HomeMy WebLinkAbout53207-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#: 53207 Date: 08/17/2026
Permission is hereby granted to:
DeRose SR Rev Liv Trt
PO BOX 215
New Suffolk, NY 11956
To:
install window replacements to an existing single-family dwelling as applied for.
Premises Located at:
1415 Fourth St, New Suffolk, NY 11956
SCTIVI# 117.-7-3
Pursuant to application dated 08/03/2026 and approved by the Building Inspector.
To expire on 08/16/2028.
Contractors:
Required Inspections:
Fees:
Single Family Dwelling- Alteration $250.00
CO-RESIDENTIAL $100.00
Total $350.00
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 https://www.soutlioldtownii u'�.
s.MsJ^c�"s ri'.ti
Date Received
APPLICATION FOR BUILDING PERMIT
For office Use Only
PERMIT NO.__5%9��L Building Inspector. 3 N2
Applications and forms must be filled out in their entirety.Incomplete ttrnent
Applicant is not the owner,an ui9clin
Where the A �B �
Pons wiN not be accepted. pp ' +o
applrca r - you
Owner's Authorization form(Page 2)shall be completed. -town of
Date:
O ` R1S1 OF PROPERTY:
Name: CI M# 1R19Cb-
" .. . �.�
S .
Project Address:
S
G
Phone#: _ > _ Email ('z i � olC;N r 313 � �
s'. Cl_ ........... �,1 SU �.�5._ �... .S'�, ...
MailingAddres
CONTACT PERSON:
Name-
Mailing Address: �� S .. .,,
J 3 q
Phone#: Email: V i Cle n� 1 r
DESIGN PROFESSIONAL INFORMATION:
Name:
Mailing Address:
Phone#: Email:
,CO'�l T1 4wC1""OR iN FOIRF CII
Name: J... , �'� s .It .
�; �S lS�.� �� 6 7 el _,.
Mailing Address:. tt
Email: �, !' Z-C� e�oU, G c iti.
Phone#:.. ` � J,m C��,r .n n
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition ❑Alteration ❑Repa"r ❑Demolition Estimated Cost of Project:
I4...
� ,� $ ��
❑Other I� �.
Will the lot be re ,.,.. . _.,
-graded? ❑Yes�[plo Will excess fill be removed from premises? ❑Yes ❑No
1
PROPERTY INFORMATION
g property-v O'�S1dn�
Existing use of roert : . 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)21�No IF YES, PROVIDE A COPY.
❑ Check Box After Reading: The owr r/comractor/design profemional k responsible for all drainage aWstomrraWIssuesesprovi bff
Chapter 236 of the Town ibde. APPUCATIUN IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Blinding Zone
Qrdlnance of the Town of Southold,Suffolk,county,New York and other applcable taws,Ordinances or Regulations,for the oanstn ci`oni of buUngs,
addRions,alterations or farremavalAr dernoRtioh as herein described.The applicant agrees to conpty 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 230.45 of the New York-State Penal taw.
Application Submitted By(p rint ame): L ome_ n f\ e []Authorized Agent -wowner
Signature of Applicant: Date:
STATE OF NEW YORK)
SS:
COUNTY OF S 1 )
�� -p �`e-'NnP_�
t UI ,being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract) above named,
(S)he is the C)W h`P—r
(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 1
clay of J S T" 20_2_(�
Notary Public
MARIA PRIHAS GANLEY
Pubic-' State ofPROPER OWNER AUTHORIZATION Notary NO'o1PR5oo32 Gew York
Qualified in Suffolk County
(Where the applicant is not the owner) My Commission Expires Oct 19, 2026
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