HomeMy WebLinkAbout1000-61.-2-7.3 FOR INTERNAL USE ONLY
.BAN 0 11.
DETERMINATION
PLAN USE DETERM wWI
SITE
initial Determination
n rf Date Sent: �.....
Date: � 31_ " 5
LLC� ..�. �_
Protect Name:
..
Project Address: _5 ���.....�.. .
Suffolk Count Tax Map No„ 100
B �l � �,J Zoning District:.�_mm
Suff y
Request'.
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(Note: Copy of Building Permit Application and supporting documentation as to proposed use or uses should
be submitted.)
Initial Determination as to whether use ispermitted: LL.,
..'��..�..�..�..,..�-� .�m_.�..__.�..�. � .. .��
Initial Determination as to whether site plan is required
J_
Signature o ui ding Inspect r
Planning Department (P.D.) Referral ..__.�._ ._._...� .. ...�.. .. .._. _.. .. ../ .. _. .. .__.
P.D. Date Received: _��
Date of Comment:
Comments; _._m...�.�..�.....Y...__....�...� �...�..,.�_
gnature of Planning Dept. Staff Reviewer
Final Determination
Date: _�—�.� . ....
Decision:
Signature of Building Inspector
str�s 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 ]ili)s,�aNv stzrltl oj(lt(: l�si
p ) )
Date Received
APPLICATION FOR BUILDING PERMIT
I ,
For Office Use Only
for°.Building Ins �1
PERMIT NO. R
Applications and forms must be filled out in their entirety. Incomplete
applications will not be accepted. Where the Applicant is not the owner,an
Owner's Authorization form(Page 2)shall be completed.
Date: / ✓ `I� Z
OWNER(S)OF PROPERTY:
Name: /� �. SCTM#1000- ®� r Z °�; go 3
Project Address: 5!f v'7 fj d2&A,/ / 5�y-ICV(�✓
Phone#: j) 0 7 7 Email:
Mailing A dress:
CONTACT PERSON:
Name:
Mailing Address:
Phone#: , 7 -7 Email: ire C �de`O:✓.�/c�, La�j
&3 - �1e
DESIGN PROFESSIONAL INFORMATION:
Mailing Address: 2, 10
Phone#: ® E m ail:
3
3�� zr9 3
CONTRACTOR INF
ORMATION:
Name: C-
Mailing Address: GJ-' j Gj O may, �j LQ v/�� �Y IV
Phone#: + �� _ r Email: 4 6 * �
DESCRIPTION OF PROPOSED CONSTRUCTION
[]New Structure Addition ❑Alteration ❑Repair ❑Demolition Estimated Cost of Proje
❑Other ..—.., I� y
Will the lot be re-graded? ❑Yes XNIo Will excess fill be removed from premises? XYes ❑No
1
PROPERTY INFORMATION
Existing use of property: - Intended use of property: 1, ccu "
�'o �� DG��1 CA
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
f this property? ❑Yes XNo IF YES, PROVIDE A COPY'.
Cite
Chapter ck Box
the Town Cod After il,e. diii '"u The owner/contractor/design professional Is responsible for all drainage and storm water issues as provided by
e. APP CATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone
Ordinance of the Town of Southold,Suffolk,County,New York and other applicable laws,Ordinances or Regulations,for the constructlon 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
u uant to Section 210.45 of the New York State Penal law.
Class A misdemeanor pursuant punishable as a Cla P
Application Submitted By(print name): C7)�Yir71Authorized Agent ❑Owner
Signature of Applicant:
Date: /:2
STATE OF NEW YORK)
S ' )
COUNTY OF t5-uJ 'l�
�7� v, h �r7h being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract) above named,
(S)he is then
(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
�j day of �" 20
° No tar blic
PR01)Il lk 'I ' o�"�'"Ir ((14,01 RZA If(� )
(
..__ µere t..W..�, ., ..
(Where he 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
2