HomeMy WebLinkAbout43392-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 Planning Board approval__
FAX:(631)765-9502 Survey_.................
-SoutboldTowil.NoythFork"t PERMIT NO. Check
Septic Form
N.Y.S.D.E.C.
...........................
Trustees
C.O.Application
Flood Permit
Examined 201 Single&Separate
Storm-Water Assessment Form
Contact:
Approved__........... 1.4le............. WIL Mail to: Robert Wilson .................
Disapproved a/c PO Box 49 Southold NY 11971
J
Phone: f631l5-04-8B42
Ru ICATION FOR BUILDING PERMIT
Date December llth_20 18
"JI INSTRUCTIONS
T1IWN OF
a.This applicidimh%4,1� �c�omplctely 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 oflot 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 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 Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold,Suffolk County,New York,and dthoir-applicable Laws,Ordinances of
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 licint or name,if a corporation)
PO Box 49 Southold NY 11971
(Mailing address of applicant)
State whether applicant is owner,lessee,agent,architect,engineer,general contractor,electrician,plumber or builder
Agent ............................................
Name of owner of premises I'll Stuart Thorn ..................
(As on the tax Toll 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:
= � Ave ........
House Number Street Hamlet
County Tax Map No.1000 Section 51 Block 01 Lot 210 1
_Lot——---------mt�
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 Single family residential
b. Intended use and occupancy ,�, ��.p�n ter„ M „
....__M..., ° - n
3. Nature of work(check which applicable):New Building Addition J 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 1 _Number of dwelling units on each floor---- 1
If garage,number of cars
6. If business,commercial or mixed occupancy,specify nature and extent of each type of use.
7. Dimensions of existing structures,if any:Front 77.6 Rear77.6 Depth 56.1'
Height 28' Number of Stories 2
Dimensions of same structure with alterations or additions:Front 77.6' Rear 77.6'
Depth 56.1' Height 28' Number of Stories 2
8. Dimensions of entire new construction:Front 77.6' Rear 77.6' Depth
Height 28' Number of Stories 2
9. Size of lot:Front 140.22' Rear 164.07' Depth 295.78'
10.Date of Purchase Name of Former Owner
11.Zone or use district in which premises are situated R-40
12.Does proposed construction violate any zoning law,ordinance or regulation?YES NO J
13.Will lot be re-graded?YES NO V Will excess fill be removed from premises?YES NO
19305 Sound Ave.
14.Names of Owner of premises Stuart Thom Address Southold NY 11971 Phone No. (631)504-8842
Name of Architect Address Phone No
Name of Contractor Address Phone No.
15 a.Is this property within 100 feet of a tidal wetland or a freshwater wetland?*YES V 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 V 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,)
{f S:
COIDNITY Of S_1 rb1S
Robert Wilson _being duly swom,deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)He is the Agent
(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 marmer set forth in the application filed therewith.
Swonn to before me this tl Y C E,"1 L.t b10 F1 C
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�N$tv Pubbe Signature of Applicant
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