HomeMy WebLinkAbout53134-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#: 53134 Date: 07/16/2026
Permission is hereby granted to:
Erick Haas
1265 Park Ave
Mattituck, NY 11952
To:
Install an accessory generatorto an existing single-family dwelling as applied for.Generator must
maintain a minimum side yard setback of 10 feet.
Premises Located at:
1265 Park Ave, Mattituck, NY 11952
SCTM# 123.-2-28
Pursuant to application dated 07/29/2026 and approved by the Building Inspector..
To expire on 07/15/2028.
Contractors:
Required Inspections:
Fees:
GENERATOR $125.00
CO Accessory $100.00
Total $225.00
Building Inspector
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 htt s://ww.southoldtow n . o
Date Received
AFTLICATION R BUILDING PE
For Office Use Only
PERMIT NO. I Building Inspector. JU'N 2 9 2026
Applications and forms must be filled out in their entirety.Incomplete Building Department
applications will not be accepted. Where the Applicant is not the owner,an Town of Southold
Owner's Authorization'form`tl* 2)shall be completed.
Date:
OWNER(S)OF PROPERTY:
Name: .y SCTM#1000-
J
Pro ect Address:
role,
Phone#. 1 ' JZ Email: �S
Mailing Address:
CONTACT PERSON:
Name:
Mailing Address: � .
Phone#: 1
Email: �1��
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name:
Mailing Address:
Phone#: Email:
DESCRIPTION OF PROPOSED CONSTRUCTION
EINewStirtlaure ❑Add' ion ❑Alteration ❑Repair ❑Demolition Estjrr ated CostofProject:
Y11
Other
Will the lot be re-graded? ❑Yes VNo Will excess fill be removed from premises? ❑Yes OrNo
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 rNo IF YES, PROVIDE A COPY.
❑ Check 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 Departr cant for the Issuance of a wilding Permit pursuant w the Building Zone
Ordinance of the Town"of Southold,Suffolk,County,New York and other applicable Laws,Ordinances or Regulations,for the construction of bulYdle ,
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 buldingls)for necessary inspections.False statements made herein are
punishable as a Class A misdemeanor pursuant to Section 21GAS of the New York State Penal Law.
Application Submitted By(print name • I i �qetS ❑Authorized Agent 00wner
Signature of Applicant: CONNIE D.BUNCH Date:
ry Public,State of New York
No.01SU6185050
STATE OF NEW YORK) Qualified in Suffolk County
Commission Expires April 14, 2�
SS:
COUNTY OF
d m
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 bey'performed in the manner set forth in the application file therewith.
d n v.
Sworn before me this
�j
w�_ of �►� 20
Notary Public
PROPERTY OWNER AU MORIZATION
(Where the 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