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Home My WebLink About40734-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)765-9502Survey– SoutholdTown.NorthFork.net PERMIT NO. Check_...... Septic Form—.,, N.Y.S.D.E.C.__.-- Trustees,— C.O.Application—- Flood Permit Examined 120Single&Separate--- Storm-Water Assessment Form— Approved 2. Contact: Disapproved a/c Phone., Expiration 201t Building Inspector D) APPLICATION FOR BUILDING PERMIT MAI 2 4 2016 Date 20 UUMING DEPT- INSTRUCTIONS D 3 iSOMOLD Qation N1 UST 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 buildino Perm nced%ithin 12 inonths after the date of it shall expire if the work authorized has not cornine issuance or has not been completed within 18 months from such date.If no zoning amendments or other reguations affeciing the property have been enacted in the interim,the Building Inspector may authorize, in writiug,the extension of the permit for an acid iton 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 descr%bed.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 —C, (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 4 Electricians License No, Other Trade's License No. �� 1. Location of land on which proposed work will be doiie: House Number —Street Hamlet County Tax Map No. 1000 Section....- I a,5 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 S. Nature of work(check which applicable):New Building Addition5' .O..W'V) Alteration_ Repair RemovalDemolitionOther Work, (Description) l. 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 5. 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 St6r!eSL?J �,j 3. Dimensions of entire new construction:Front Rear DppLh Height Number of Stories 3. Size of lot:Front Rear Depth7-1$-A 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 NOX 13.Will lot be re-graded?YES NO K NO 4—Will excess fill be removed from premises?YES,�5 14.Names of Owner of premises Address 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. 6.Provide survey,to scale,with accurate foundation plan and distances to property lines. 7.If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. 8.Are there any covenants and restrictions with respect to this property?*YES_NO ✓ * IF YES,PROVIDE A COPY. ;TATE OF NEW YORK) SS: -OUNTY OFSZLEL�'J) being g 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.) ,f said owner or owners,and is duly authorized to perform or have performed the said work and to make a'nd file this application; hat all statements contained in this application are true to the best of his knowledge and belief;and that the work will be �erformed in the manner set forth in the application filed therewith. TRACEY L.DWYER :worn W)erore me this NOTARY PUBLIC,STATE OF NEW YORK f� day of 20 rNO.9IDW6306900 QUALI BED IN SUFFOLK COUNTY COMMISSION EXPIRES JUNE 30,2 Notary PPM Signature of App]i nt lcvnoo 7-gyne 9101 o � �\ � n w ° \co S, �+� r0. ot- Ip 0o 4 ab b 10'1 Nom �� p3 N� r c0 z m z omwb r b mA m y cimv�mm�o �oo�zab ` c,z'�vaiG7b�b m�azo�' cnzakO pwopaT � �my rp nE� c mo_pcn o,m�� A m�mm�a~"mo o AOzoo orn aT�nOti N-,b o�000 rm,y-+moo ba„ o ANo yA= Nmrn:o�i amy r b n O rmb OTZOOb <A rn pZ, O nAS O�np 1+ I'.npfr^n � 'nrn+✓ L" �c)m Anp��A o!i -_j O 6B'E5t' A x ay pN��Z om o m o�A 2 n�zOy co m y =ov zx zi m c N Zw— Cl1� zl�C m m N oyA m xmhl o cy p "C o mom w ^mss cQi, TI m On HIM N 1A AWA 4 l spa f 1V�llll�h i � „// � � �M�✓,�p �� / phi u�� f/rlp n/ 2 ria ^ r/ gqm Ak L 6Gk'rl SvrvVL� 0,4 Ap i „�l U e�. ��'uurumwWr"nwa iauuN. wrw,� ,gw��,� mPmt�uwtii�nv�iww!�lm' ��i a r v t Ie FOP ' }r4 " 2. n. +J, BE � ��t'��n• a� AL T 1"E" '�`°:'�(�i G�!�'�,� i "=.4 w„ YORK o d ! 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