HomeMy WebLinkAbout40805-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.
Check
Septic Form
N.Y.S.D.E.C.
Trustees
C.O.Application
Flood Permit
Examined— 20L Single&Separate
Storm-Water Assessment Form
Contact:
Approved a 20_1k_ Mail to:
Disapproved a/c
Plaune:W'1�
�p,� r
Expiration w 2011-
t
u in or
AN 2 2 2016APPLICATION FOR BUILDING PERMIT
BUILDING Date'. ��" .201�
TOWN OF O t1LD 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,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
" tee i(9:P-
State
93
State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder
r........-._.... _..-._............................. ..........................................................................._.
Name of owner of premisesi, A _ •,,,v,
(As on the tax roll or latest deed)
If applicant is a corporation,signature of duly authorized officer
..........w.:......_......_................._..............._
(Name and title'of corporate officer)
Builders License No.
Plumbers License No.
Electricians License No.
Other Trade's License No.
1 Location a land
�n which proposed worwill
House Number Street Hamlet }}
County Tax Map No. 1000 Section Block Lot m _.t� ' 1
Subdivision Filed Map No. Lot
2. State existing use and occupancy of pretnatses and intended use and occupancy of proposed construction:
a. Existing use and occupancy
b. Intended use and accupancr
3. Nature of work(check which applicable):New Building _Addition Alteration
Repair---Removal Demolition °
.�......—.—Demolition —........_.tither Work_ ...�� .......
4. Estimated Cost Fee (Description)
(To be paid on fiii ng this application)
5. If dtvelling,number of dwelling units i Number of dwelling units on each 1loo
If garage, number of cars -
- –
6. If business,commercial or mixed occupancy,specify nature and extent of each type of use. 6 r'
7. Dimensions of existing structures,if any:Front Rear 1
Hei ht
umber of Stories
Dimensions of same structure with alterations or additions: Front Dear
Depth Height Number of S;torij '
8. Dimensions of entire new construction:Front Rear L}epti7
Height Number of Stories
9. Size of lot:Front Rear Depth X.
10.Date of Purchase' ,z, � Name of Former Owner s 1 r
11.Zone or use district in which premises are situated
12.Does proposed construction violate any zoning law,ordinance or regulation?YES__1`:10
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 Flo
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 REQCJIi'T-5.
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 OF )
being duly sworn,deposes and says that(s)lje �s the aappl ic;am
(Name of individual signing coittr, above nKamedc CONiNIE p,SUNCH
Notary Pcabl ,S¢ate of N w k"ork
(S)He is the (Contractor, No.t�tal.�51860;j B
oraamisal'pr E.a lrt —
( r,Agent,Corporate Officer,etc.} p ,qp 14 ��O
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.
S%v'it'
rn to before me this
e day of �-A r,,X 20
Notary Public Signature of ApplpcaanV;
Town Hall Annex Telephone(631)765-1802
54375 Main Road (63076
p.0_Box 1179 ra er.rictlert � 91.Sf7d +�(.r1 .0 r
Southold,NY 11971-0959
BUILDING DUAR'IM14T
%W OF SOUrMOLD
APPLICATION FOR ELECTRICAL INSPECTION
REQUESTED BY: _.:..� i Date:
Company blame: _
!Name.-
License
arne:License No.: - 'ea,
Rsl
Address:
Phone No.
JOBSITE INFORMATION: (*Indicates required information)
*Name: °+
*Address:
*Cross Street, G -_
*Phone No.:
Peanit No.: 4
Tax-Map District: " 1 000 Section: Block: Lot:
*BRIEF DESCRIPTION OF WORK (Tease Print Clearly)
(Please Circle All That Apply)
*Is job ready for inspection: ES NOr�hl Final
*Do-you need a Temp Certificate: _ YES t VQ
Temp Information (If-needed)
*Service Size: 1 Phase 3Phase 144 154 200 300 350 400 Other
*New Service: Re-connect Underground Number of Meters Change of Service Overhead
Additional Information: PAYMENT DUE WfTH WITHAPPLICATION
.82=Request for Inspecfiork Form wo
L-d L99tZ69-L£9 00lsaiJlaal�]1100 siuua4 eL9:01 9L 9L uof
Scott A. Russell STOWWWAT]EIK
SUPERVISOR
SOUTHOLD TOWN HALL-P-Oe Box 1179Town of Southold
53095 Maur Road-SOUTHOLD,NEW YORK 11971 4°Vi lyf ` p
CHAPTER 236 - STORMWATER AIANAGEMENT WORK SHEET
( TO BE COMPLETED Y THE APPLICANT )
DOES 111IS PIkOJECT INVOLVF, ANY OF THE FOL,LO INN-
(CHECK ALV._ THAT APPLY)
El 1 A. Clearing, grubbing; grading or stripping of land which affects more
than 5,000 square feet of groundsurface.
Excavation r filling involving more than 200 cubic yards of material
i i -c or any contiguous area_
C. Site preparationslopes which exceedfeet vertical rise to
100 feet of horizontal distance.
Site i within feet of wetlands, beach, bluffcoastal
erosion hazard area.
Site do within one-hundred-year floodplain as depicted
1LM,Ma f - y - .al-eFc- -rse_----- -- -
DIE] F. Installation of newr resurfaced impervious surfaces 1,000 sure
feet or more, unless prior approval for r Management
Control Plan was received by the Town and the proposalincludes
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,
Signature, Contact Information, Date & County Tax MapNumber! Chapter 236 does not apply to your project.
If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan
and a completed Check List Form to the Building Department with your Building Permit Application.
APPLICANT, (Property Owner,Design Professional,Agent,Contractor,Other) S.C.T-M- #` 1 000 Date.
LM'CsCP'IiG'P.
r
NA)wIF_ Section Block Lot
-G DU'P'-'. t p N
4
Contact infornMaGorr
Reviewed Bye gem
... �.
/ Location flair c� C°c�r�.t��cl ..�
Property� 9res bate.
s Approved for processing Budding Permit.
. ��_....... .. .... _ Storrnwater—
_.. — ....... .
Stormwate r Management Control Plan t Control Plan � _d.
Required,
(Forward to Engineering Department for Review.)
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