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Home My WebLink About42287-Z `7 L,5 ►6t 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)765-1802 Planning Board approval FAX:(631)765-9502 Survey_ Ff ( .. _ South oldtownny.gov PERMIT NO. ._ Check Septic Form_ N.Y.S.D.E.C. Trustees C.O.ApplicaCooiv Flood Permit Examined---_ ,20 .._k Single&Separate Truss Identification Form Storm-Water Assessment Form Contact: I I .... . 20 Disapproved a{c L .......�, _....w.._ _ Phone:kap t Expiration _ 2 ✓ 11 'm {GtSpeetQY APPLICATION FOR BUILDING PERMIT j j?.b Date -� .... ........... ,20 1 INSTRUCTIONS a.This ala�licatio�o.gn MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets er(ol'k 't �L t9P o 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 steal 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. 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 1S 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 all applicable laws,ordinances,building code,housing code,and regulations,and to admit authorized inspectors on premises and in building for necessary inspections. (Signature of applicant or name,if a corporation) (Mailing address of applicant) State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder O„to a _._ -------------- Name of owner of premises_[_k ��r /'ec (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 on which proposed work will be done: lio . ----------street HamletHouse Number County Tax Map No.1000 Section_,..91— Block 7- Lot Subdivision 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 b. Intended use and occupancy 3. Nature ofwork(check which applicable):New Building Addition_ Alteration,.... Repair Removal Demolition Other Work (Description} 4. Estimated Cost 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 Vusiness,camgi0 eial or mixed occupancy,specify nature and extent of each type of use. T,Dirrpensiionsofexigtingstructures,ifany: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`' € hear Depth 10.Date of Purchase Name of Former Owner I I.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__NOWill excess fill beremovedfrom premises?YES___._--Nf3___ 14.Names of Owner of premises Address Phone No. Name of Architect Address Phone No Name of Contractor Address Phone No. 15 .9 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) COUNTYU _ ._._._......._..._._being duly sworn,deposes and says that(s)he is the applicant (Name yf individual signing contract)above named, CONNIE U.BUNCH Notary Public,State of New York (S)He is the.,.. No.01BUB185060 uua(Contractor,Agent,Corporate Officer,ctc) rtrr in i olk` out Commission Expires April 14,��0 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. S, r� a before methis a n _..day of -51ht t11tG\f\ 71 Q_ e . c�� Notary Public Signai'tire ofApphcant i °°j6 _ $ _m 4 (�Zt• cr- ako ca DL F 1� 'CL w Q w Fow kb tr Z)O -v 7 V} Q V) to Ci Jyr I I A� Z 90 060 Cb qb 'L r a 9 1 e� LL Z W b CP tp M wr M 4 r- 19 z