HomeMy WebLinkAbout40699-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. b�cl`� Check
Septic Form
N.Y.S.D.E.C.- .
Trustees
C.O.Application
1 d Perim)
Storm-Water
a'�Separate,
Examined 20 r"
..... Assessment Form
Gantact:
Approved._ 20........_. Mail to:
Disapproved a/c
1 Phone:6231 70a 35'9$
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Expiration W 20 I i s i 3 CP dc9`4 J
ming Insp,ctor
APPLI( r�,J�lQN FQR BUT ING P9kM_IT
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Date c� 20
BUILDING loll INSTRUCTIONS
TCkVVMi nVT 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,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 v l
(As on t tax roll or latest deed)
If applicant is a corporation,signature of duly authorized officer
icons No.
Plumberso
ame and
No
le of corporate officer)
b
Electricians License No. i "
Other Trade's License No. kj,E., r
I. Location of lant which proposed work will be done: �°J ��h
/ � b
House Number Street Hamlet
County Tax Map No. 1000 Section Block Lot r
Subdivision Filed Map No. Lot
2. State existing use and occupancy of prem and intended use and occupancy of proposed construction:
a. Existing use and occupancy_ A
b. Intended use and occupancy
3. Nature of work(check which applicable):New Building Addition Alteration---
Repair
lteration _Repair Removal Demolition _Other Work �_✓
(Description)
4. Estimated Cost S/5 , 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 ndeer
Depth Height, Number of Stdrfesl �i \1 E
8. Dimensions of entire new construction:Front Rear Demh
Height Number of Stories
9. Size of lot:Front_ Rear, Depth .. x y
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 Will excess fill be removed from premises?YES®NO_
14.Names of Owner of premise ' Address4/0
1 .6&u; Phone No.
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
*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-
*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 .
1) being duly sworn,deposes and says-that(s)he is the applicant
(Name ofindividual fining contract)above named, CONNIE D.BUN
CH
Notary Public,State of New York
(S)He is the � No.01 BU6186050
(Contractor,Agent,Corporate Officer,etc.) i ual fieri In Suffolk County
Comm) fon Expires April 14,2 0
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 iti the manner set forth in the application filed therewith.
Sou rn before nye this
day of 2GY k
Notary Public 5 edaeure f. plicant'
G `Z
Town Hall Aimex � Telephone(631)765-1802
Main
5P O_Box 11179d r0 e_Fiche" � .., 7c,
ax l5-95
Southold,NY 11971-0959 r
BUMDINGDEPARTMIENT
?,.
TOWN OF SOU7['HOLD
A0PLICAI-ION FOR ELECTRICAL INSPECTION "
-
REQUESTED BY: Date:
Company Name: a
Name. I.
License No.:
Address:
. . ,.
I I vorle No.-- , �
JBIT INFORMATION: (*Indicates required information) n
*Name: '"��
*Address:
*Cross Street:
*Phone No.:
Permit No.:
Tax-Map District. 1000 Section: Block: Lot
*BRIEF DESCRIPTION OF WORK(Please Print Clearly)
(Please Circle All That Apply)
*Is job ready for inspection: u
YES/ NO, Rough In Final
*Do-you need a Temp Certificate: YES/ NO
Ternp Information (if needed)
*Service Size: 1 Phase Whase 100 150 200 300 350 400 Other
*New Service: Re-connect- Underground Number of Meters Change of Service Overhead
Additional Information: DA ME T l �E WITHAPPLICATION
p.
.82®Re uest for Inspection Form
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SUPERVISOR MA T��NJA,((J',14"AW JE 11411
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SCRITHOLDIFOWN HALL-P,0.Box 1.179
5305",Maba Road SOU'l"HOLD,NEW YORK 11.97.1 �4 Ir/awn
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CHAPTER 236 - STORMWATER MANAGEMENTR ; T
( TO BE COMPLE'"FED BY THEAPP11CANT )
DOES THIS, FROJEC-T 11'QV01.,VE ANY' (W 77 FE. F0110WIN&_
Ll EI .A. Clearing, grtibbirig
grading or stripping of lai�.id which affec-ts mlore,,
t1han 5,000 sqi,.j.are feet of ground surface,.
B. Excavation or filling involving .more than 200 cu.biss-of materi u.1
within any parcel, or any contiguous area
C. Site preparation on slopes wl-Ach exceed 1.0 deet veil cal rise to
100 feet of hr rub. .]. d1st , . _
_ Site preparationh 1.00 Feet ofTwetlands, 1)eacli, blu,ffor coastal
erosion hazard area. f
„ _ site preparation within the orae- a-ndr' (,:- .j'- floodplain w) ,epict '.
on, FIRM Map of any watercourse.
I' F. Installation of newor-, resiirfaced inipe . iou surfaces ' 1,000 squms
feetOF More, unless prior .p prova of a. torni aterlr . (..,,. �:� t
Control. Plan wa��s received by the "Fown and the propo.sal includes
irl kind replacement of 81.irfaces.
Ifmm.answered NO to&U of the questions above, Vim"DPI Cruipldclh section belaw with your Name,
ftnature, Cantad.Information, Date & Cnunty Tax p 1m u"m Chapter' 236 does not apply to yomm:uc prAject
If you answered YFS go one or more of Lhe a,bove, please subTWt 'Two ropies of a&armwafer Management Coutirol Plan
and a completed Check 11 t Form to Lheimu Department with your Building Permit Application.
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f C,'O strmuct On Work
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