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Home My WebLink About40823-Z TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN ALL Board of Health SOUTHOLD,NY 11,971 4 sets of Building Plans_,, TEL®(631)765-1802 Planning Board approval ----- FAX: (631)7659502 survey SoutlioldTown.NorthFork.net PERMIT NO. Check Septic Form ......... N.Y.S.D.E.C._... ...... Trustees C.O.Application, Flood Permit Examined 120.1� Single&Separate Storm-Water Assessment Form — Contact: Approved 201 MITI to: Disapproved a/c—----- Phone:.--Tlq� �A`it 2 Fxpiration_._._,20_ La° OVE BuiA'ingli rd.ec't 7(o,r J 2016 N DAPPLICATIOFOR BUILDI,NG PERMIT UN 3 0 Date c7 20 L BUILDWG DM. OLD INSTRUTATS TOWN OF SOUTH a.This application MUST be completely,filkd 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 ofbui I Idings 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. c.Nobuilding 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,a'dditions,or alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable Ya%ks,ordinances,building code,housing code,and re Irdations,and to admit authorized inspectors on premises and in building for necessary inspections. (Signature ofapplicant;r name,if a corporation) G-, (Mailing address orapplicant,) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder CQ-- Name of owner of premises,.......... (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. Electricians License No. Other Trade's License No. 1. t- nn of land on which propused work xitt be gone. House Number Street Hamlet County Tax.Map No. 1000 Section Mock 7' Lot Subdivision Filed Map No._ -Lot 2. State existing use and occupancy of pr rises anti i.nte do use and occupancy of proposed construction: a. Existing use and occupancy q o b. Intended use and occupancy �t..- 5th ti_ z ':K'2-6 t lac 3. Nature of work(check which applicable):New w' ing Addition Alteration Repair _ Removal w i, y�Other Work 4. Estimated Cost 1,�- Fee (Description) (To be paid on filing this application) 5. If dwelling,number of dwelling unitsr� 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. z R � 7. Dimensions of existing.structures,if any:Front . ti Rear V Depth Height / Number of Stories n Dimensions of same structure with alterations or additions: Front Depth Height Numbe�Sioa s 8. Dimensions of entire new construction:Front lk Rear Height Number of Sties i ) Size of lot:FrontY�L „ , Rear Depth C I� Date of Purchase .,ame of Former Owner � t `1 D Zone or use district in which premises are situated A 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 premises o-Q Address�� 7rw �� w Pane No. 5i f� -3(6 4 Name of Architect Address Plione.No Name of Contractor Address Phone No. 15 a.Is this property within 100 feet of a tidd1wetland 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? * `t"ES NO *IF YES,D.E.C.PERMITS MAY LE,RFQ1-TIRED. 16.Provide survey,to scale,with accurate f6imcl•ation plan and distances to property lines. 17.If elevation at any point on properly is at 10 feet or below,must provide topographical data on survey. �u 18.Are there any covenants and restrictions with respectto this property?* YES NO * IF YES,PROVIDE A COPY. STATE OF NEW YORK) SS COUNTY OF 1 -being ing duly sworn, (Name of individual d al s ing contract)above named, M deposes and says that(s)l e is the app)ir;;Ktrzt (S)He is theF (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 � ELINDA L.TOPPIN NOTARY PUBLIC,STATE OF Y Notary Zi Registration 'a a Signature of ApplicM n4 Chu tte�i is St€ctk Cauaty Commission Expires May 31, LO Ii I' zz> mu ® Q A *L<"- 0 L'o P)