HomeMy WebLinkAbout52993-Z TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Ila,
�¢ 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#: 52993 Date: 05/19/2026
Permission is hereby granted to:
Adam J Irving
PO BOX 301
Orient, NY 11957
To:
construct additions and alterations to an existing single-family dwelling as applied for.
Premises Located at:
75 5tephensons Rd, Orient, NY 11957
SCTM# 17.4-11.4
Pursuant to application dated 05/01/2026 and approved by the Building Inspector.
To expire on 05/18/2028.
Contractors:
Required Inspections:
Fees:
Single Family Dwelling- Addition &Alteration $406.50
CO-RESIDENTIAL $100.00
Lng
al 506.50
Inspector
� TOWN OF S�IT.�T'HOLD—BUILDING DEPARTMENT
Town Hall Annex 54375 Main Road P. 0. Box 1179 Southold,NY 11971 0959
�" vo 1tn �Telephone(631) 765-180►2 Fax (631) 765 9�02 °� pro
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only
w
q1
n
j PERMIT NO. Building Inspector:
01 A)111111111 (
u
Applications and'Forms must be filled out in their entirety.incomplete
applications will not be accepted. Where the Applicant is not the owner,an
, n
Owner's Authorization form(Page 2)shall he completed, .
G..............
..............ate: '5 2 0 (o
...............
OWN ER(S)OF PROPERTY:
Name: SCTM#1000- 1 -7
Project Address: ' 0.'' �i''"
Phone#: I qqq .. L Email: ►/M4'T) 1P4VJVtr& '��I &
Mailing Address: PJ zo &,
CONTACT PERSON:
.....Name: a
,�V � :IV
Mailing Address: o 3,01
Phone#: Small: lV)V& .n
6ep/f/6
DESIGN PROFESSIONAL INFORMATION:
Name:
' 0 Z.(f
+ � I�wI� �/ � � ,"+0116), r gyp ' 063
Marling Address: � ocil.� i P �,,•,- .1"'r�
Phone#: b3 j Email:�j 0 Z CA�4, R 6
CONTRACTOR INFORMATION:
Name: , "V
b
Mailing Address:
i
Phone#: Email
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ClAddition k'Alteration Repair ElDemolition Estimated Cost of Project-,
❑0th e r
i
Will the lot be re-graded? ❑Yes (No Will excess fill be removed from premises? nYes No
1
.............. ...........
PROPERTY INFORMATION
4", 1
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? ElYes 5dNo IF YES,PROVIDE A COPY.
heck Box After Reading: -me aww/cwtrattor/desjtoi,pro lowI Is responsible for all drahop and storm water issues as provided by
Chapter 236 of the Town Code.APPUCATION IS HEREBY MADE to the Building DepartnWat for the Issuame of a SuNding Permit pursuant to the suildins zone
CWdInafte of tho Town C4 SWAU%aws,SWU94 comft'r New Vwk v4 e0w wpV4t*b&e,Umr.%Ordiinant", at%"m%tiomo fw,**camokntio"of buklinpo
additions,alterations or for removal or demolition as herein described.YM opkant agma to comply wlth all applkable ordinances,buildlog code,
housing cod*and regulations and to admit auk dzecl htspectois on prenthm and In buildlogis)for necessary inspections.Patse statements made herein am
punishable as Class A misdemeanor pursuant to Section 21CLAS of do New York State PoW Law.
Application Submitted By(pri name,. DAuthorized Agent owner
14 1�>h/Vi O/wr
Signature of Applicant: Date:
CONNIE,D.BUNGH
Notary public,,,State,of Ne�w York
STATE OF NEW YORK) No,,01 BU61,8505,0
SS: 0,,utal1fied.1�n Suffolk,County
)IJ ly,
COUNTY OF Commi'sSion expjres April 140
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
�+-day of 20 /V
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 Owners Name
2