HomeMy WebLinkAbout52312-Z TOWN OF SOUTHOLD
' BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, NY
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES
WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS
UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)
Permit#: 52312 Date: 10/02/2025
Permission is hereby granted to:
Lambertsen Rev Living Trt
211 N Carmel Ct
Vero Beach, FL 32963
To:
Install HVAC to existing single family dwelling as applied for..
Premises Located at:
380 Gin Ln, Southold, NY 11971
SCTM#88.-3-6
Pursuant to application dated 08/18/2025 and approved by the Building Inspector.
To expire on 10/02/2027.
Contractors:
Required Inspections:
ELECTRICAL- ROUGH, PLUMBING, ELECTRICAL- FINAL, FINAL,
Fees:
CO-RESIDENTIAL $100.00
HVAC $250.00
Total $350.00
Building Inspector
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TOWN OF SOUTHOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. O. Box 1179 Southold, NY 11971-0959
Telephone (631) 765-1802 Fax (631) 765-9502 litt ://ww ,sotjtlioldt+ wilil ,.ov
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only
PERMIT NO, /v N Building Inspector;,
Applications and forms must be filled out in their entirety.Incomplete
applications will not be accepted. Where the Applicant is not the owner,an .own of Southold
Owners Authorization form(Page 2)shall be completed.
Date: 4�/J I /8- a 002 1-
OWNER(S)OF PROPERTY:
Name: 0A1 V tfIGk Lam :r" . "e.n SCTM# 1000-
Project Address: 3 g 0 &i-ei .Qh e. So✓�-A o ld
Phone#: �5-1&-- Sa -I U Email: v 1 a-,44 b r r- 6f) ® I-'L& e-0M
Mailing Address: --k1d44 AO-rA-S,-n69"af L/I
CONTACT PERSON:
Name: �j GI�VI hQ►' Sev�
Mailing Address:
Phone#: s/r—5a y_/ppq Email
DESIGN PROFESSIONAL INFORMATION:
Name: A,R,
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name:
Mailing Address.
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition 1 Wteration -IRpnair ❑Demolition Estimated Cost of Project:
Other _#k/ �- O 000
Will the lot be re-graded? ❑Yes ONO Will excess fill be removed from premises? ❑Yes El No
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PROPERTY INFORMATION
I
Existing use of property: h 061Se. Intended use of property: ,5etlne—
Zone or use district in whichpremises is situated: Are there any covenants and restrictions with respect to
�C25Ide �1TIt� this property? OYes>�No IF YES, PROVIDE A COPY.
❑ Check Box After Reading. The owner/contractor/design professional is responsible for all drainage andestorm water issues as provided by
Chapter 26 of the Town Code. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone
Ordinartee,of,the Town of Southdrd;Suffolk,-County,New York and other applicable Laws,Ordinances or Regulations,for the construction of buildings,
additions,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(s)for necessary inspections.False statements made herein are
punishable as a Mass A misdemeanor pursuant to Section 210.45 of the New York State Penal Law.
Application Submitted By ri. Y
e V Y(p nt name): ' �(,�{ j>v® �%"I ❑Authorized Agent Owner
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Signature of Applicant; ' Date:
CONNIE D.BUNCH
Notary Public,State of New York
STATE OF NEW YORK) No.01BU6185050
SS: Qualified in Suffolk County
COUNTY OF ) CoMrniAion Expires Aprfl 14,2�.
being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
(S)he is the Q ,,6
(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/her knowledge and belief; and
that the work will be performed in the manner set forth in the application file therewith.
Sworn before me this
Qd—aly of I � QJ 0
Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
I, residing at
do hereby authorize to apply on
my behalf to the Town of Southold Building Department for approval as described herein.
Owner's Signature Date
Print Owner's Name
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