HomeMy WebLinkAbout42676-Z TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
BUILDING DEPARTMENT Do you have or need the following,before applying?
TOWN HALL oard of Health
SOUTHOLD,NY 11971 sets of Building Plans
TEL: (631)765-1802 Planning Board approval
FAX: (631)765-9502 .Survey al! CA l
Southoldtownny.gov PERMIT NO. Checky
, eptic Form
trustees
4Z-�7
,,2.0.Application
Mood Permit
Examinedt
2p -5"1ngle&Separate
,Afuss Identification Form
A _ Aorm-Water Assessment Form
Contact:Approved20
Disapproved a/c TO Fso
Phone: C�
Expiration--L-4. ).Z 20 "
-
Buil ng
APPLICATION FOR BUILDING PERMIT
Date - '� ,201 '
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
shall be kept on the premises available for inspection throughou€the work.
c.No building shall be occupied or used in whole or in partfor any purpose what so ever until the Building Inspector
issues a Certlficate 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?one 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 her 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.
(Signalure of applicant or name,if a corporation)
BOX -a° °" ,i " 7/(,3 5
(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.
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which roposed work will be done:
House Number Street Hamlet
County Tax Map No. 1000 'Section Hj,� at Block .. Lot y�Grp
Subdivision •• _r
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy 6,
b. Intended use and occupancy rr
3. Nature of work(check which applicable):New Building Addition Alteration Y
Repair Removal Demolition Othcr Work (Description)
4. Estimated Cost Fee
n number of dwelling Nf
' F, �•� rl�i t to filing this application)
5. If dwelling, g wellin I eh floor
n unitsg ttr�a o s
ars
If garage, number o IqIor mixed occupancy,specify nature and extent a �
6. If business,comm of each type of use. _
Depth:,
7. Dimensions of existing structures,if any:Front y
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 Rear Depth d
f�
10.Date of Purchase .g Name of Former Owner
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 ✓r Will excess fill bexemoved from premises?YES NO
Phozle No.
)k-7L.16
14.Names of Owner of p ,remises_ 6 Address l . ` +
,^r,
Name oCArchitect 6KO r) Address 90�? La4o—ffiLe--6,0honeNo�
Name of Contractor Address Phone No.
15 a. property Is this within 100 feet of a tidal wetland or a freshwater wetland?*YES NO
*IF YES,SOUTHOLD TOWN TRUSTEES'&DEC.PERMITS MAY BE gQUIRE,D.
b.Is this property within 300 feet of a tidal wetland?*YES NO
*IF YES,D.E.C.PERM:ITS 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)
SS:
COUNTY OrsaL
C r oo being duly swom,deposes and says that(s)he is the applicant
(N ne of indivi ual 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 me this
day of 20—BaL
TRACEY L.D\NYEpt
X
ISLlC STATE:DE NEW YORK
otary ublir No.(),j)W630690Ty 0 Signature of Applicant
QUALIFIED i:yPiRES JUNE 30,� A
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 I%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
Date.
New Construction: Old or Pre-existing Building: (check one)
Location of Properly:
gqn�ne/�0
House No. Street r 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:
_ -w (check one)
Request for: Temporary Certificate Final Certificate:
Fee Submitted: $
�.... Appli ntlsig r
Scott A. Russell STORIMIWAT]E K
svPERvisoRAMIA1�A\,G]ENHEN T
SOUTHOLD TOWN HALL-P.O.Box 1179
53095 Main Road-SOUTHOLD,NEW YORK 11971 Town of Southold
C TER 236 - STORMWATER MANAGEMENT WORK SHEET
( TO BE COMPLETED BY THE APPLICANT )
DOES THIS PROJECT INVOLVE ANY OF THE FOLLOWING:
Yes No
(CHECK ALL THAT APPLY)
,
[:]M/A. Clearing, grubbing, grading or stripping of land which affects more
than 5,000 square feet of ground surface.
[]ESB. Excavation or filling involving more than 200 cubic yards of material
within any parcel Or any contiguous area.
C. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
�] . Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
1 [] . Site preparation within the one-hundred-year f loodplain as depicted
"'ren FIRM Map of any watercourse.
n[F. Installation of new or resurfaced impervious surfaces of 1,000 square
feet or more, unless prior approval of a Stormwater Management
Control Plan was received by the Town and the proposal includes
in-kind replacement of impervious surfaces.
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.
Agent.Owner,Desi n Professional,A n' rare Other) 00 Date:
APPLICANT; (Pr per)r S S
S.C.T.M. 1 41"', 4NAME. Lat
FOR BUILDING DEPARTMENT USE ONLY
Contact Informa[iorc
,.,
Reviewed By: °
Date: '
Property Address / Location of Construction Work; [�/ '
Approved for processing Building Permit.
Stormwater Management Control Plan Not Required.
_
Stormwater Management Control Plan is Required
(Forward to Engineering Department for Review.)
FORM # SMCP-TOS MAY 2014