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HomeMy WebLinkAbout40810-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)765-1802Planning Board approval FAX:(631)765-9502 %� Survey�4 - ,_ SoutholdTown.NorthFork.net PERMIT NO. b V µ w. Check Septic Form_ ........ N.Y.S.D.E.C., ..... Trustees VC.O.Application — /^� Flood Permit„ Examined .�"` �._�(/ 20 Single&'Separate m.... .__ s.eR.!x'ter Assessment Form Contact: LL Approved_ ,20 Mail to: }P& � 04 Disapproved talc _ � / Ny Phone: a\4 � Expiration ,20.2 B tng In or APPLICATION FOR BUILDING PERMIT Date az 2010 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 a rees to "' tly plicable laws,ordinances,building code,housing code,and regulations,and to admit autlrl I' r e in building for necessary inspections. ra. (Sign tote of applicant or name,if a corporation) JON JMMTO 1pl� G OI (Mailing address of applicant) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Ouj, .e-. Name of owner of premises on the tai u+w. d� ( x roll or latest deed) If applicant is a corporation,signature of duly authorized officer (Name and title of corporate officer) Builders License No. Pl Plumbers License No, Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: w House Number Street Hamlet Sr County Tax Map No. 1000 SectionBlock Lot Subdivision--cYlWI 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 110w.-e_-. b. Intended use and occupancy 2.. 3. Nature of work(check which applicable):New Building Addition Alteration Repair Removal Demolition ItOther Work 1= rz (Description) 4. Estimated Cost * S1000 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 Stories 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, aw,ordinance or regulation?YES NO c/ 13.Will lot be re-graded?YES NO ✓Will excess,fill be removed from premises?YES NO 14. Names of Owner of premises 'Kow tte-IL' Address t i t 4 t Phcne No. Name of Architect Address Phone No Name of Contractor Tl' �6-v- 6or4oem , Address (,33 ,, 1 i Phone No. b3 t S93 00-4 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?* S NOm * IF YES,D.E.C.PERMITS MAY BE REQUIRED. ell 16.Provide survey,to scale,with accurate foundation plan and distances to propert" w1t es ..) i m? ' 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 O-IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF } being duly sworn,deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is thewwer� (Contractor,Agent,Corporate Officer,etc.) 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. Sworn to before me this day of 20, Notary Public Signature of Applicant 3. Nature of work (check which',raticable): New Building•.................. Ai_ .ion .................. Alteration ............,. Repair .................. Removal ......... ........ Demolition,.,.,,,,..:...,. Other WorkAgj eB!w R! 4. Estimated Cost 200.00 (Description) r ,,,, ..-- (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......................... & If business, commercial or mixed occupancy, specify nature and extent of»each type of use^............................ 7. Dimensions of existing structures,if a Front Rear • any: A�7...,...:.,. !'t .................. Depth ..3 ,..... Height ........................ Number of Stories ..12......... Dimensions of some structure with olterations or additions Front tt0 Rear ,...,, Depth ............................... Height ...... ,.„. Number of Stories . 8. Dimensions of entire new construction: Front Rear ...._.��0 ..,.....,,. Depth None ,.,....., Height .................... Number of Stories • .. ..................., 4. Size of lot: Front ...._ . r Rear....r... p r , :Aug. X975 De th�...,,.,r"� ................ 10. Date of Purchase Name of Former Owner N »„& eno. 11. Zone or use district in which premises are situated ...�:..........12. ....... Does proposed construction violate any zoning low, ordinance or regulation: .AV. 13. Will lot be regraded ..... �!................ Will excess fill be removed from premises: ( ) Yes (x) No 14. Name of Owner of premise,,,, ranco NonaCel1i.,.& ' IfBK*York N Name of Architect .. rem ..!......sxo Phone No....................... ..Address Phone No, P newtood deca 1 �. d .......... Name of Contractor .... Address CutChogue, NY Phone Na7� 6007 .......... .................. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or Proposed, and indicate all set-back dimensions from property lines. Give street and block numbet or description according to deed, and show street names and indicate whetherinterior or corner lot. tro: .3 cv�LO Co- E r, .' � STATE OF NWUMik COUNTY F fS.S ....Ni�naekar ..................:..::....:.:...:.....................being duty sworn, deposes and s (Nome of indual signing contract? oys that he is the applicant above named. He is the ..,,.Landscape contractor agent_...,..,, (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed a said work and to make and file this application; that all statements contained in this application are tru best of his knowledge and belief; and that the work will be performed in the manner set forth in the applicoti filed er f Swan to before me this day of ............. .. xs,-� 1'9 Notary Public, ............. ,...... t;.... ,ff . County ....... .1—....... .. ................ (Signature at applicant) % �ANN kEYfi.LE ' NOTA,Ry PUBLIC, S1sia o! 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