HomeMy WebLinkAbout53289-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#: 53289 Date: 09/18/2026
Permission is hereby granted to:
David Surozenski
39765 CR 48
Southold, NY 11971
To:
install window and door replacements to an existing single-family dwelling as applied for.
Premises Located at:
39765 CR 48, Southold, NY 11971
SCTIVI# 59.-9-30.1
Pursuant to application dated 09/03/2026 and approved by the Building Inspector.
To expire on 09/17/2028.
Contractors:
Required Inspections:
Fees:
Single Family Dwelling- Alteration $250.00
CO-RESIDENTIAL $100.00
Total $350.00
Building Inspector
Ffi
� d 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 litt :H ww1%a.Southoldtouwnn . -oN,
Date Received
APPLICATION FOR BUILDING PERMIT 4 �
For Office Use Only
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 boa t
Owner's Authorization form(Page 2)shall be completed. loo
"tom
63
Gate:8/28/2026
OWNERS)OF PROPERTY:
Name:Monica Surozenski SCTM# .000-
A
Project Address:39765 Rt 48 Southold, NY 11971
Phone#:(631)445-0497 Email:msurozenski@yahoo.com
Mailing Address:
CONTACT PERSON:
Name:Lindsay Loson
Mailing Address:2029 New Highway Farmingdale, NY 11735
Phone#:3153358730 Email:rli-39765route_bpwd@permitflowteam.com
DESIGN PROFESSIONAL.INFORMATION:
Name:
Mailing Address:
Phone#: �11
:
CONTRACTOR INFORMATION:
Name:RENEWAL BY ANDERSEN OF LONG ISLAND
Mailing Address:2029 New Highway Farmingdale, NY 11735
Phone#:631-843-1713 Email:rli_39765route_bpwd@permitflowteam.com
DESCRIPTION OF PROPOSED CONSTRUCTION
❑New Structure ❑Addition RAlteration ❑Repair ❑Demolition Estimated Cost of Project:
Mother $15,042.00
Will the lot be re-graded? []Yes ®No Will excess fill be removed from premises? E]Yes RNo
Page i of 24
PROPERTY INFORMATION
Existing use of property: Residential Intended use of property:Residential
Zone or use district in which premises is situated: Are there any covenants and restrictions with respect to
Southold this property? Dyes l@No IF YES, PROVIDE A COPY.
8 Check Box After Reading: The owner/contractor/design professional Is responsible for aq 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,Now 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 210AS of the New York State Penal Law.
Application Submitted By(print name):Lindsay Loson IIWAuthorized Agent ❑Owner
Signature of Applicant: o`Z 4,W44 oc won, Date: 08/28/2026
Nevada
STATE OF ft9)*)(QRV
SS:
COUNTY OF Clark )
Lindsay Loson being duly sworn,deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
(S)he is the Agent
(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
28th day of August 2026 40 A J / 01/07/2030
Notary Public
. r " Mark A 9raddy
NOTARY PUBLIC Notarized remotely using audio-video communication technology via Proof.
STATE OF NEVADA
"2 Appt.No,22.s937.01 PROPERTY OWNER AUTHORIZATION
Expires January7.2030 (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
Page 4 of 24