NO Will lot be re-graded?YES—NOWillexcess fill be removed from premises?YES—NO _______ Names of Owner of prernises,AU& &C90 Addrcss��'f2YOePhone.No. Name of Architect Address 6MY5 ' Phone No Name of Contractor Address Vac AM-) honeNo. &,,31 ,.�451--r�'rce ' i.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO T YES,SOUTHOLD TOWN TRUSTEES&D.E.C.PERMITS MAY BEPQUIRED, 3.Is this property within 300 feet of a tidal wetland?*YES_NO T YES,D.E.C.PERMITS MAY BE REQUIRED. Provide survey,to scale,with accurate foundation plan and distances to property lines. If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. Are there any covenants and restrictions with respect to this property?*YES—NO [F YES,PROVIDE A COPY. kTE OF NEW YORK) 'I SS: UNTYOF5S� Q being duly sworn,deposes and says that(s)he is the applicant 7k-L I Je is the Agent,Corporate Officer,etc.) aid owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application; all statements contained in this application are true to the best of his knowled-MiA-69NI�efbV�+gKit the%vork will be Formed in[lie manner set forth in the application filed therewith. NOTAqy PUBLIC,STATE OF NEW YORK NO.OiDW6306900 QUALIFIED IN SUFFOLK CObUNTY nn 19 before ine this COMMISSIONEXMIRESJUN 30,4g _J�Tj_ day of.._4r j. 20 6019' Notary Public (j Signature of Applicant so Town Hall Annex Telephone(631) .799&5.1802 75 ro er,richert � ICI .n .us P.O. x 1179 SouthoK NY 11971-0959 w BUaDIN G DEPARTIUNT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL L I SPECTI REQUESTEDY: ate: ny e• � . License o.: � Address: Phone .: JOBSITE INFORMATION: (*Ii required information) k .. 'L mow., Name: "CrossStreet: "Phone o.: Permit No.: Tax Map District: 1000Section: Block: LLot: " "BRIEF DESCRIPTION OF WORK (Please Print Clearly) (Please CircleI That Apply) "is job ready for inspection: YES /00 Rough In Final "Do you need a Ternp Certificate: _ Y / O ` Temp Information (If needed) *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other * Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT T IUE WITH APPLICATION est for Inspection Form Scott A. Russell SUPERVISOR IWA N ( r ] N `c � SOU OLD TO HALL-P.O.Box 1179 ", `t~ 53095 Maur Road-SOU OLD,NEW YO ,11971 r o' "/0' /`1 ^ .ZU, CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET ( TO BE COMPLETED BY THE APPLICANT ) DOES THIS PROJECT INVOLVE Y OF THE FOLLOWING: O INN: (CHECK ALL THAT APPLY) Yes No ffA. Clearing, grubbing, grading or stripping of land which affects more than 5,000 square feet of ground surface. 913. Excavation or filling involving ore than 200 cubic yards of material within any parcel or any contiguous area. C. Site preparation on slopes which exceed 10 feet vertical rise to 100 feet of horizontal distance. El ffD. Site r aration within 100 feet of wetlands, beach, bluff or coastal erosion hazard area. Site preparation within the one-hundred-year floodplain as depicted -on- FIRM-Map-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 a e, Signature, Contact formation Date & County Tax a Number! Chapter 236 does not apply to your project. If you ..... _....._.. . _ answered to one or more of the above, please submit Two copies of a Star water Management Control Plan and a completed Check List Form to the Building Department with your Building e it Application. S. APPLICANT- _wrruti act"T: (Property Owner,Design Professional,Agent other) C.r.�i. i®QQ Date: NAME: [7isirsct un .� lock Lot Section B i 'tir ivurcl ..m..... i.,vii0 N 1 W A h '"I L W f �"a+�'Id�l `.�, l,�i�. l.�i�~�1.�� IL Contact Information Reviewed By: UV�� n of Construct ion Work: .... f�u��.ew L oCatlo A roved for processing Building Permit.rol PIan Zio .,, Star�mwater Managementg ro�(er't Address t Required Storrnwater Mann a eient Control Plan is Required, (Forward to Engineering Department for Review.) FORM # SMCP-TOS MAY 2014 LA X0 C,Aet, ko ELECTRICVIII,,,. "I IVNI;[i D ATE LYIO xykN, APPI'lOVED AS NGIED ENI4 N1 TO CODE j/ A ll� foo DATE: # 05' �JPON COMPLETION —vw BEFORE IVATEFI- R: E: _;�D ,LZ) BY- NOTNFY BUMNG 765-1802 FN UA T(.) 4FIM FORII IE FU 1OWNG NSPEUK)NS: 1OLJN�[WION - TWO i::N`--MPRE[) FOR POW:?,El,D CONCRETE 2. F-30UGH - 1:::RAWNG & PUME,NG I NSULATM 4. MAL - CONS"MUM)N MUST i-0 BE COMPLE"ll FOR 0,0, AR I CONFS"FRUCI BON SHAU M E ETTI-IE C-OL, f:lE0LhREMF.--,Nl'S oF: n�E"M!S OF NEW YORK s-rATE. NOT RESpl"`cNS-'G FOR [)N.MNOR CONSTRUCTON ERROR& L COMID!,,Y WITH AL L CODES RETAIN STORM WATER RU OFF NEW YORI(STATE &CONDITOWINJ CODES OF' PURSUANT TO CHAPTER 36 AS REQUII�lED A��11,0 I'lONS OF THE TOWN CODE. '�17 I�17 I.Aml 4GVR4%, tt)Y", folfft qq OCCUPAI"YCY OR USE IS 14" WIT,'HOliiiiiiiff CE R'111111111111 Fl CAT, I OF OCCUPANCY IF 0CG /0"' gyp° X y l � r r � e w z p r vlo 4 % y E'� 614 °mow" V k f