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Home My WebLink About11564-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy No. Z.1.1.251 .......... Date ..... .Qc t,o~o.e.e...13 ................ 19 .$.~ THIS CERTIFIES that the building ................................................ 70 Boisseau Avenue - . ............... S. .... Location of Property . .55765 ............... :. ~.a,q House No. Street Hamlet County Tax Map No. 1000 Section . .Q6 3 ....... Block . . .q3. .......... Lot .... 0..0.8 .......... Subdivision ..... X ......................... Filed Map No..X, ...... Lot No....X .......... conforms substantially to the Application for Building Permit heretofore filed in this office dated · . Fe.b. nua~'y.. 16 ...... , 19 B.2~ pursuant to which Building Permit No... 1. .15.6.4...Z ........... dated ..... ~'.e b~'u.a.e, y..1.9. .........19 .8.2., was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ......... .......................... a..e.~ ~.1. ~ .~p?.e., .................................... The certificate is issued to ........... ~[~.~ J.O./~.hq .mp.s. qn. ............................... (owner, I~ ~r-t~ne~t~ of the aforesaid building. Suffolk County Department of Health Approval S.-.5 0 ,..$./. l $/.8.2. ~..R.q b..~ :..A.: . .V.i.l. 1..a ~..~.: .~: UNDERWRITERS CERTIFICATE NO ........ p.~12qt ;[lrl.g ................................. Building Inspector Rev. 1/81 BE KEPT ON THE PREMISES (THIS PERMIT MUST COMPLETION OF THE WORK AUTHORIZED)~! UNTIL F JLL Building ~nspectO~ BUilding Irlspector. Fe~ '""""-- :' · . pERMIT IN]cLUDEs APPROVAL TO R~.MOyE £XCESS FILL ~OM ASov~ ,a~,s~s B~ R~GRADiNG ~OT ~ DKIv~WAY C~s~ucTiON ~ ~-;-, ~4kiSTRUCTION / C~LLAR cONSTRUCJ~~ FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall $outhold, N.Y. TEMPORARY Certificate Of Occupancy No..T.. g.1.1. 159 ...... Date ..... ~,ug, uA 4. ~75. ................. 198¢. THIS CERTIFIES that the building ................................................ 70 Bolaseau Avenue Location of Property .. 55.7.65 ............... l~aS.n..~l;r~.~ ................. ~9~.t. llqlgl. House No. Street Hamlet County Tax Map No. 1000 Section .. 0fi.3( ...... Block ... 03. ......... Lot · · · .0.0.~ .......... Subdivision .... Z .......................... Filed Map No.. ~ ...... Lot No...X. .......... conforms substantially to the Application for Building Permit heretofore filed in this office dated ·..F..e Or,.ay. y..1.6· ...... 19.8gpursuant to which Building Permit No .... 1.!5.6.4. .g. .......... dated .... F.e br.u.av, y..1.9. ........... 19.6g, was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ......... ............. ~, .r.e.t~il. Is.t.c~'e.. ................................................. The certificate is issued to .... .Iy.w..i.n..T.h. 9.m.p.q .o.n ...................................... (owner, Iossee.ee',te~aotJ- of the aforesaid building. Suffolk County Department of Health Approval . S, 5.0 ~. B./. 13/B~. ~. Rt~.h t ,. 14. ~. ViLla ~. -P. ~15. UNDERWRITERS CERTIFICATE NO ......... pex~d in& ................................ This Temporary Certificate of Odcupancy is valid for 30 days from the date of issuance,(through September 24, 1982.) Building Inspector Rev. 1/81 FORM NO, 6 TOWN OF SOUTHOLD Bu ilding Department Town Hall Southold, N,Y, 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted in duplicate to the Building Inspec- tor with the following; for new buildings or new use: 1, Final survey of property with accurate location of all buildings, property lines, streets, and unusual natu raj or topographic featu res. 2. Final approval of Health Dept. of water supply and sewerage disposal-(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings. Multiple Residences and similar buildings and installa- tions, a certificate of Code compliance from the Architect or Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of peoperty showing all property lines, streets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspectipn of buildings or premises, or other pertinent informa- tion required to prepare a certificate. / Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use 3. Copy of certificate of occupancy $1.00 $5.00 New Building ..... ~ ..... Old or Pre-existing Building(Z) .. ......... =/Vacant Land" . Location of Property .... .~'~_-.."~..D?'.... j~) ~ ! ~ .~. ............... ~.~. c.¢.-~?.~-~... [. ~ .... House No. Street Ham/et Owner or Owners of Property .//~.~.~./..~. / >.~.~._z:~ .?,z'2 ./+T:.....~./..~...~/~..~.~'?.~.. County Tax Map No 1000 Section ....~?.('~.. ~ ..... Block .. ~. i:~.'. ....... Lot...(~...Z__J..~. ....... ./ Subdivision ......................... Filed Map No ........... Lot No .............. Permit No../../.~...~'~ .~. , Date of Permit .......... Applicant .~. ~.(~./. '.z~.....~..~...~.~..Z. ~../'~.. .... Health Dept. Approval .... ~ .................. Labor Dept. Approval ...................... ~.. Underwriters Approval ... ~¢'.. .................. Planning Board Approval . k~. ............... ~ .., Request for Temporary Certificate ..................... Final Certificate ~ Fee Submitted $... '.~..~ ~ ..................... FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall SouthoJd, N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted in duplicate to the Building Inspec- tor witi~ the following; for new buildings or new use: 1. Final sunyey of property with accurate location of all buildings, property lines, streets, and unusual natural or tooograohic features. 2. Fina~ approval of Health Dept. of water supply and sewerage disposal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, industrial buildings, Multiple Residences and similar buildings and installa- tions, a certificate of Code compliance from the Architect br Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of peoperty showing all property lines, streets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent informa- tion required to prepare a certificate. / Co Fees: 1. Certificate of occupancy $5,00 2. Certificate of occupancy on pre-existing dwelling or land use 3. Copy of certificate of occupancy $1.00 $5.00 Date.. New Building ............. Old or Pre-existing Building(X) ......... = ZVacant Land ............. ' Location of Property . .~..?.f~-~.. ~v~).. .~ ....................... Hou~ No, ~ S~reet Owner or Owners of Property ~.~..~,. ' ~ GountvTaxMapNo..]OOOSeetion ..~, . .~. Block ............... Lot ................ ParmitSub~ivis~°n~.~... ................................. FUed Ma~No.~ "': ..... ~No__ ~ .............. ~ ~. ~p~o~.., ~.~.~ ............. ~ ~. ~o~ ..... ~- ............ ,.. Undemlr ters Approva ....... Planninn Board Annrm,~l Request for Temporary Certificate, .Final Certificate Fee ~ubmitted ~ ........................ FIELD 1. I~SPECTION COMMENTS FOUNDATION (1st) FOUNDATION (2nd) ROUGH FRAME & PLUMBING INSULATION PER N. STATE ENERGY C,ODE FINAL ADDITIONAL COMMENTS: PE,M ¢2d (9/eD) STATE OF NEW YoRK ~ DEPARTMENT O~ANSPORTA~ION Permit Fee ' $ 100,O0 , ~; ' *~ Total Received $ ~ ~ ~ Check or M.O. No. --~ HIGHWAY WORK PERMIT Liability I~surance Potic~ No. ..... Expiring ..... Disability Benefit Coverage Policy No. Per~ittee ~ [~[~ ~D S~ THO~S0~ ~ C~rgeable t~ Bond N~. Address 8~ TOpp~ ~ or Undertaking on File City R~ve~ead s~te NY Zip ~90t ' ~ WOrkmen's Cb~pen~tion p~licy :~o. Mai~ing Add[ess for Return of Bond or Deposit - ~{urn of Deposit Made Payable To: {C~mple~e only if different from above.) ~ ? , (Complete Only ~f Different From P ..... e) Name ~ Name; . Address ~ ~ AddreSs ~. ' C~ty, ~i,' ~ ; ; State _ Zip City ,~ ~ State r Zip Under ~he'p~ov~sion~ of the Highway ~aw or Vehicle & Traffic Law permission {~ h~rDby gra,te~e th~ permlttee to open the nZs 2, !~2~ ~:~se ~ohalt 1 1/2~ TOp (Hot mtxl. tn~emal,d~ a~c. ~ ~ottf~ :hi~_offiee p~r t~ ~s~r~ng construction. ,~ ~ , ; ? ~ - ] in the cobnty of t ~ as set forth and represente~ ~hcat~oa;' ' ~ at the pa~icular location or area, or over ~he teu~e~ as stated therein, if required; and or special, and methods of p~rformi~g work, if any; all of which are ~t forth,~n the apl Dated at Hauppau~e , , N.Y. Date Signed Feb~a~ IMPORTANT PERMIT, WITH APPLICATIONAND DRAWING I !SHALL BE PLACED IN THE HAH D~S OF TH, E cONTRAd,'F0 , ~ - SH No. 8229 Est, ~mpl,'Date 0551 /Permit NO, X-81--- Deposd: Rec. for $ Check ?r M O. No _ Dated . 3,000 NoTicE +~li is absqlutely necessary that the permittee notify ' 'H '"i ! ' Thyber,q~, ,1~$ DOT ' ~,~¢ev~Vp~Englneer, whose address i~ ~YS' 0,~i e Bidg.'~etS~rial H~y.~Hauppauge '~4 h~,: mat~cat~on mm~d TeLNo. ~7~1~ before w~tk is sta~ed and upon tscompeton NY The J~uing authority rese~es the r~ght to suspbnd or revoke this permit, at its discretio~ wi~hout a he~rih~;or th~ necessity of showing cause, either 1178~ ~f~r~.or du~n~ the op~ratio~, authorized. ~ ; *' ~ . - T~e"Permittee ~will cau~ an approved copy of the application to be and remain attac~ed~he~to until all work under the permit is satisfactorily com- pleted, in a~co~dance w~th the terms of the attached application. ~ - (SEE OTHER SIDE) )PIESTHEBEOF) IiBEFORE ~NY WORK IS STARTED. HENRY E. RAYNOR, Jr., Chairman JAMES WALL BENNETT ORLOWSKI, Jr. GEORGE RITCIIIE LATHAM, Jr. WILLLLM F. MULLEN, Jr. T~VN OF~'SO~' '[HOED SUEFODK C( NT, Y Southold, N.Y. 1 1971 TELEPHONE 765-1938 July 7, 1982 Mr. Irwin Thompson 82 Topping Drive Riverhead, New York 11901 Re: Irwin Thamp~on Site Plan Dear Mr. Thompson: Pleae let this confirm our conversation this morning regard- ing the curb cut on the Main Road and the additional curbing on the west of your construction site. The following action was taken by the Southold Town Planning Board, Tuesday, July 6, 1982: RESOLVED that the Southold Town Planning Board approve the amendment on the site plan of Irwin Thompson to r__ealign the existing curb cut approximately four feet east of that which is designated on the approved map, along with additional curb- ing and sidewalk to be placed west of the construction site; east of Boisseau Avenue. We would request such amendments to be designated on the filed map for our records. If you have any questions, please do not hesitate to contact this office. Very truly yours, HENRY E. RAYNOR, JR., CHAIRMAN SOUTHOLD TOWN PLANNING BOARD cc: Sup't of Highways By Susan E. Long, Secretary NL~/ YOHr~ DEPARTMENT OF TRANSPORTATION Reg~o~110 Office: New Yolk S~ate Ofhce Building Veterans H~ghway, Haupp~uge, New York 11787 Dale: August 17, 1982 Building Department Main Road Southold. N.Y, ilO71 Re: ?ermit # 81-0551 - open the n/s Route 25 e/o Boissea'~li Ave.~ SOUTHOLD for the purpose.__ of installing..one 30' curb cut~ remove old and install new curb and sidewalk, etc. We have no objection to the lssuance of a Certificate of Occupancy for tha BUILDING located at the above noted site. This is not, in any way, to be construed as final acceptance of the work required under the State Highway Wurk Permit, since all aspects of this work may not yet be satisfactorily completed. We thank you for your continued cooperation. Sincerely yours~ Regional Permit Engineer Region 10 HRT:RD cc: File DONALD A. DENIS A,I.A.. P.C. AQUEBOGUE $OUARE- RTE. 25 P. O. BOX 565 AQUEBOGUE. N. Y. 11931 May 4, 1982 Mr. George Fisher c/o Southold Town Building Dept. Main Road Southold, New York 11971 Re: Proposed New Building for Mr. Irwin Thompson NE Corner Main Road & Boisseau Ave. Dear Mr. Fisher: Please be advised that the use of PVC for the drainage piping on the above captioned project meets with our approval in lieu of the cement asbestos~piping, as indicated on the Drawings. Ve ! ;ruly yours, DAD/iv cc: Mr. Irwin Thompson 82 Topping Drive Riverhead, New York 11901 HENRY E. RAYNOR, Je,,Chairman JAMES WALL BENNETT ORLOWSKI, Jr, GEORGE RITCHIE LATHAM. Jr. William F. Mullah, Jr. T( LD Southold, N,Y. 11971 TELEPHONE December 30, 1981 Mr. George Fisher Senior Building Inspector Southold Town Hall Southold, New York 11971 Dear Mr. Fisher: At a regular meeting of the Southold Town Planning Board, Monday December 28, 1981 the following action was taken: RESOLVED that the site plan of Irwin Thompson be referred to the Building Inspector for certification, at which time the Planning Board can make a determination. I have attached the site plan maps for your review. Yours very truly, HENRY E. RAYNOR, JR., CHAIRMAN SOUTHOLD TOWN PLANNING BOARD Long, Secretary attch. TEL. 96S-2660 TOWN OF SOUTHOLO 1000344 THE NEW YORK BOARD OF FI'RE UNDERWRITERS BUREAU OF ELECTRICITY ]~ 8S JOHN STREET, NEW YORK, NE~V YORK 1OO:B8 ..re July 8, 1982 ~.plieati.n No. °.fie 162178-82 N 5 6 8 3 8 0 THIS CERTIFIES THAT only the electrical equipment ~ ~scr~bed be~ and introduced b~ t~ aoolicant named on the above ~plicatlon number in the ore~nises of ~s. T~r, ElS ~ivate ~., 300' S/O in thefoHowing location; ~ Basement ~ 1st FI. ~ 2nd FI. ~Si~ Section Block Lot was exatni.ed on July 1, 1982 aud found to be in co.~plia.ce with the rfquirements of this Board. FIXTURE OUTLETS DRYERS RECEPTACLES SWITCHES FIXTURES RANGES OVENS EXHAUST FANS FLUORESCENT SYSTEMS NO. OF FEET E R V I C NO OF CC, COND. PER ~ A, W.G. NO OF HI-LEG OF CC COND OF HI-LEG OTHER APPARATUS: 1-G.F.I. (~ Pool) This eer~ificate covers compliance a~ ~he da~e of inspection only. Bec~ase of unusual environme~r$ it is adv._sable to have frequent test and/or repairs r~ide by a qualified person. A. WG OF NEUTRAL 12 ~e~ sr., ..6~_' ,"i: .-. ~, , Port Jefferson Station, N.Y. 11776 L%¢:ll01E J CO~~EPARTMINT. tHIS COPY OF CERTIFICATE ~$~ ~OT ~Bl ~ R~ L AN HENRY E, RAYNOR, Jr,. Chairman JAMES WALL BENNETT ORLOWSKI. Jr. GEORGE RITCHIE LATHAM, Jr. William F. Mullen, Jr. Southold, N.Y. 11971 TELEPHONE 765- 1938 January 20, 1982 Mr. George Fisher Senior Building Inspector Southold Town Hall Southold, New York 11971 Dear Mr. Fisher: At a regular meeting of the Southold Town Planning Board, January 18, 1982 the following action was taken: Monday, RESOLVED that the Southold Town Planning Board approve the site plan of Irwin Thompson subject to the applicant receiving approval for a curb cut from the state. . ' ~ Yours very truly, HENRY E. RAYNOR, JRo, CHAIRMAN $OUTHOLD TOWN PLANNING BOARD cc: Irwin Thompson Mr. Irwin Thompson Proposed Retail Store February 12, 1982 ~?~,0, BeE 565 JOB N~'~i%~IR ~ 8103 3 Appli~9~for Building,Permit *TO BE NOTARIZED* 3 sets SIGNED & SEALED Architectural ~awings 1 Drawing 1 of 4 indicating Health Dept. ~.~ ......... 2 Highway Work Permits -THESE ARE TO BE GIVEN TO THE BUILDER BEFORE ANY WORK IS STARTED. HENRY E. RAYNOR, Jr., Chairman JAMES WALL BENNETT ORLOWSKI, Jr. GEORGE RITCHIE LATHAM, Jr. WILLIAM F. MULLEN, Jr. Southold, N.Y. 11971 TELEPHONE 765-1938 August 31, 1982 Mr. Victor Lessard Building Administrator Southold Town Hall Southold, New York 11971 Re: Irwin Thompson Site Plan Dear Mr. Lessard: The following action was taken by the Southold Town Planning Board, Monday, August 30, 1982: RESOLVED that the Southold Town Planning Board grant final approval on the site plan known as Irwin Thomps0n. e located at Southold, for the issuance of a final CO. cc: Irwin Thompson Very truly yours, HENRY E. RAYNOR, JR. , CHAIRMAN SOUTHOLD TOWN PLANNING BOARD y usan E. Long, Sec ~ LETTER OF TRANSMITTAL DONALD Ao DENIS~ AaIoAo~ PoOo BOX 565 Aquebogue~ New York 11931 Telo Noo: 516~722-3511 Gen'tlemen: We are enclosing herewith~ As Requested~/~ For Your Records~=~ For Your Use~ For Appr~ral~ For Your Review & Comments Shop D rawtngs~==~ Remarks= FOI~M NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. INSTRUCTIONS a. This application must be completely filled in by typewriter o~ in ink and submitted in tripilcote to the Building Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets o~ areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this application. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the work. e. No buiMing shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. 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 che construction of buildings, additions or 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 buildings for necessary inspections. (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. OWNER Name of owner of premises ........ ~.~win..,Th,o~p. sD~ .......................................................................................................... If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Plumber's License No. Electrician's License No. ?...~..a..~.k.....D..~...~.$~....Z...~.g.,....r. 290 Other Trade's License No ..............~r..%rr. ...................... 1. Location of land on which proposed work will be dqn_e. Mop No.: :..~.0...0.,0..~.~..3.~:.3..-..8. ........... Lot No ......................... Street and Number ..... ~N..~E.~Q~.e~i~.~D~is~e~u~.V~e~u.~3a~3~d.~..~.Y .................... Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ......... ..~.f~.~.F~-..~....~..g~.iD,a~. .................................................................................. b. Intended use and occupancy ~,etail B~s~ess ./~...~]'.~. ,.~;~/-'~: ~ ..AT.~.~..~..~.../.~ 3. Nature of work (check which iapplicable): New Building ....~..~...~.. ....... Addition .................. Alteration Repair Removal I Demol't~an .................... Other Work New ?arking Area ' J (Description) 4. Estimated Cost .....8...Z..0..0..~..0..0.,.0, ..................................... Fee ...~.......~..(~..,.~ ......................................................... : (to be paid on filing this application) 5. If dwelling, number of dwelling units ............................ Number of dwelling units on each floor ............................ If ga!age, number of cars ...... i ................................................................................... 6. If bgsiness, commercial or mixed occupancy, specify nature and extent of each type of use .~.e..~.a...i.~...~..~.,o.~.e 7. Dimensions ofex,sting' ' structures,~ If' any: Front ......... ~..5 ............... Rear ................................ 45 Depth .................... 25 Height 30' Numb:~r of Stories TWO (2) Dimensions of same structurel With alterations or additions: Front ...I..N..O.....C..~...A..~...G.~.I ........ Rear ............................ Depth ................................ Hreight ............................ Number of Stories ................................ 8. Dim<~nsions of entire new conbtruction: Front ......... .6...0..'. .................... Rear .......... .6..0..~ ............ Depth 80 ' Height 15' Number)of Stories ONE 9.' Size df lot: Front ....... ~. .4, .4. ,. ,,. .0 ................................... Rear ...... .2..2..~..,.Q.~.'. .................... Depth ..].53~99 ' irre,cj. ~ Cochran, Barbara & 10, Date' of Purchase December 17, 1980 Nome of Former Owner ..................... '~.':~:~'~.'"]B~'~'~' ..... 11. Zone or use district in which premises are situated .., .~,.-..~.,..~.~,~.~..e.~..~. .................................................................... 12. Does proposed construction vitiate any zoning Iow, ordinance or regulation: ....... ..N..O. ............................................ : YES 13. Will lot be regraded . .............. k ............ Will excess fill be removed from premises: ( ) Yes (~) No 14. Numeral Owner of premises ...,Z.~wjj~ .~homp. son Address ..~.,1..v.,e...~..~..e..~.¢...~.~. Phone No. ?2?-0210 Name':of Architect ...D...o..~.~.~.~.....A..:...D.,e.~..%.~.~....A..:..Z..:,.A..;.,.. Address ..A..c,[.~,e.b..o.g....~..e..l.....N.~ Phone No. 722-3511 ' . ........................................................... 1445 NY Avenue~, · 271-9402 Name of Contractor Jebc(~ Builders, Inc. Address ........... ~ ................ ,~.. I'ngne ixlo ....................... Huntzngton ~tatzon, J~LOT DIAGRAM NY 11746 Locate clearly and ~dJstinctly all buJJdJngs, whether exi.ctJng or proposed, and indicate all set-back dimensions from property lines. Give" street an~d b obl~ number or description according to deed, and show street names and indicate whether interior or corner lot, r ' **SEE SITE PLAN*? STATE OF INEW YORK, L e S COUNTY OF ...... S~.E~.Q~]I ......... ~ fi' ' IRWIN THOMPSON , . ................................................................................................. Dmqg duly Swam, deposes and says that he is the applicant IName of individual sig~[ng contract") above named. He is the OW.N. R j (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 ahd file this application; that all statement~ contained in this application are true to the best of his knowledge and belief; and thru fha wdrk will be performed in tee manner set forth in the application filed therewith. Sworn to before me this j ........ day of ......, , , ~ ELIZABETH/FIN NEVILLE ~iOTARY PuBLIc, State ~f New York . No, 52.$125EiSD, Suffolk I / PERM 33d (3/'81) RESPON,~BILITI'ES OF' PERMITTEE REVERSE 1. PROTECTIVE LIABILITY iNSURANCe: COVERAGE Permlttee must have protective li~J~illty ~n%~rance coverage in ~ccordanc~ wltJl Department requirements. (See motion on Protective Liability Insurance Required for Highway Wore Permits and/or Special Hauling Permits, Form PERM-27). Expiration of~ or lack of, liability insurance automatically terminates the permit. Insurance coverage may be provided by furnishing the Department with one of the following: a. A Certificate of Protective Liability insurance for Permits on State Highways (Form PERM 17, NYSDoT). b. A $2.50 remittance (check drawn on a New York State Bank or Certified) for coverage under the Departmental Blanket Policy. c, An Undertaking may be furnished by Public Service Corporations and Government Units only and Must include the wording required by the Department. 2. COMPENSATION INSURANCE AND DISABILITY COVERAGE The applicant is required to have compensation insurance end disability coverage as noted in the provisions of the Workmen's Compensation Lawand Acts amendotorythereof forthe entire period of the permit, or the permitis invalid. 3. NOT, IEtCATIONS Notify CommJssioner~ through Regional Office, one week prior to commencing work, except emergency work by public service utilities which should be reported the next work day. Work must start within 30 days from date of permit. Notify area gas distributors 72 hours prior to any blasting, Notify Utility Companies with facilities in work area (permission must be obtained before doing work affecting utillties~ facilities) before starting work. Notify land owners of abutting lands, before disturbing trees. Notify Department of Transportation at conclusion of work and return o~iginal copy of permit to Regional Office. Annual Maintenance Permit Notifications: Notify by telephone the District or Resident Office, one week in advance, each time regular maintenance work is to be performed. In emergencies, notification by telephone should be made the next work day. 4. SITE CARE AND RESTORATION An Undertaking, a bond or certified check in an amount designated by the Department of Transportation mai berequlred by theRegionaIOffice, before a permit is issued~ to guarantee restoration of the site to its original condition. Jf the Department is obliged to restore the site of its original condition, the costs to the Department will be deducted from the amount of the permittee's guarantee deposit at the conclusion of the work. The permittee is responsible for traffic protection and maintenance, including adequate use of signs and barriers during work and evening hours. Anyone working within the R.O.W. will wear an orange vest and hard hat. No unnecessary obstruction is to be [eft on the pavement or the right of way or in such a position as to block warning signs during or between work hours. No work shall be done to obstruct drainage or divert oreeks, water courses or sluices onto the right of way. All falsework must be removed and all excavations must be filled in and restored to the satisfaction of the Regional Traffic Engineer. 5. COSTS INCURRED BY ISSUANCE OF THIS PERMIT Alt cos~s beyond the limits of the protective liability insurance, surety deposits, etc., are the responsibility of the permittee. The State shall be held free of any costs incurred by the issuance of this permit, direct or indirect. 6. SUBMITTING WORK PLANS The applicant will submit work plans and/or a map as required by the Department. This shall include such details as measurements of driveways with relation to nearest corner, positions of guys supporting poles and a schedule of the number of poles and feet of excavation necessary for completion' of the work on the State right of way. A description of the proposed method of construction will be included. Plan work with future adjustments in mind, os any relocation, repJecement or removel of the inst~iJation auth~ized by this permit and made necessary by future highway ma. intenance~ reconstruction or new construction, will be the respon- sibility of the permlttee. Thepe~mittee must coordinate his work with any sfa~'e c.enstruetion being conducted. 7. TRA, FFIC MAINTENANCE Traffic shall be maintained by the permittee on the highway, in a~ safe manner, during working and non-working hours until con- struction is completed. Suitable safeguards, to reduce' ¢ondltiens dangerous to lite, limb and property to a minimum, must be pTa- vided by the permittee (including flagmen when requested by the Depar'~ment). 8. COST OF INSPECTION AND SUPERVISION If~ in the accounts kept by the Department, costs of supervision are found to be exceedingJy high, the Department serves the right to bill the permitfee for actual expenses incurred by the supervision and inspection of the permi,ffee~s protect. 9. SCOPE a. ~reas Covered Permits issued are for highways, bridges and cuiverts over which the New York State Departn?nt of Transportation has jurisdiction. (Local governments issue permits for their own jurisdict[od'~) ~ b. Legal The privilege granted by the permit does not authorize any infringement of federal, state or local laws or regulations, is limited to the extent of the authority of this Department in the premises and is transferable and assignable only w~th the written consent of thelComm~ss~onerk)~Tr(~n.spor_t?t~on.. c. Commissioner's Reservatien~ TheCommi?sioner afl Transportation reserves ,ti, he right to modify fees and to revoke or annul the permit et any time, at his discretion without a hearing or the necessity of showing cause. d. Locations Work locations must meet approval of the Department. (Additional pages to this application vary according to the purpose, and type of work to be permitted) PERM 33d (3/81 1 1. Requested duration from 19 2. Protective Liability Insurance covere' by policy No. 3. Workmen's Compensation Insurance p~l[cy No. Application Is hereby made for a hlghwa work permit TRt~Ii~t AI~D $/~IDRA Tfl011PSON 8Z Topp~ngs D~t~ : Rtven~ead, ~t.Y. 1190~ STAT~ OF NEW YORK- DEPARTMENT OF TRANSPO?TATION HIGHWAY WORK PERMIT APPLICATION FOR NON-UTILITY WORK Highway Permit No. Effective Date ENTER NAME AND MAILING ADDRESS IN THIS SPACE _1 IB0~ID: 1~3,000 //719831 Indef, thru DisabifH' Benefits Covera~ Policy PREPARE 3COPIES X~1-~I 19-- , to apply to the operation(s) checked below: ; expires on 19 expiring Check Type J Permit I Show Ins. Fee in! 'oral Amount,I Guarantee ' Fee Alt. or PERM- of Pea and/ Deposit Amount of Operation, J 17 pr Under- or Insurance and/or Bond ~ taking on file [~4. Single iob- Permit issued for each joi [] a. Driveway or roadway ~] Private j NC [] Subdi¥ision Street J $200 [] Temporary access road orjstreet -- -- . $ 20 [] b. Improvement [] Private ! N c [] Commercial Check additional description ~elowJ [] Install sidewalk, aurl~, paving, stabilized sboulder~d?ainage, etc. [] Grade, seed, improvejjand contour, clear land of brush, etc. ]Resurface existing roadway or driveway [] Removal or planting! [~Traffic control signals ! $200 E~ Warning and entrance si!ns $ 20 "~] 5. One permit issuance which remaln~ in effect indefinitely and $ 20 '-~]6. Compulsory permit required whenw~rk performed []Demolition [] Movllng NC TOTAL PAID i To open the n/s Route ~§ e/o Boisseall Ave., SOUTHOLD for Work may be described briefly as foH?ws= the purpose of Instal)tnB one ~' cu~ cut, remove old and install new curb a~d sidewalk, asphalt replacement tn Shoulder area will be 2 1/2" Base Asphalt 1 1/2" Top (Not mix), 'tntemal dretnage etcl.' Nott~ this office ~4 hrs. D~r to sta~ttn~ construction. [] Additional work description is attached;, [] Plans pages and/or,..~(~(~-I Mop is filed showing work to be performed at: LOCATION ( ~ ~ ~ State ~.~)h~(~)~.~ County of and) station " ,,- in tho Town of known as I Acceptance of the r~ed permH ~he permitter So~ restrictions, regulations and obligations stated on this application and on the permit. ~ Applicant Slgnatur~ ~/1~ ~ ~Date of Appllcatlon~ ~[~.~g[o n~ No, 19__ t EngineerApproval recommended ~m ~ Ap~rove~~19~~ By Regional Traffic Engineer. L ~41r Ill co,'pT, co,~T T~T d TF---CbT k oLF_. AP,"~,~O;'Z.D AS NOTED NOT~BUILDING DECARTMENT AT 7&54809 9 AM TO 4 PM FOR THE FOLLOWBIG IWqPECT]ONS: 1. FOUPnAmION _ TWO REQUIRED FOR P ~U:YD coKrCRETE 2. ROUGH - FRAMBfG & PLUMBING 3. IMSULATiOhl 4. FINAL - CmNSTRUCrbN MUST BE Co~nLFTE FOR C O ALL CONSTRrlCTION SHALL bFFT THE REQUIEHENTS OF -FFF N Y STATE CONSTRUCTION & Ehr~0Gy CODES. NOT RESPONS$_E FOR DESIGN OR CONSTRUCT/ON ERRORS DONALD A. DENIS A.I.A., AI:ICHI TECT M~ r¢,~I ~'~F DONALD A. OENI9 A.I.A.~ I~.C. ARChlI.T EE CT II