HomeMy WebLinkAbout1000-114.-11-5 S,bF
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FOR INTERNAL USE ONLY M,(�KEOWMB
SITE PLAN USE DETERMINATION AY 14 2D26
011THOLD TOWN
BOARD
Initial Determination
I'� Date Sent:
Date: S �
Project Name. �
Project Address: AIL
II ) r Zoning Dist rict;
Suffolk County Tax Map No.: 1000-�! -�- �
A 0
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Request:
osed use or uses should
(Note: PY Co of Building Permit Application and supporting documentation as to prop
be submitted.)
Initial Determination as to whether use is permitted:
Initial Determination as to whether site plan is required:
Signature f Building Inspect r
Planning Department (P.D.) Referral:
Date of Comment:
P.D. Date Received-
Comments:
Signature of Planning Dept. Staff Reviewer
Final Determination
Date: ____/_�
Decision:
Signature of Building Inspector
i
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TOWN OF SOUTHOLD BUILDING DEPARTMENT
Town.Hall Annex 54375 Main Road P. 0. Box 1179 Southold,NY 1197 1-0959
�. Telephone (631) 765-1802 Fax (631) 765-9502 ht!ps://www.southoldtownity.crov
Date Received
APPLICATION FOR BUILDING PERMIT
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For Office Use Only r
PERMIT NO. 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
Owner's Authorization form(Page Z)shall be completed.
Date:
OWNER(S)OF PROPERTY:
Name: . � SCTM # 1000- Z-1
C—ce M V_C.;
Project Address: - -2
Phone#: � Email:
/JC Z
Mailing Address: a t
CONTACT PERSON:
Name: A o
Z...
Mailing Address:
Phone#; fqj� L
Z Email:
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name:
Mailing Address:
s
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition []Alteration [:]Repair ❑Demolition Estimated Cost of Project:
❑Other
Will the lot be re-graded? El Yes El No Will excess fill be removed from premises? ❑Yes ❑No
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hiding epartmeut Applicallon
AUTHORIZATION
(Where the Applicant is not the Owner)
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A resi ing at
Print property owner's name Ma i l in} ( g Address)
�o hereby au th y ors ze Af�r�
(Agent)
to apply on my behalf to the
Southold
Building Department. -•
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(OvVer's Signature) Y
(Date) Y��
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(Print Owner's Name)
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