HomeMy WebLinkAbout40873-Z '�'C���i�1 C)F'��U�` fJLI) F3UILI�INC'r PERMIT AP�'I�IC�ITIC3N C�T�CKI,IST°
���� ������������� Do yau have or need the followin�,hefore ap�SEyin�"?
'�'C.DW1�I EI�.I�L �aacdofHea(th
.............
SC3LI�'T3C)I1 ,l�d�1297�. 4 sets ofBuilding Plans
..�.
"I'E�,e (631)765m1�02 Plannii7g f3oard approval
.. _�—
bo�hm d'�`o���1���hk crc-�,re�t �F`FL]�[�'7["1��a �"�i� (���y��' Survey
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Septic F'osrrz
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N.Y.S.D.E.C.
Trustees �
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C:.�.Appticatron�
. Flood'��rra�i[ � ._....
Exai�iined_�'.��. 20 ..... Single&S��r�i�age ... ..
� Stcsrm-Water Assessment Fornt
....
t:or��act:
A€sproverJ.. � ,2Q Mail ta:
Disapproved alc �....�._.__ �.
— �,. —.... . ��m .., .....�.—
_ ... ....... . � �"� Phone: � -.��� .�.
Expiratio�b .2�
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���'��.,���'�`�CDlY F(3I2�lUt�IlIIyIG I�]Ei�II`�`
� �. �I 9 �01 Dat� .........�r 2Q
������7������
a.'' i� campletely filled�n by ryp�writer ar zn ink and submittea to the F3uild`rng Inspectar with 4
sets of plans,acc�€rate plat plan tcs scale.Pee accord�ng to sc�aeduCe.
b.�'lat plaaa showirig Iocation of 1at and of buildangs on prcrnises,relatianshap to adjoxncz�g pr�rraises ar pu6lic sYreets or
areas,ancl waterways.
c,Tl�e worl<cavcred by this a�pl�cation may not b�cammenced before issuance of'Bu�Sding Perrni2.
c[.Upon appraval of this applicatran,the Surid�ng Inspector will issLte a Bt[�ldizag Permat to ihe applic�nt.Such a permit
sl7all be I<ept on the prem�ses available for ins�eclion tEaroughaut th'e work.
e.No buildie�g shall be€�ccupied or used in whe�Ie or in part for any purpose w(a�t so ever until the F3uildin�Inspectc�r
issues a Certificate€sf C3ccupancy.
f. Every builcfii�g perrnit sl�all expire if the work autharized hzts not cornrnenc�d withzn 12 mon9hs after th�riate of
issu�tnce or I�as not bean compCeted within 1&months frc�m suuh date.If no z,onrng amen�finents€�r other regulaticrns affecting the
property have been enacte€1 in the interirr�,the F�uilding Inspector tnay authoraae,in�n�ritrng,the extension afthe permat far ax�
additior€six anantl�s.T'here�rfter,a new perrr€it shall be required. ,
APPLICATIC7N fS HEREF3Y Ml�LJE to tl�e F3u�lding i�epatrr�ent for the issuance af`a�uitding T'ermit pursuant to the
Building Zane Ordir�anc:e of'the Town of Southold,Suffcrlk County,Ne�u�'ork,ant�other applicable Laws,Qrd�nances or
RegEilations,fbr tC7e ccsnstruct€Qn of buildings,adciitians,or aiterat3ons car far removal car clsma�itian as her�in descrtbec�.`I'l�e
applicai�t agrees to cca�np[y with al[appficable laws,ordinances,building code,hous�ng cade,�nd regc�l�tions,and to aclmit
a�.itl�orizecl in�pectors on premises and in buildieog for necessary inspectians.
.�__.r................__.__... ......
(Signature of applic�nt or name,if a corporatian)
.._...._..,._.....
(Mailing address of applicant)
State whethec applicant�-c���n��lessee,agent,architeut,e�gineer,general cantractor,elecirzc�a�n,plumber ar builder
�"� �. ��_.�. . _.........�..
_.......�-m��......� �.__.�"�.�.............................. ....,...,.,........._._
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Narne of awner af premises �..�m���n��5 ����
. .. _.__.______.
(As on the tax.rcal�or latest deed)
If�aa�ali�ry�o��ts� ���erc�t�an,signature of duly autharized officer
�` ��`,��
�,Q `aix�e�nd title c�f c�zporate offieer}
F3ui8�i��ti Zicer�se Na.
Plumbers L�cense No. ..........._
Electricians L,icense N�T�f.�.�.�..__.__m___..._.__m_.._...__.._.....�.......__�
CSther T'rade's I�icense No.
1. I c�catic,n of land o�n whzch�r��rp+�sed u�csrk�vill be c�czne: - � 4
.�'.�+�.�..._. P��P.�..����'�� �
..�m ... __...____...m__ ........_ _ � __.�....�... .....� ....... _.._.__....._.
Hause Number Street H et
C.o��nty T`�i,�Map Na. 1(}()(� Section �Z� �31oc�C � I.c>t J
u ivasion
Filed Map No. I,ot
. State existing use and aecupancy of premzses az�d intended use and occupar�cy af proposed construction.
a. Existin�use and occuparzcy_ _
b. Intendec�use ar�ci occupancy
. Nature af work(check which applicable}:New Bu�Ic�ing�__ Additian 4atti;r��xic�n��� _
Repa�r_............ Remova�___ Dem€�lzrian C3ther Wc,rk ..._. .. "t+,�.'�t0�
_....__.
(Descript�on}
. Estimat�d Cast Fee
..... ....... .........._.._
(Ta be paid on filzng this application)
. If dwelling,nurnber of dwelizrcg units�Number af dwell°zng units an each floorw _
.�..................�
If garage, number of cars
. If buszncss,cammerciai ar mixed accupancy,specify n�ttue�nd extent af each 2ype af ti�se. ww_
. Dimensions of existing structures,if any:Front _�Rear 1C��q:at��
Height Number of Stories � �mm �
�
Dimensions of same structure with alterations or additions: Frant� 1 Rear �: �
Depth Height Number c� ta'���s ,�"°��-.?� �
� �° ...�_
., ; �. ; �, � � . .a ,
Height Number of S�tod�r e����ea�r�.���_���;p cl� ,�-
Dimensicrns af entire new construcfi€�n:1"��a��� � >
������ �����a� �
. Size of lot:Front Rear �Depth
x _. .�:.
Q.Date of Purchase Name of Forxner Owner � . . �'_��� � ������
1.Zone or use district in which premises are sit�aated -
y�,
2.Does propased constructic�n vzolate�.ny zarung�aw,ord�nance or regulation?YES 1�l�b��'"
�✓"r
3.Wi111at be re-graded?YES______NO_ �Wiii excess�11 be removeci from pierr�ises?Y�S�. Na�""'�
4.Names vf Owner of premzses Adcfress Phone No.
Name crf Architect Address I'����a��'�s
Name of Contractor, A�dr��;� Phone No. �
5 a.Is this pro�erty within 1f}0 feet of a t�ctal we2land ar a freshwater wetlan�?*YES S^���A �
* IF YES,SC}UTHOLD TO TRUSTE�S&D.E.C.PE ITS MAY EiE REC�UT�D.
b.Is ihis praperty witF�in 30C1 feet of a tidal wetianc�?*YES NO
*IF XES,I�.E.C.PE ITS MAY E3E �QUI D.
6.Prov�c�e survey,tc�scale,with aceurate foundat�on plan and dist�tnc�s ta property i�nes.
7.Tf elevatzan at any point on property rs at 1 Q feet or b�low,must prov�cie tapographrcal data on survey.
8.Are there any covenants ancf restrictians wxth respect tc�tl�s prt�perty`?* YES NO_ �
*IF YES,PROVII�E A CC7PY.
TATE C1F NEW Y(�RI4)
SS:
:OUNTY C} , � „�c,o
r'+`
.� _m _n_�1(2 R __Y w___betng duly sworn,de�oses anc€says that(s}he is tl�e applicant
{Name of indiv`rduai s�gning contract}aE�ove narned,
5}He is the �IrM'P. ���" h`�- .,
.. �.�. ........... m._m...._,.,.,�...........
{Contractor,Agent,Cc�rpnrate Offic�r,e�c.}
f said owner or owners,and�s cfuly autharized ta perform or have performed the said work and to make and file this application;
�at all statements cont�ined in thls appticat€on are true to the best of his knowiedge and betief;and that the work wilE be
erfarmed in thc manncr set forth in the applzcation filsd th�rewrth.
worn� b�t"bre rne this-�"'"`�
���� �l�ig� `r 20 �
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�� ,rr . ��&�'���,&�G�u������"b1�N�1��R , t� � � �,
�?"`� �a�y� �d�a� ec ��`�aa��r°�6'�as���Gms �r���a����R"���'"�"�'� .�_ � Signnt�.tr�c�f�,p�linant
��w�9��"��a�� ���r�Y���V,���"
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"�'�a������ac��g��s�w�p�r�-r���y,��r"��Ua�.sm��'
Subdivision Piled Map No._mww Lot
State existing use and accupaney of premises and intended use and oecupancy of proposed eonstruction:
a. Existing use and occupancy�
b. Intended use and r�cc�i�����;w��
N�etu�r�e ofwork checRe o al� licable � Demalition� � o�Adci�tior� A]ter�}tion_8
� Pp ) �
._. ....
P .....� er Wark���"�,,�L �c�
..... �.
(Description)
Estimated Cost Fee
_ _...... ...... ......... _._ .. ...._ ..
(Tc�be paid on flling this applieatinn)
If dwelling,number of ciwelling units � Nurnber of dwelTin�units on each flaar
........ ........
If garage, number of cars
If business,commercial or mixed accupancy,specify nature and extent of each type of use.
Dimensions of exist�ng structures,lf any:Frc�nt Rear. _ l�epth�__
Height Number of 5tories IT� �����
Dimensions of same structure with alterations or additions; Front � ��Rear /y
Depth Heighfi Number af���ir�,�s� "��,���" �� ,_ �...
.. � r... ) �.' � r�-' �; 1
Dimensions of entire new eonstruction:I�s�a�a�� �.���---,��� '. C,�����k; �.. ', ,
Height Number of�tar���� _: �,�,„,.. _� ; �
� ryG���
Size of iot:Front �a;aa� I����tg�
�.Date of Purchase Name of Fornier Own�r '� � ";��+� � �;�°��°
.Zane or use district in which premises are situated
.Does proposed canstruction violate any zoning law,ord�nance or regulation?YES NC}
.Will lot be re-graded?YES Nd �V`i11 excess fill be removed from premises?YES NO �^'"''�
.1Vames of Owner of premises Address Phone No.
Name of Architect fi�c{�3x�ss p',��������
Name af Contractor ,h ef�9 r���, Phane No.
a.Is this praperty within 100 feet af a tidal wetland or a freshwater wetland?*YES NO R,�^''�
IF YES,SOUTHOLD TOWN TRUSTEBS&L).E.C.PERMITS MA�BB RBQUIREL7.
b.Is this property witkun 3 QO feet of a tidal wetland?* YES Nd
TF YES,D.E.C.PERMITB MAY BE REQUIREI3.
.Prcav�de survey,to scale,�vith accurate founc3atioaz plan anci distaaces to property lines.
.If elevat�an at Any paznt on praperty is at 10 feet or below,znust provide tc�pc�graphrcai data on s�zrvey.'
.Are there any covenants and restrictians with respect to this property?*YES NO '�r�
IF YES.PROVIDE A COPY.
;^�T���f��NC1�'YC����
�S�
��di"�17"1'r����: �, '
r''�.`
.��d�„,,������� b�ing duly sworn,deposes and says that(s)he is the applicant
(Name of ind�vid€aal signing cantract)above named,
He is the ��P�, � h "' `
. _.....__ ................. ...
(Contractor,Agent,Corporate Officer,etc.}
said owner or owners,and is e�u1y authorized to perform or have performed tha said work and ta make and fiIe this application;
t atl staterr�ents ccantarned in this apptication�tre true to the best€�fhzs knowl�dge and betief;aztd that•the wesrk wi[1 be
formed tn the manner set forth rn the applzcatzon�leci therew�ttt.
�orn C �1"r�a°�me tP�as°--'"'"��
_c.��av � � 2Ck�'�
_ � ���
r" �.x�-C'P���.�r��'6��¢"�v�d'N�""R� � e �`---..�..�::�,
.�' � .� ��r��� �i�fi�. �az��H°�6�a��r�b� ����¢�a�m I"�aur,��i�a���"� � Sagnature of t�pplicar�t __........�
��+���4���V� �rt,u���ze�,��s�E�'�
��30"k'V"��.9�"4tl14C�'�aww�',sf7"��I',�°AiFMM"��ia.�a.".A�''�
Form Na.6
TOWIY OF SOUTlT4LD
BUILDING dEPARTMENT
TOwIV HALL
765-1802
APPLTCATION FCl[t CERTIFICAT[�E7P OCCIIPANCY
`I'his application tnust be filied in by typeweiter or ink and sixbmitted to the Buildirig L7epartment with the folfowing:
A. For new bualdang or new use:
1. Fgnai survey of property with accurate[ocatian of nJl build�n�s,property lines,streets,and unusual natural or
topographic features.
2. Frnat Approval from Health i7ept.of water suppiy and sewerage-disposal(S-9 form}.
3. Appresval rsf`electrical installatian from Board of Fire C7nderwciters.
4. Sworn statement from plumber certifying t}sat the scalder used in system contains less than 2/tQ af 1%Eead.
5, Comme�cial buildzng,industria[building,artultip[e residences and sicni[ar buildangs and anstallations,a certificate
of Code Compliance fram architect or eng�neer respansible far the bu[lding.
6. Submit Plann�ng B�ar3 Approval af�camp4vted site plan requixements.
B. For existmg bualdAngs(prior to t#pril 9,1957)non-cc�nforming uses,or bulldings and"pre-existing"land uses:
F. Accurrite sarvey€�f properry showing a11 proper(y lanes,streets,b�ailding and unusua�naturat€�r togographic
features.
2. A properly campleted appiicat�occ and ccrnsent to inspect signed by the applicant.If a Certifieate of Occupancy fs
denied,the Building Inspector sha31 state the reasons therefor in writ�ng to the appl�cant.
C. Fees
l. Certificate o£Occupancy-New dwelling$56.00,Additions to dwellang$SO.dQ,Aiterationa to dwetlzng$50.0�,
S ' m7ng pool$SO.QO,Accessttry bsx�lding$50.00,l3dditions to aceessory buxldAng$50.00,Btcs�nesses$Sf3.OQ.
2. Certificate of Oecupancy on Pre-exist3ng Building- $I OO.OQ
3. Copy of Certificate of Qccupancy-$.2S
4. Updated Certificate nf Occupancy- $50.00
S. Tempo Csrtificate€�fOccupancy-Residentaal$15.�0,Comrr�erczal$tS.(�Q
_. _ ._ _
Date. �`��F ~'Z�
New Constcuction, C3Id c>r Pre-ex€sting Building: (check one)
.__....
Location of Progerty .. ��Q(� � ��„C�"� �,,,�,,�-
._w. ... ...... �_,..�. ...... ...,.., .�.�.
Hause No. �.- ,,�m Harulet
C?wnec ar Owners ofProperty:� � ���� �-�
Suf£oIk County T`ax Nfap No 100(l,Seet�on BEock Lot
Subdavzs�on .. _ FiEed MaF•_.._ . Lot:
Permit Ato.�...._....._.�.....Date of Permit. ^��lalic�r3t:�. ...
Hea�th Dept.Approval: _Une�erwriters Approvale m
Planning Board Approval: yA,
R.ec�uesf for. Temporary Cert€ficate Fireal Certificate: �°`s (check one)
�, ........ __m.
�
Pee Submitted:$�� _ ��
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pla8acdrti Srgn.. �
��... ��^"�a° s�¢�2a,i;�����-�---��_.,
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SCJCFI`HC3LC1"I'CJ WN ELA$.[.-C'_C3_F3ax 1174 � "s"��"r s� ;'��„ "�.^�y r' Cv {�,`,� ]
53055MaixiTLoed-SOUI'HOC.CJ,[JELn+YORK 119'71 "�r,P" �-�"/ft� �1.��� ��1.�.9��LfL�L�
a� r ,x., ��`�
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l.i TE 23� - cS'd` ��� ''.—.:,...:�..._l.�fR�...,.§J`;N A...��. .....�. .�J......�-�r
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C TQ d.7E. C.UI�E�r..E CED BY �HF APPC.[�.fil�T 1
, � ..�. . ._. `tNfl]lTCie
��T�4 D�.,'4/� fi��f"§� �.P�" �"��&�" �'�E,m�.......�
I�C��,`'1 �'��S �°�a.�d�Ulf 4(CHE.._-_� �. . _�.. ._—..._�
' �...�u..����. . CK ALL TtIAT A.{'F'LY} �
��� �°es��a��
; [��'(� A_ C;le�ring, gr��zb�ing, grad�ng �r str�i�a�Jing of land tuhich aff�cts znor�
` �� th�n 5,OQ0 sq�a�.re �`e�t c�f gco�zid srarface�
�_ �x��.v�ti�r� a� f�iiling it►vol�ir�g rr�«re tClan 20Q cubie y�rcls�f materi�l
withzn �ny p�rcel c�r any contig�caus ar�a.
� � ' Sit� �reparation t�n s[ap�s �ulticE� exceed 10 f�et vertic�l ris� Ca
� 1Q0 feet of horizontal distarrce�
D. Site preparation within 100 feet of wetlands, beach, bluff ar �aastal
^� erosion �azard area_ '
� r"
,J � �� °1��f��ndred-year f�oodplain as depicted
�� � Site preparation within t
. ...._en �"�-�;����-�� ���a� �-���c-����-��: _.......__ _ _. __. ... _ ,.,... .. . . T. . .
� ... _ _.�,
F. Instaliation of �e� or resurfaced impervious surfaces of 1,00Q square �
feet ar ore, �nless prior approva� of a Stormcuater anagement •
' Control Plan was received by the Town and the proposal includes
it�-kir�cl repl�c� e�� cr� i p�rvious surfaces.
If yau _ _ _ . , ..
_. _ . �answered Ndinforma6on� .
Sfgnature,Conta_^ µ
� q�testtnns above,STOP! Cttmpiefe ihe A,pplFcant sect5on 6elow 'fh your Name,
' I3ate� Cow�ty Tag Map N�auzbea? d�apCea z36 doe5 nat�ppIy fo your project
If gao� ered t�a one ar mare of the above,please submit ��vo copies s�f a Stnrmwater l4fana�e�aa�rt C6nirol Plan
4� and a cewa�a�lefied Cheek Lrst Form ta the�ualding�9e�artrnerti wr^�:CY���uus L��ild�s��ff e EL Applic�fian.
__ . , S.C.T.M. *:� 1 d00 n��:�u,
� APPLIC11i�i':(Property C7u?ner.De,ipn Prufessioseal.Aaent Coacrac�ar,Otherl , piyr;�i ������ ....
� �, � 2� � _L_6 �. _�.
� I�tAME ... .. ��� .�...�..._,.,_.,...� �- Sec[ion Block LoC
aeM.e � ... . .
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�-...��._..�...�.m.m,,.. _ -, .
cr��,.� .�4;.=t��R.E���'ii.�iJE'�zr;;P}1�P:�P.T`�i:r.i�IT f.�tiL tl��.?'`<:�
Concac�En€ormatn�rc , ' �� °'�"' .....�._..�.,,--�
-�.���.�;;�" fteviewed Eiy- ...— ....�.C�'-��.�...
_._ .Y_, _ � _ . _.. _ �
— �, _... � � .� — ._ _ "', '"� P.�'''
, Date:
__.—., � —......
Pro�ea-ty Address/l.ocatirrn c�f Canstruct�c�n Work: - - - —
_ - ... , _ _._ _ T
���_°°� A r��^ec.io� rr�r,a�:,�,ingP�udldrng�'r�rmit
k:aea.) _...._ � Contr€�I b'lai�IdoE Require.t�
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I�P
— ... wStoc�i�wu.�REr{�awvA����7�rer�t� _. _ _,_ .__ ___�
�����(' �._� � Storn�water Management Conlrol Plan is Require�l.
�_.. —.
tForward to Errgineerii2U Departrr�ent(or Review_)
FOP.M " SNICP- fC)S MAY 2Q14
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T����� Telephone(631)7651$42
54375 MainRoad �,.y ,�:(�3BR 7�a5-�.yQ`
P.O.Box I179 � � �'����.�"ta�hf:���,IC�"�N�i.SCY4���L�1�.,9i .0.15
Sauthold,NY 1197I-0959 "'� �•�
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$UII.DING I}EP NT
TO O�SOUTHU
APPLiCATION FOR ELECTRlCAI�1NSPECTION
REQUESi'ED BY. L �l�,.w Date: 7 �3 �,�
��mp��y�Jamea �."`� � °
I��a�e:: �
�icense Nae ������
�,d��°��s_ , � `�� �� k� � �
�har��.No.: � r '� d �
JOBS[TE INFOI�N1AT10N: (�Ind.icates required informatian)
*Name: .
�Address: �� •
*Gross Streef: r .
/Yi ' Q.
#F'hone Na.: �l���..-` �..3�
I'erm�E I�o.:
Tax�Map Distr�ct: 100d Secfion: Bfock: Lata
*BRIEF DESCR�FTiON OF WQRK(Please Print�[ea�iy)
(Pfease Crrcle AI17°hat p!y)
*1s jo6 ready for inspection: ��7 Rough In F�nal
k�o yau need a Temp Certf�cate° ��� �
Temp lnformation(ff�neededJ �
4SenriCe Size_ 1 Phase 3Phase 100 150 2fl0 300 350 400 Ofher
kNew SefviCee Re-connecC Underground Number at Meters Change of Service Overhead
4dd9tiona!Infarmation: PAYMENT DUE WiTH APPI�I�A�tON
�a ����. ���° � N � _�
82=Requestfortnspec6nn Form
;n;�v�l%r�i�,��9wr v i r „���uu�//r i , .
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