HomeMy WebLinkAbout12449-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hale
Southold, N.Y.
Certificate Of Occupancy
No. 7.122,1.6 ......... Date .... J.~, .~.~.R.¥..25 ................. 19.8.{
THIS CERTIFIES that the building . .hl~W. DV/~II&Ih!G ................................
Location of Property ... 2,100..G.L$~'~..R.Q.~D. .............. .S.O..-t4T...H.O.L.D' .................
House No. Street Hamlet
County Tax Map No. 1000 Section .'. 0.7.2 ...... Block ..... 2 ......... Lot ..... ~8 ..........
Subdivision .hrl~IST..CREF.,.K .ES~PATES ......... Filed Map No.. 3.8.48..Lot No ..... 2.1, ......
conforms substantially to the Application for Building Permit heretofore filed in this office dated
.... 4Ulq~..21 .......... 19~t3. pursuant to which Building Permit No ..... .1.2 .4.4. 9. ~ ..........
dated ...... JLID.¥ · 28 .............. 19 .@3, 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 .........
.... ~or..a. n~.~t .on~ .family. d.w~i.qg .........................................
The certificate is issued to ... ROBERT .&, CAlgl. Lhl~ .['/;[~QN ............................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ....1,3.,-so,.,57 .............................
UNDERWRITERS CERTIFICATE NO... N..6.23 l~9.fi .....................................
Rev. 1/81
Building Inspector
I~OF,~ NO. 2
TOWN OF $O~JTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. ¥.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 12449 Z
Permission is hereby granted to:~_~ .
........ ~.~.~/~...././.~.~.../..~..c:...
...~~....~..~ ............ z~z
,o ......... ~.~.~.z.g.~.~ ...... ~....~.~.~.~....~.~gf~.....~.~ ..............
................................................ ~ ........ ~.~:.~.....~a~....L~L~.~ ..................
~,~,~,~,ed ~,....~z.aa ........ ~/~...~...., ........ ~-La~..~.~w
County Tax Map No. 1000 Section ..~...~..Z ....... Block ....~..~... ........ Lot No. ~.~.....~.. ..........
pursuant to application dated ......... .~.~/x~.......~./. ................ , 19.¢~,., and approved by the
Building Inspector.
Fee $..../....~........~... ....
Budding Inspector
Rev. 6/30/80
FORM NO. 6
TOWN OF SOUTHOLD
Building Depar'(men"~
Town Hall
Sauthotd, N.Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
This application must be filled in typewriter OR ink, and subr~itted 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
natural or topograohic features.
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.
4o Commercial buildings, Industrial buildings, Multiple Residences and similar buildings end instatla-
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.
For existing building:; (p~ior to April 1957), Non-conforming uses, or buildings end "pre-existing"
land uses:
1o 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 6f buildings.
3. Date of any housing code or safety inspection of buildings or premises¢ or other pertinent informa-
tion required to prepare a certificate.. /,
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
N ildi x. Old P isti g 8 ildi g(X) /Va ant L d
ew Bu ng ............ or re-ex n u n ......... ~ o an ............
Location of Property. 2~1~' Gl. on Road, Sout? old
Hous~ No. Street Ham/er
Owner or Owners of Property .... .Fp.b,e?.t and... .Ca~, iJj, e ,,,,..-Wllsqn.. ...............................
County Tax Map No 1000 Section . .. 72. . Block 2 Lot
Subdivision, W. est. Creek Estates 3848 21
................... Fil p No. .
........... ed Ma .......... et No ..............
Permit No. ........ ].2~.~9.Z Date of Permit 7./.2.8./.8.~..Applicant Riverside ........ Homes, Zr.~? .'
Health Dept, Approval ...~, .SO. ,5,7 .............. Labor Dept. Approval ...................... ~..
N6.23,1.96 Planning Board Approval
Underwriters Approval .......................................
Bequest for Temporary Certificate Final Certificat~ .x.
structton on above described b~e~ all es and regul, ations.
1035018 :
THE N£W YORK BOARD OF FIR£ UND£RWRIT£RS
~ BUREAU OF ELECTRIC!TY
~- 85 JOHN STREET, NEW YORK, NEW YORK 10038
.a,e November 11, 1983 ~p.,leati.. No. o. fle 227321--83 N 6 2 3 1 9 6
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the aboRe application nu tuber in the preo*ises of
R~ Wilson, S/S Glem Rd. 2070.57 E/O Bayvi~w Rd., Southold, N.Y.
in the followlng location; [] Basement [] 1st FI.
.~.sex,,,nl.edon November 3, 1983
F,XTORR ~XTURES
OUTLETS SWITCHES
FLUORESCENT
20 42 30 20
[] 2nd FI. Section Block
and found to be in compliance with the requirements of this Board.
rot 971
RANGES EXHAUST
DRYERS FURNACE MOTORS
APPLIANCE FEEDERS TiME CLOCKS MULTI-OUTLET
SYSTEMS
NO. OF FEET
DIMMERS
SERVICE DISCONNECT
OTHER APPARATUS:
Motor~: i~F
1-G.F.C.£~
1-fmoke Detector
S E
R 'V I C E
A.W.G NO, OF HI-LEG A,W.G. NO OF NEUTRALS A.W G
OF CC, COND OF HI-£EG OF NEUTRAL
1
1
1
Peter Charbonneau
35 Sheppard La.
Srmithtown, N.Y., 11788
LIC~ #2697
mvst not be altered in any manner; return to the office of the Board if
Inspectm may be
MANNER·
Riverside Homes, Inc.
P. O. BOX 274
1159WestAAain Street Riverheed, N. Y. 11901
Phone: 516 - 727-3395
December 15, 1983
Building Department
Main Road
Southampton, New York
11971
RE: Building Permit No. 12449Z
Gentlemen:
I understand that this house is approved for issuance
of C/O. I am enclosing herewith application for C/O and
the $5.00 fee required. Board of Health approval will fol-
low shortly.
I also enclose a copy of the Fire Underwriters Certif-
icate.
EC:jg
Enclosure
Sincerely,
E1i abe~~nnazaro
Riverside Homes, Inc.
P. O. BOX 274
1159 West Main Street Riverhead, N. Y. 11901
Phone: 516 - 727.3395
January 16, 1984
Building Department
Main Road
Southold, New York 11971
Re: Permit No. 12449Z
Gentlemen:
Enclosed please find final Board of Health approval in the
captioned matter. You have all other final papers.~ Please issue
Certificate of Occupancy.
Sincer~y,//~
Enclosure Eli~Cannazaro
TOWN O~..$OU~fl~OLD
FIELD ,{NSPECT~ON.~ '~
FOUNDATION (1st)
FOUNDATION (2nd)
2.
COMMENTS
ROUGH FRAME &
PLUMBING
INSULATION PER N. Y.
STATE ENERGY
qODE
FINAL
ADDITIONAL COMMENTS:
Riverside Homes, Inc.
P. O. BOX 274
1159WestMain Street Riverheed, N. Y. 11901
Phone: 516 - 727-3395
July 21, 1983
Building Department
Main Street
Southold, New York 11971
Attn: Mr. Hinterman
Re:
application for building permit
for Robert and Camille Wilson
Glenn Road, Southold
Gentlemen:
Enclosed are the surveys showing mean sea level elevations
as prepared by Van Tuyl surveyors. As you can see, near the house area,
we have 15 feet above mean sea level.
The lowest opening to mean sea level would be the Bilco door,
which would be on the southeast corner and would be approximately 10
feet above sea level. Please note that this elevation will be plus
or minus 1 or 2 feet; but please keep in mind that we will still be
well above the 8 foot minimum.
We would aprpeciate the Building Department issuing us a
building permit at this time so that we may go ahead with construction.
Thanking you in advance, I am
S~i~n~erely,
Riverside Homes, Inc.
P. O. BOX 274
1159 West Main Street Riverhead, N. Y. 11901
Phone: 516 - 727-3395
July 8, 1983
Building Department
Main Road
Southold, New York 11971
Re: Wilson - Glenn Rd off Bayview Rd, $outhold
Gentlemen:
Enclosed please find application for development permit
required by your office. I am including another copy of the survey,
and cross section, 1 copy of which was sent to you the other day.
DEC
I hope that this is what you are looking for, and we would
appreciate receiving the building permit ASAP.
Call if you need anything else.
Enclosures
Sincerely~
Eli~'abll~ A. Cannazaro
Riverside Homes, Inc.
July 6, 1983
Building Department
Main Road
Southold, New York 11971
Re:
Robert and Camille Wilson
Property on Glenn Road off
Bayview Road, Southold
Application for Building Permit
Gentlemen:
Enclosed please find copy of DEC approval, copy of cross
section of house with mean water indicated and copy of survey showing
elevations to mean sea level.
Enclosures
NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
0-83-0400
PERMIT
UNDER THE ENVIRONMENTAL CONSERVATION LAW
[ ARTICLE 15, (Protection of Waler) [] ARTICLE 25, (Tidal Wetlands)
ARTICLE 24, (Freshwater WetlalMs) La ARTICLE 36, (Construction in Flood Hazard Areas)
PERMIT ISSUED TO
Robert & Camille Wilson
~DDRESS OF PER~ITTEE
145 Adam Road, Massapequa, NY 11758
LOCATION OF PROJECT (Section of stream, tidal wetland, dan building)
West Creek off of Goose Creek, Lot 21 on west side of Glenn Road, 2,070 1.f. east from Bayview
DESCRIPTION OF PROJECT
Construct one family house 50' from Glenn Road and associated septic system; all parts of house
and septic system are to be within IZ/ 1,I. ct Glenn Road in accordance with plan submitted
May 13, 1983. There is to be no disturbance to terrain or vegetation greater than 147' from
Glenn Road by filling, grading, clearcutting or excavating without additional approval ~rom
NYSDEC.
COMMUNITYN~ME(City, Towo, VillaBe)
Southold
TC~oNuthold
COUNTY J FIA COMMUNITY NO. J DAMNO. PERMIT EXPIRATION DATE
Suffolk June 30, 1984
GENERAL CONDITIONS /'
1. The permittee shall file in the office of the appropriate Regional
Permit Administrator, a notice of intention to commence work at least 48
hours in advance of the time of commencement and shall also notify him
promptly in writing of the completion of the work.
2. The permitted work shall be subject to inspection by an authorized
representative of the Department of Environmental Conservation who may
order the work suspended it the public interesl so requires.
3. As a condition of the issuance of this permit, the applicant has ac-
cepted expressly, by the execution of the application, the full legal respon-
sibility for all damages, direct or indirect, of whatever nature, and by whom-
ever suffered, arising out of the protect described herein and has agreed to
indemmty and save harmless the State from suits, actions, damages and
cosls of every name and description resulting from the said project.
4. Any material dredged in the prosecution of the work herein permitted
shall be removed evenly, without leaving large refuse piles~ ridges across the
bed of the waterway o, flood p~ain or deep holes that may have a tendency to
cause injury to naviRable channels or to the banks of the waterway.
S. Any material to be deposited or dumped under this permit, either in
the waterway or on shore above high-water mark, shall be deposited or dumped
8. That the State of New York shall in no case be liable for any damage
or injury to the structure or work herein authorized which may be caused by or
result from future operatioes undertaken by the State for the conservation or
improvement of navigation, or for other purposes~ and no claim or right to
compensation shall accrue from any such damage.
9. That if the display of lights and signals on any work hereby authorized
is not otherwise provided for by law, such lights nod signals ~s may be pre-
scribed by the United States Coast Guard shall be installed and maintained
by and at the expense of the owner.
10. All work carried out under this permit shall be performed in accor-
dance with established engineering practice and in a workmanlike manner.
11. tf granted under Articles 24 or 25, the Department reserves the right
to reconsider this approval at any time and after due notice and hearing to
continue~ rescind or modify this permit in such a manner as may be found to
be just and equitable. If upon the expiration or revocation of this permit, the
modification of the wetland hereby authorized has not been completed, the
applicant shall, without expense to the State, and to such extent and in such
time and manner as lbe Department of Environmental Conservation may require,
remove all or any portion of the uncompleted structure or fill and restore the
site to its former condition. NO claim shall be made against the State of New
York on account of any such removal or alteration.
12. This permit shall not be construed as conveying to the applicant any
right to trespass upon the lands or interfere with the riparian rights of others
to perform the permitted work or as authorizinR the impairment of any rights,
title or interest in real or personal property held or vested in a person not a
party to the permit.
13. The permittee is responsible for obtaining any other permits, ap-
provals, lands, easements and rights-of-way which may be required for this
pro)ect.
14. If granted under Article 36, this permit is granted solely on the basis
of the requirements of Article 36 of the Environmental Conservation Law and
Part 500 of 6 NYCRR (Construction ia Flood Plain Areas havio8 Special Flood
Hazard, s - Buitding Permits) and in no way signifies that the project will be
free from flood, in8.
15. Ry acceptance of this permit the permittee agrees that 'the permit
is contingent upon strict compliance with the special conditions on the
reverse side.
95-~0-4 (9/75)
(SEE REVERSE SIDE)
,;?ECIAL CONDITIONS
16.
A copy of plan submitted May 13, 1983 showing all parts of septic system "107' min-
imum from mean high water," is to be available on site while work is in progress.
(NOTE: The tidal wetland edge has been determined to be 7' landward of "ordinary
high water work" shown on plan, therefore septic system location shown is at the
100' minimum setback distance)
SEE ATTACHED CONDITIONS A - J
PEP~IT ISSUE DATE
June 16, 1983
PERMIT ADMINISTRATOR ~ ~,~ /~ /~ I ADDRESS
Bldg. 40, SUNY--Room 219
Stony Brook, NY 11794
PERMIT SIGN
No m 10-83-0400
has been issued to:
address: ~,~ Adam Road, Massapequa, ~
11758
Construct one family house 50' from Glenn Road and associated septic system; all parts of house and septic System are
for: to be within 127 1.f. of Glenn Road in accordance with plan submitted May 13, 1983. There is to be no disturbance tc
terrain or vegetation greater than 147' from Glenn Road by filling, grading, cIearcutting or excavating without ad-
ditional approval from NYSDEC. Project is located West Creek off.of Goose Creek, Lot 21 on west side of Glenn Road,
2,070 linear feet east from Bayvie~
under the Environmental Conservation Law,
Article 15, [Protection of Water)
Article 24, [Freshwater Wetlands)
Article 25, [Tidal Wetlands)
Article 36, [Construction in Flood Hazard Areas)
New York State
Department of Environmental Conservation
' // Permit Administrator
June 16, 1983
Date Issued
95-~04 (9,v5) June 30, 1984
Formerly EAo93 Expiration Date
3068
BRONZE SLDG: PNL,'
5/8 INSULATED GLASS
1104812 ?
SLIDING PANEL INSTALLATION
Standard Stack
This sliding panel is assembled for X--O operation as viewed from the
outside.
Reverse Stack
To reverse the panel, simply remove the one round-head screw at each
end of the interlock and carefully pull the stile completely off the glass.
Replace after turning top to bottom.
C H M C ACCEPTANCE #7361
P-N31070620 LB-AP132 REV 1-83
765-1802
BUILDING DEPT.
INSPECTION
FOUNDATION 1ST ~,~ ROUGH PLBG.
FOUNDATION 2ND [ ] INSULATION
~] FRAMING
FINAL
76S-1802
BUILDING 'DEPT
INSPECTI'ON
[ ] FOUNDATION 1ST [ ~K)UGH .PLBG.
[, 1 FOUNDATION ZND [)/J INSULATION '
[ ] FRAMING [ ]FINAL
'REMARKS:
DATE /5~
Examined ............................... ,
proved ........ ,
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
19~. ,~,,, Permit No .....................
Disapproved a/c ........... ct:L"" ............................ ~ ............i~: ...................
(B'uil'ding Inspector)
Application No.../...~....~...~...~.. ...........
APPLICATION FOR BUILDING PERMIT
Date ....... ,..~. :.~...( ........................ ,19 ...... 2..~..
INSTRUCTIONS
a. This application must be completely filled in by typewriter or~ in ink and submitted in triplicate 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 or
areas, and giving a detailed description of layout ofproperty must be drown 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 building 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 Zane Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the 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.
(Signature of applicant, or name, if~ corporation)
P.O.Box 274, 1159 W. Main St.,So~, NY ll901
(Address ,gl-applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
.......................................... .~.e...n. ~ / .B..u. ~ ~ .d..e. ~ ...............................................................................................................................
Nome of owner of premises ..~P~.¢£.tZ..~...~.~]-.~-..Z.~....~..]-..~..o..n ....................................................................................................
If applicant is a corporate, signature of duly authorized officer.
........... S..:....g..o.£,.d..o...q..,..~.e,..q ~.,e. ~. a..~ ~../..?.C .e .a.,.s.,u,.,~ e q
(Name and title of corporate officer)
Builder's License No .....................................................
Plumber's License No ..... .2..0.~.0..P. ..................................
Electrician's License No. ...2..~..?.2.~;. ...............................
Other Trade's License No ...............................................
Location of land on which proposed work will be done. Map No.: ....D.~B.C..R..Z..B.~.D...?.~.0.~.B.~]. Lot No .........................
Street and Number BlS Glenn Road. 2070.57' .E./O B.a~v.i. ew Road, Southold. NY 11~.01
~1~ ~'o~ Municipality
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Exisiting use and occupancy Yacant ~and
b. Intended use and occupancy ....0,1g..e....~..~.~.~..Z.~....D.~.e..]_.Z.~..~.~ .......................................................................................
65 $+ / oqo Io.Ur-, l.u/
3. Nature of work (check which applicable): New Building.....~ ........ Addition ...: ........... ;.. Alteration ................
Repair .................. Removal ................... DemolJtio~ .................... Other Work ....................................................
~(.,.~..~.~.. ' . ~ ,~ ~-- (Description)
4. Estimated Cost (~...~...~.. ............. i ........ Fee ...~.~.......~'.~...~ ...............................................................
(to be paid on filing this application)
5. If dwelling, number of dwelling units ......... ~ ................. Number of dwelling units on each floor ............................
If garage, number of cars two car ~ara~e .....................
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ............................
7. Dimensions of existing structures, if any: Front ............................ Rear ................................ Depth ....................
Height ........................ Number of Stories .................................................................................................................
Dimensions of same structure with alterations or additions: Front ....................................Rear ............................
Depth ................................ Height ............................ Number of Stories ................................
8. Dimensions of entire' new construction: Front ..... .q..0..'..2..". ..................... Rear .....~?..'..0..'~ .............. Depth ....5.~.'..0..'~ ...........
· 26' .
Height .................... Number of Stories ...R,q ............................................................................................ l. .................
lO0 O' 102 48" 251 O'
9. S~ze of lot Front ......... : .............................................. Rear ......... : ................................ Depth .......... :.V. .................
10. Date of Purchase ....k.~..~.8.:...~.9..8..3: ....................... Nome of Former Owner ...~.o.~u.~.d.~..~.:..~.a..c..c..a. .....................
11. Zone or use district in which premises are situated .....................................................................................................
t2. Does proposed construction violate any zoning law~ ordinance or regulation: ...~.q .................................................
13. Will lot be regraded ..~.e..s. .................... Will excess fill be removed from premises: ( ) Yes (×) No
14. Name of Owner of premises ....R..°..b..e.~..,&...C..a..m.~.e...~)-..U.°..n.... Address .~..a..s..s..a..p.e. ct..u..a.:....N.~... Phone No ?.9...8.T.~..5.,5.7. ......
Name of Architect ...R..'.z..qh...a.~.d...~.a.~.o.~.o.~'.z. ....................... Address ?..~..y..e..~.}?.~.s..d.:....N.~ ..... Phone No. ?..2.7.T..3..3..9..5. ......
Name of Contractor .R.~ver.s..i..d..e...~.o..m..e.~.....Z.~.c..: ................. Address ?.~z.e..~...h..e ~a..d.:....N.~ ..... Phone No. ?.2..?.T..~..3..9..5. ......
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-b~ck dimensions from
property lines. Give street and block number or description according to deed, and show street names and indicate
whether interior or corner lot.
SEE ATTACHED SURVEY
STATE OF NEW YORK, t S S
COUNTY OF ..~.b'.~.o..L..~ ................ f ·
................................................................................................. being duly sworn, deposes and soys that he is the applicant
(Name of individual signing contrecf)
above named. I
He is the i....AX~g..n..t...~.o.~...B.~,d..e.Y...~ ................................................................................... ......................................................
(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 stqtements contained in this application are true to that of his knowledge and belief and
that the work will be perforr~ed in the manner set forth in the application file~erew~h.
Sworn to be ~-me this / /
......... · ~.../... ~' day ~f .~: ............... , 19....~....
ta n .
No ry J~ ~'"'"V~/ ...... ~".~ ........ COU ,t~ ~, .......... ~,......J...,~ ......................................................
/~ ~,/~'~J) / ~ ~(,,~,,6/C/ / (Signature of applicant)
SUFFOLKCO.HEALT~'DEPT.
H~$.,NO.,
~T
~U~'.c'OL.Y_ COUNTY,
"It should be noted that cnce t~is
property is Io~td in ~.
~r~, the ~ossi~llt~ ~,i~s that the
wCer supply moy conldn tr6ce
~mounts of pestic~es and/or nltrotes.
Special ~t~[s r~¢,
Contect this Dement ~ior to
sampling% , ~
GRE:Eflt~'ORT NE~
CONSTRUCT t
DATE:
~ oO-0
tn~ected b~ this
LICENSED LAND SURVEYORS
GREENPORT NEW
SUFFOLK CO. HEALTH DEPT. APPROVAL
H.S. NO.
STATEMENT OF INTENT
THE WATER SUPPLY AND SEWAGE DISPOSAL
SYSTEMS FOR THIS RESIDENCE WILL
CONFORM TO THE STANDARDS OF THE
SUFFOLK CO. DEPT. OF HEALTH SERVICES.
(si ......
APPLICANT
SUFFOLK COUNTY DEPT· Of HEALTH
SERVICES -- FOR APPROVAL OF
CONSTRUCT ION ONLY
DATE:
H.S, REF. NO.. l~ ~<~3-~7
APPROVED: I
SUFFOLK CO. TAX MaP DESIGNATION:
DIST.
1000
OWNERS ADDRESS:
SECT.
DEED: L. N~
TEST HOLE
STAMP
SEAL
L ,.o/~.. £,C.) '= 1~
STATEMENT OF INTENT
THE WATER SUPPLY AND SEWAGE DISPOSA
SYSTEMS FOR THIS RESIDENCE WIL
CONFORM TO THE STANDARDS OF TH
SUFFOLK CO. DEPT. OF HEALTH SERVICE
APPLICANT
SUFFOLK COUNTY DEPT. OF HEALT
SERVICES -- FOR APPROVAL O
CONSTRUCTION ONLY
DATE'
H. S. REF, NO.
APPROVED:
SUFFOLK CO. TAX MAP DESIGNATION:
DIST. SECT. BLOCK PCL
OWNERS ADDRESS.
STAMP
- SEAL
OCCIJ id (I¥ OR
Of OCCIIi HC¥
If copper tubing is used
for water distributing
syslem; piping shall be
ol~ types K or L only
,Il
NOTIFY BuI~bJNG DE~Aff~N~ AT
765~18D2 9 AM TO 4 P~ FOR THE
F~Lk~WlNG INS~ECTIOMS~
l.. FOUNpATION ~ TWO REQUIRED
FO~. POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING
3 INSULAT~
4. FINAL - CONSTRUCTION MUST
BE C~MPL~E FOR C. 0
ALL CONSTRUCTION S~ALL MEET
THE REOU~RfiMENTS OF T~E N Y,
~ATE CONSTRUCTION & ENERGY
CODES. NOT RESPONSIVE FOR
DESIGN OR CONSTRUCTION ERRORS.
~0
J