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:
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Approved_ ,20 Mail to: }P&
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Disapproved talc _ � / Ny
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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! New V
N.. 52,�6125B5o. S1f1101k C'a+unir
T?cm Edvires March 30
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