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HomeMy WebLinkAbout42145-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 se of Building plans TEL: (631)765-1802 , lanning Board approval FAX: (63.1)765-9502 i<<Su ey Southold town ny.gov PERMIT NO. _r �1. Check Septic Form N.Y.S.D.E.C. T=5tees ! Applicaton Flood Permit Examined 20 Single&Separate Truss Identification Form Storm-Water Assessment Form — Approved � trntact; Approved .20 G�) .... .i 2011 Disapproved& w 03......Q I—oa BHH MIN' DEPT. Phone:— Expiratiosti r " 20JAOF 50 LD Bua ing Inspector APPLICATION FOR BUILDING PERMIT Date 20 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 shal I 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. I°. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of i�Sstsance 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 rno ths.Thereafter,a neve 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 ail applicable laws,ordinances,building code,housing d;e,and regulations,and to adrnw t, authorized inspectors on premises and in building for necessary inspections. tw (Signature of applicant or name,if a corporation) . Illi 85`4^ Q oi?6 1117 f,l hJ`✓l l^tl kyw 'fFJ`r (Mailing address of applicant) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder Name of owner of premises T1Ui�,-t tAle(SS (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. Location of land oil which pro cised work wvilI e Clone: M1"f fir I d j� t House Number{ Street Hamlet County Tax Map No. 1000 Section—S-3 Block © ° Lot D, 7 di Subdivision L 6W7(C )IIt A^ Filed Map No, 7'x"7 Lot 10S /'12 `f 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy b. Intended use and occupancy Is 3. Nature of work(check which applicable):New Building V Addition alteration Repair Removal Demolition Other Wor (Description) 4,',Estimated Cost Fee (To be paid on filing this application) 5. If dwelling,number of dwelling units iutacr alIw, ➢larua unts''on each floor If gardge, number of cars Cy � � I ;. 6. If business,comntieccap or mixed oceupa ,Ispecify nature and extettReaplr type of use. t., 7. Dimensions of existing structures,if any:Front Rear Depth . ......... Height Number of Stories Dimensions of same structure with alterations or addb�^�l'Ions: Fant Rear Depth . Height p Ku�mber 6,f Stories 8. Dimensions of entire new constr /ction:Front Rear Depth Height Z Number of Stories � 9. Size of lot:Front Rdar depth 10.Date of Purchase Name of Former Owner 6 11.Zone or use district in which premises are situated 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 plIemises?YES._._NOS E 14.Names of Owner of premisesLW L&j, Address,—)-030 64t& ( Phone No. Mn f 03 7f1 Name of Architect Address :Phone No Name of Contractor Address, }"'hone 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 REQUIRED. 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) S: COUNTY OFae 1 Imo, h. 1 being duly sworn,deposes and,says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the__. (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 roe this r ay of Qy' f(. 20q{ t � j� LIg r Notar Public NOTARYPUBLICSATEOFNEWYORKSignaiUre�of Applicant No.otoWssosso OUAUFIE0 IN SUFFOLK COUNTY COMMISSION EXPIRES JUNE 30,212-0 v d", t�,C7tF AD" w w O Nr -s o .rR �Jry bT. ` {�Q 7G G` OCV o C \ O$ . a m f mZ0--r:n 0 CL dee n m m z C) > O xm ® Po ® >N Z d'$w Z ' r d w m _u O C C O err --� rca r^ n co w p Z--iz M _ w > O W O --i*2>O co a N �DCND 0 �p Z z m a coM � QO i< m YO ' m Cf) `J r O � n x s z c� o) Q, co k, t Xkl DEERK 5 PE .` phone:(631)298-7116 REAR ELEVATION FRONT ELEVATION _. 9CALE�I!4"=I'-0'° SCALE: 1!4".I'-O"- fis 6TlCr FEE ltiei—'= D7.1^.-d 1 i-TA-'€ h�3 Piir 2X,­UDWAU SEC 1� S TION A-A LFT ELEVATION _RIGHT- L V TI ALE.3t6"-Iv o" Sc 3C3,°E. .1_<�•:'-0' BGALE:1/4" 1'-0" ate, , n 4 _ E ni� ta 3 'LN [ $. 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