HomeMy WebLinkAbout52557-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
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#: 52557 Date: 12/17/2025
Permission is hereby granted to:
Monica Kelley
360 S Harbor Rd
Southold, NY 11971
To:
Legalize as-built mini split HVAC at existing single family dwelling as applied for,
Additional certification may be required.
Premises Located at:
360 S Harbor Rd, Southold, NY 11971
SCTM# 75.-3-7
Pursuant to application dated 11/10/2025 and approved by the Building Inspector.
To expire on 12/17/2027.
Contractors:
Required Inspections:
Fees:
As Built HVAC $500.00
CO-RESIDENTIAL $100.00
Total S600.00
Building Inspector
TOWN OF SOUTHOLD-BUILDING DEPARTMENT
411 Town Hall Annex 54375 Main Road P. O. Box 1179 Southold,NY 11971-0959
7v Telephone (631) 765-1802 Fax (631) 765-9502 litt s.//\vwNv.soutlioldtowyan .il.ov,
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only k
Y I
PERMIT NO. Building Inspector. V ( ,
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Applications and forms must be filled out in their entirety. Incomplete C? nt
e;„gym applications will not be accepted. Where the Applicant is not the owner,an i''1�'epa b"Me
PP P pP Eta,
Owner's Authorization form(Page 2)shall be completed.
Date:
OWNER(S)OF PROPERTY:
Name: SCTM # 1000-
ue 3
Project Address: 60 3oum "0'V60'r eocd S OI J J
Phone#: (O Wad.'- I q 4 1 Email: ��(�9 �� f' tm�, ', o
Mailing Address: 15
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CONTACT PERSON:
Name: �
Name: (`��niC�A O
Mailing Address: 155 r— L4 V'11 St '' Nl�e'u.1 Ac. ` NY D'�) u
Phone#: �6Z- �� � Email: Vr0 (& 0&m 4mo 11 ISO-M
DESIGN PROFESSIONAL INFORMATION:
Name: Wl
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name,.
1 +
Mailing Address: -2® �. 2 flqoTf KW 404 cUP S N
Phone#: 1� Email: I 't K OJO(od f I00� mat I,(0a)
DESCRIPTION OF PROPOSED CONSTRUCTION
t.3ther ructure ❑Ad dition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Project:.
❑New St
Will the lot be re-graded? ❑Yes o Will excess fill be removed from premises? ❑Yes ❑No
1
PROPERTY INFORMATION
Existing use of property: ` Intended use of property:
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
this property? ❑Yes No IF YES, PROVIDE A COPY.
Check Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provwed by
pter ka eTown Code. APPLICATION IS HEREBY'MADE to the Building Department for the issuance of a Building.Permit pursuant to the Building Zone
Ordinance of the T"n of Southold,Suffolk,Crounty,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 Class A misdemeanor pursuant to SectI042 ti.45 of the New York State Penal taw.
Application Submitted By(print frame): t,,:a/ d moy uthorized Agent ❑Owner
Signature of Applicantf / Date: /® lVo J w S
D.BUNCH
STATE OF NEW YORK) )CONNIE
y Public,State of New York
SS: No.01 SU6185050
COUNTY OF ) Qualified In Suffolk County
Commission Expires April 14, , 2-
A-
f ' being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing co/ntract)above named,
(S)he is the x-) r ",.
(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
L-hdayof "+... 20
Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
I, 1V residing at V 50 hul a oU
r.
� J e 1 �� ` ' �do hereby authorize ' to apply on
my beAelflo t; ib Town of Southold Building Department for approval as described herein.
N ✓�
N
r
wrier's Signature Date
Print Owner's Na4e
2