HomeMy WebLinkAbout42317-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)765-1802 I Planning Board approval
FAX:(631)765-9502 `� Survey
SoutholdTown.NorthFork.net PERMIT NO. \ Check
Septic Form
N.Y.S..O.E.C.
Trustees
C.O.Application .
Flood Permit_
Examined ,20 Single&Separate,
Storm—Waterr Assessment Form
Contact: / q/
Approved 20 ` Mail to:
l.s CiC
A.
Disapproved a/c
Phone: , l- 472
—&r ,
Expiration 20
Building Inspect
APPLICATION FOR BUILDING PERMIT
JAN 1 6 2018
Date 20 10
INSTRUCTIONS
TO OFs,,OUI'ROLD
a."This app kation MIDST 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 Ins*torwill issue a Building hermit 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 Southpldl Suffolk-County,bl'e'w York,and other applicable Laws,Ordiaiances or
Regulations,for the construction ofbuildin °s,additi•ons,'or altel:ations 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
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, /3p C,3 Iql
Plumbers License No.
Electricians License No.
Other Trade's License N,o.
which proposed work will be done:
1. Location of land on wh 2 EA U
House Number Street Hamlet
County Tax Map No. 1000 Section Block d� Lot
Subdivision Filed Map No. Lot
2.I 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 Gbet-�i<e 2C!e9iC
3. Nature of wpi{ (check which applicable):New Building Addition Alteration
Repair V, Removal Demolition Other Work
(Description)
4, Estimated Cosh 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.W OCD ---Wtbp
7. Dimensions of existing structures,if any:Front Rear 2-0 Depth Z
Height 42.2 ' Number of Stories
r
Dimensions of same structure with alterations or additions: Front .-D Rear 2
Depth 23- Height Number of Stories
S. Dimensions of entire new construction:Front _Rear Depth
Height Number of Stories
9,I Size of lot:Front a RearDepth
10,Date of Purchase Name of Former Owner
11 Zone or use district in which premises are situated
i
1 .Does proposed construction violate any,zoning low,ordinance or regulation?YES_NO
1 Will lot be re-graded?YES_NO_k/Will e;cess fill be removed from premises?YES_NO IUTA
14.Names of Owner of premises Address r>62�" 4e'A&hone No.631-21,6-i223
Name of Architect �1 "" 1 C ✓ ,.c " Address ,/y � Phone No'10i-4W '`^',,,Sa1
I Name of Contractor' Address / . •Phone No.
15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES NO V"
*IF YES, SOUTHOLD TOWN TRUSTEES&D.E.C.PE1tMI€'S MAY BB REQUIRED,
b.Is this property within 300 feet ofatidal wetland?*'YES NO
IF YES,D.E.C.PERMI'lIS MAY BE REQUIRED.
I .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.
I,, .Are there any covenants and restrictions with respect to this property?*YES NO
IF YES,PROVIDE A COPY.
STATE OF NEW YORK)
SS:
C",Ou'wr y OF
tieing 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.)
1
of said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application;
thtit all statements contained in this application are true to the best of his knowledge and belief;and that the work will be
pdriormed in the manner set forth in the application filed therewith.
I 1
Swore me thjs a
✓ew day of -leas)"y- 200ON141E D.BUNCH
n i
ata vert
Notary public Nm 01BU61 850K Signature of Applicant
Qua5fled In Suffolk County
Commission Expires April 14.2,.D�
Scott A. Russell ST01 h\11 wA TIERE
SUPERVISOR MAN A\G1EMENNIF
SOUTHOLD TOWN HALL-P.O.Box 1179
53095 Main Road-SOUTEIOLD,NEW YORK 11971 , Town ®f Southold
CHAPTER 236 - STORMWATER MANAGEMENT SHEET
( TO BE COMPLETED BY THE APPLICANT )
ee
DOES THIS PROJECT INVOLVE ANY OF THE FOLLOWING:
(CHECK .ALL THAT APPLY)
Yes No
A. Clearing, grubbing, grading or stripping of land which affects more �!
1 than 5,000 square feet of ground surface. '
Ge . Excavation or filling involving more than 200 cubic yards of material
l� within any parcel or any contiguous area.
11bffC. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
G/D. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
E. Site preparation within the one-hundred-year floodplain as depicted
on FIRM Map of any watercourse.
0 RoeF. Installation of new or resurfaced impervious surfaces of 1,000 square
feet or more, unless prior approval of a Stormwater Management
' 1
Control Plan was received by the Town and the proposal includes
in-kind replacement of impervious surfaces.
�eeeeeee� "I'll, -11,11,11111-11 ® �
If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name,
Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project.
If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan
and a completed Check List Form to the Building Department with your Building Permit Application.
SCTM *: 1000 Date
APPLICANT (Property Ottner,Desi,nProfevru�onalAgentractta�° . . . .
Other) District
� tNAME:- .. w � � r✓ � r '� � r� G l �T
Section Block Lot
......................................
.--. h Y k Y p P'K" y
Contact Information: 17�77,
777-
r �
n — _ .-. _ ..- -- .-
Reviewed By:
Date:
Property Address/ Location of Construction Work: — .-
�� �U G Approved Permit.
Stormwater ManagementControl Plan No
t Required.
Stormwater Management Control Plan is Required.
(Forward to Engineering Department for Review.)
�,ee . ...... � ..
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N/O/F SOUTHOLD FIRE DISTRICT
Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be filled in by typewriter or ink and submitted to the Building Department with the following:
A. For new building or new use:
1. Final survey of property with accurate location of all buildings,property lines,streets,and unusual natural or
topographic features.
2. Final Approval from Health Dept of water supply and sewerage-disposal(S-9 form).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1%lead.
5. Commercial building,industrial building,multiple residences and similar buildings and installations,a certificate
of Code Compliance from architect or engineer responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
B. For existing buildings(prior to April 9,1957)non-conforming uses,or buildings and"pre-existing"land uses:
1. Accurate survey of property showing all property lines,streets,building and unusual natural or topographic
features.
2. A properly completed application and consent to inspect signed by the applicant.If a Certificate of Occupancy is
denied,the Building Inspector shall state the reasons therefor in writing to the applicant.
C. Fees
1. Certificate of Occupancy-New dwelling$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00,
Swimming pool$50.00,Accessory building$50.00,Additions to accessory building$50.00,Businesses$50.00.
2. Certificate of Occupancy on Pre-existing Building- $100.00
3. Copy of Certificate of Occupancy-$.25
4. Updated Certificate of Occupancy- $50.00
5. Temporary Certificate of Occupancy-Residential$15.00,Commercial$15.00
a't'e'. r
New Construction: Old or Pre-existing Building: (check one)
Location of Property: +r _ �,,.
House No. Street Hamlet
Owner or Owners of Property:.�. � ".�� ) �'"` ._....._ ...................._.._
Suffolk County Tax Map No 1000, Section Block Lot
Subdivision Filed Map....__. Lot:
Permit No. Date of Permit.
Applicant:
Health Dept.Approval: Underwriters Approval: ..........
Planning Board Approval:
Request for: Temporary Certificate --Final Certificate: �A", (check one)
r
Fee Submitted: "
V'
plicant Signature
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