HomeMy WebLinkAbout52947-Z �e 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#: 52947 Gate: 05/05/2026
Permission is hereby granted to:
Robert Milstein
80 Beverly Rd
Southold, NY 11971
To#
Legalize as-built alterations to an existing single-family dwelling as applied forto include window/door
replacements and a mini-split HVAC system. Floodplain development permit application is required.
Premises Located at:
80 Beverly Rd, Southold, NY 11971
SCTM#52.-2-39
Pursuant to application dated 04/24/2026 and approved by the Building Inspector.
To expire on 05/04/2028.
Contractors:
Required Inspections:
Fees:
As Built Alteration $500.00
CO-RESIDENTIAL $100.00
Flood Permit $150.00
Total $750.00
Building Inspector
Y TOWN OF SOUTHOLD--BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. 0. Box 1179 Southold, NY 11971-0959
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Telephone (631) 7 -1 02 Fax (631) 765-9502 htt: sI: � .sou , o dto . g�v
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only
I
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PERMIT NO Building Inspector: „III
Applications and forms must be filled out in their entirety. Incomplete
applications vu*ll not be accepted. Where the App lficant is not the owner,an
Ownee's Authorization form(Page 2)shall be completed.
Date:
OWNER(S)OF PROPERTY:
Name: 66c4fI SCTM #1000- �- -- 3 4�
Project Address:
- -------------------- -
Phone#: Email:
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Mailing Address:
..............
CONTACT PERSON:
Name:
............
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o
Mailin Address, ,+
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Phone#: Email-
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address: ��
Phone#. __ . Email:
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CONTRACTOR INFORMATION
Name:
:
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Mailing Address ,():� , /1-77 C
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Phone#: Email: jjJy c sa"litt l
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DESCRIPTION OF PROPOSED CONSTRUCTION
stIated Cost of Project:CWAddltlon C�AIto atIonRe airDe Dirtio�
Other ,,L,eWill the lot be re-graded? [:]Yes C-1 No 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? OYes ❑No IF YES, PROVIDE A COPY.
Ncheck Box After Reading: The owner/contractor/design professional is responsible for all drainage and storm water issues as provided by
Chapter 236 of the Town Code. APPLICATION 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,S uffol k,,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 A 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 Section'210.45 of the New York State Penal Law.
� I .�
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Application Submitted By(print name): TOwner
ElAuthorized Agent
Signature of Applicant: Date:CONNIE D.BUNCH
Notary Public,State of New York
STATE OF NEW YORK) No.01 BU6185060
Quallfied In Suffolk County
S S Commis.slon ExpiresApril 14,2(e)o)y
pr"O
COU NTY OF t
0 t5k 61-1� being duly sworn, deposes and says that (s)he is the applicant
(Name of individual 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/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
d
y
2 l' if Notary Public
PROPERTY OWNER AUTHORIZATION
(Where the applicant is not the owner)
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
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