HomeMy WebLinkAbout53195-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#: 53195 Date: 08/11/2026
Permission is hereby granted to:
Marjorie T Mysliborski
c/o Elmcroft of Bella Vita
Venice, FL 34292
To:
Construct"in-kind"window and door replacements to an existing dwelling as applied for.
Premises Located at:
75 Midland PI, East Marion, NY 11939
SCTM#38.-3-10
Pursuant to application dated 07/27/2026 and approved by the Building Inspector.
To expire on 08/10/2028.
Contractors:
Required Inspections:
Fees:
Single Family Dwelling Alteration $250.00
CO Single Family Dwelling-Addition/Alteration $100.00
Total S3350.00
Building Inspector
Fc t ;A 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://www.southoldtowitn ov
Date Received
APPLICATION FOR BUILDING PERMIT
For Office Use Only E
PERMIT NO. Building Inspectrtr: JA
— W r 7 ")f ,�,
�.�)216
Applications and forms must be filled out in their entirety. Incomplete
applications will not be accepted. Where the Applicant is not the owner,an Building Iaeparfinent
Owner's Authorization form(Page 2)shall be completed. T°wn of Southold
Date:
OWNER(S)OF PROPERTY:
Name: �i`� I� Je�1.1 +i L�u.� L�, SCTM # 1000-
Project Address; 1 " �, � Q �( ✓
Phone#: 1-7 N-1 Email: 131 l' / fi0100ki
Mailing Address:
CONTACT PERSON:
Name: I /
Mailing Address: 11702
Phone#: LI Email: 1d1� 1 M'6JAJr144#7 L( �0, , 1
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address:
Phone#: Email:
CONTRACTOR INFORMATION:
Name:
Mailing Address:
Phone#: "�1� ��' Email: i
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition E]Alte ratio nXRepair ❑Demolition Estimated Cost of Project:.
El other )Y'") k
$ _.. c�
Will the lot be re-graded? ❑Yes<No Will excess fill be removed from premises? Dyes XNo
f
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? Dyes ❑No 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 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 construction 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
punishable as a Class A misdemeanor pursuant to Section 210.45 of the New York State Penal Law.
Application Submitted By(print name): �c C l Al( QUA` 1 Authorized Agent Owner
t- 'S OLv T 1 a Ivy
Signature of Applicant: Date:
STATE OF NEW YORK)
. SS`
COUNTY OF `�
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 ayid�gmake a d file this
application; that all statements contained in this application are true to the best of his/her lgled e a belief; and
that the work will be performed in the manner set forth in the application file there ' h,
Sworn before me this
day c-�of � � , ZD
Notary Public
Richard D.Noncarrow
Notary Public,State of Now Yorlit
No.01 NO62241
PROPERTY OWNER AUTHORIZATION Qualified in Suffolk Coul !
(Where the applicant is not the owner) My Commission Expires':Il'no .
1, 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