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Home My WebLink About12637-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy No...g. 1. 2..9.8.6. ........ Date ............ N. gF.e..n~..e.r .... .1.5 ...... 19~.4., THIS CERTIFIES that the building ...... .N.e.w...D.w.e.l. 1..J..n.~. ........................... Location of Property ... 7.6.5. ............ C..e.dAr., .Pg.J_.n.g..DX..~.. .e.s.~. .... .S. qu..t:.h.ql, d. ....... House No. Street Hamlet County Tax Map No. 1000 Section . .. 0.9.0 ...... Block .... .0.1 ......... Lot .... 90.6. ......... Subdivision...~¢l.~r.. l~Rq~, p.alr, k. ......... Filed Map No...9. 9 .... Lot No...~.3.8. ........ conforms substantially to the Application for Building Permit heretofore fried in this office dated .... .S.~pL.. ..... 2.~ .... 19 .8.3. pursuant to which Building Permit No .... .~.2,6..37.g ........... dated ....... S.c. p~... ..... 2.3. ........ 19 .8.3., 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 ......... ·...N.E.W., 9~q.E..F.~..I.n.y..D.W.E..L.I,.!N.G. ................................................. The certificate is issued to ................. .G.E.Q .R.G.E..P..~.U.M.B.O. ......................... (owner, I~ of the aforesaid building. Suffolk County Department of Health Approval ......... 1..3 7.S.O.~ .1.3.4 ....................... UNDERWRITERS CERTIFICATE NO N 6 5 9 8 0 4 Building Inspector Rsv. 1/81 FOR.~ NO. I~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N~ 1263~ Z Permission is hereby grante~.' · ............ ,o .~a:......~...~......~.-,..~.~.....~...~~. County Tox Mop No. 1000 Section ........ .,~,..,,~, ....... Block .......... ~, .......... Lot No ....... ,~- .............. ~ursuont ,o app,co,o, do,~ .....~..~Cq~......~l. ......... , 19.~..~L and op~rov~ by ,he Building Inspector. Fee $,.,..(~'....~. j .?....0. .... uuilding Inspector Rev. 6/30/80 FORM NO. 6 TOWN OF $OUTHOLD Building Department Town Hall ~uthold, N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitte~,!]c=t= 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 topographic 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. 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 inspection of buildings or premises, or other pertinent informa- tion required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 ! 2. Certificate of occupancy on pre-existing dwelling / land use 3. Copy of certificate of occupancy $1.00 --Pre-Existing C.O. $15.00 Vacant land C.O. $ 5.00 Date.Nov....ZS~..298~ .......... New Building .... .;~ ....... Old or Pre-existing Building ............ Vacant Land ............. Location of Property ......... Cedar. ]~q'~. House No. Street Hamlet Owner or Owners of Property P' & C. Construct~.(~. County Tax Map No. 1000 Section .... ,0.~.0. ....... Block Subdivision .M.a.p..o.~...C.e~?.~...~.e.~..c.~. ?.a,~..~ ..... Filed Map No. 9,0 ........ Lot No.. 13.~[ ........ Permit No. L 2-, Data of Permit ;, , App eant. ................ Health Dept Approval Labor Dept Approval ............... Underwriters Approval ~'~ ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate .. X ................... Fee Submitted $ ~...0.q ........................ Construction on above described building and per~it meets ~aJ[applicable codes and regu lations. P. &.C~/~ Con~s_~.r~,c~i~o,n, Inc.~__ ~ :).,/'~'1 '~l Applicant '~..y.~.~.~,~.?-/~.~(.~'~.c./.~/~-~ ................ Rev. 10-10-78 ' · THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 85 JOHN STREET, NEW YORK, NEW YORK 10038 ~rag 8eptem~r 14, 1~84 g55558/84 ..t. ~""""""~".""~"~ N 659804 THIS CERTIFIES THAT ~ Palt~, W/S C~~ ~int Drive West, ~uthotd, N~Y. in the followlng locatlonk ~ Basement l~ L~t FL ~ 2nd FL Sectlo~t Block Lot . , ~(~t~ ~ ~ l~)~ and found to be in co~npliahce with the requiren~ents of this Board. FIXTURES RANGES OVENS DISH WASHERS EXHAUST FANS FIXTURE 22 31 OTHER APPARATUS: 1-G.F.C.L ~-S,~ke Detectors. Tr~ck Lighting 8' 2 I~ttes, ~,~tors; 1.-F. S E R I C RC~,~ A W G, NO OF HI-LEG A W. G, NO. OF NEUTRALS A W G NO Ol~E COND OF CC COND OF HI-LEG OF NEUTRAL P. O. Box 1,51 This certificate mos~ not be altered COPY FOH 8OlLDING DEPAHTMENT, THI~ OOPY,O~OEHTIFIO~TE MU~T NO~E ~LTE~ED IN AHY M~NNE~. FIELD INSPECTION FOUNDATION (1st) FOUNDATION (2nd) COMMENTS ROUGH FRAME & FLUMBING INSULATION PER N. STATE ENERGY ~ODE FINAL o~ ~c ADDITIONAL COMMENTS: NEW YOI~K STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION ' PERMIT NO. 10-83-0774 PERMIT UNDER THE ENVIRONMENTAL CONSERVATION LAW ARTICLE 15, (Protection of Water) [] ARTICLE 25, (Tidal Wetlands) ARTICLE 24, (Freshwater Wetlands) [] ARTICLE 36, (Conslruction in Flood Hazard Areas) PERMIT ISSUED TO P.£C. Cnn.~ t.~ tc.t ion ADDRESS OF PERMiTIEE LOCAT ON OF PROJECT (Section of stream, .dal wetland, dam, building) Censt~action og a single f?n~]y hnmp 75' landwnrd nf Tidal W~_t]and.q and a sanit ....... ~-,~,~ ~nn, from tidal v;et!~nas~ COMMUNITY NAME (City, Town, %llage) TOWN CO~N~'~ ..... FIA COMMUNITY NO. DAM NO, Suffolk GENERAL CONDITIONS hour~ in adva.ce of the time of comme.cement a.d shall also ,otify him 2. lhe permitted work shall be subject to inspectio, by an authorized 3. As a coodiUon oi the issuance of th~s permit, the applica.t has sibiJity for aH damages, direct or indirect, of whatever nature, and by whom. costs of ever? name aod descnpt~on resulting from the said project. 4. A.y materMI dredged in the prosecution of the work herei, permitled bed of the wmterwa? or flood plain or deep boles that may have a tendenc~ to 5. Any material to be deposited or dumped under this perodt, either i. at the IocalRy shown on the drawing hereto attached, and, if so prescribed thereon, wilhin or behi.d a ~ood a.d substa.tial bulkhead or bulkheads, such as will prevent escape of the matedal ~nto the waterway. work herei, authorized. in the position of the slructure or worg herein authorized, or if, in the opinion obstruction to the free navigation of ~aid waters or flo~ flow~ 9r endanger the health, s~fety or welfare of lhe ~ople of the State, or Io~s or destruction of the natural ~e~ources of the State, the owner may be ordered by the Depar[- thereby without expense to the State; aod if, upon the expiration or ~evocation of this perodt, the structure~ fill, excavatio., or other m~ificatio, of the a.y porl~on of the u,completed structure or fill and restore to its former conditio, the .avigable aod flood capacity of the watercourse. No claim shah eptember 30. ]_984 8. That the State of New York shall in no case be liable for any damage or injury to the structare or work herein authorized which may be caused by or result from future operations 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 and signals as 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 oul under this permit shall be performed in accor- dance with established engineering practice and in a workmanlike manner. 11. If granted under Articles 24 or 25, the Department reserves the right to reconsider this approval at any hmo and after due notice and hearing to continue, rescind or modify this permit in such a manner as may be found to be lUSt 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 the Departmenl of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore the silo 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 apphcant any right to trespass upon the lands or interfere with the riparian rights of others to perform the permitted work or as authorizing 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 project. 14. If granted under Article 36, this permit is granted solely on the basis of the requirements ot Amcle 36 of the Environmental Conservation Law and Part S00 of 6 NYCRR (Construction in Flood Plain Areas having Special Flood Hazards - Building Permits) and in no way signifies that the project will be free from flooding. tS. By 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 i9/75) (SEE REVERSE SIDE) SPECIAL CONDITIONS SEE ADDITIONAL CONDITIONS: A through J (16) There shall be nol disturbance to the naturally, in 25! of means high water. o¢curing vegetation wit} PERMIT ISSUE DATE A~gu.~t ]: 1983 LPERMIT ADMINISTRATOR ~~ ADDRESS REGULATORY AFFA1][' STATE UNIVERSITY June 23, 1983 Date: Region No,: Applicant: __'P. £C,. Amount: $ ~ Application Identification No,: ~L0-83-0774 Permit Type: Tidal ~Tetlands NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION UNIFORM PROCEDURES ACT R~cei~t No.u Office:}'~ ¢~11 ] .q ~n ~1"~,'~'~ ~ 1-.~. Check ~ Money Order [] Check or M.O. No,: 1001 32-14-13 (9/77) ..... I Buffalo District, Corp"of Engineers Applicable to Regions 5-9. Addresses o~ back imge JOINT i 1776 Niagara Street Boffalo, New York 14207 DEC Applic,~tion NO., .,., APPLICATION FOR PERMITI ~ NCBCP-S Corps o! Engineers Application NO. ba~ inst~acti~ns on back betore ~o~pleting this application, Please type or print clearly in ink. use separate addenda and exhibits to provide all required data and explanations for which space on the form is inadequate. [] ARTICLE tS, TITLE 3 (CONTROL OF AQUATIC INSECTS, WEEDS, OR UNDESIRABLE FISH) [] ARTICLE iS, TITLE ;5 (PROTECTION OF WATERS) [] Fo~ the construction, reconstruction, or repair of a DAM or other impoundment structure. [] ARTICLE 15, Title 15 (WATER SUPPLY) [] ARTICLE 24 (FRESHWATER WETLANDS) [] permit [] Letter of Permission [] SECTION 10 (RIVER & HARBOR ACT OF 1899) for structures and work in navigable waters of the U. S. [] SECTION 4~4 (FEDERAL CLEAN WATER ACT OF 1977) for disposa~ of dredged or fib material /~ waters of the U. S. APPLICANT IS A/AN [] Individual j~] Partnership [] Association J~ Corporation [] Municipality [] Governmental Agency 3. NAME & TITLE OF .{."~ ~_(~ "~ '~_~0~:~,-~.~ ~ OFFICIAL SIGNING APPLICATION _ STREET ADDRESS~ 'O ~'~ ~ P. O. BOX ~, . ' , e~, '~ POST OFFICE STATE I~J' Y Z~P CODE lt772- a) City or Village of NAME OF STREAM OR OTHER WATER BODY: Town of ~ ~ , map - See Item 5b) b) 5~cific ~oject site or area Is marked on U,S.G.S. or~quivalent map, attached as Exhibit NO. fillins, and location of disposal sites; ty~ of structure to be installed; height of dam; size of impoundment; capacities of proposed water sources; extent of distribution system; etc.] ZIP CODE____ WILL PROJECT UTILIZE STATE OWNED LAND? [] Yes ,~ No 10. FEE OF S ENCLOSED 12. This project will require the following additional permits, applications for which are the responsibility of others: [] DAM [] DOCK [] STREAM DISTURBANCE [] SPDES/NPDES [] WATER SUPPLY [] FRESHWATER WETLANDS 13, NAME AND ADDRESS OF OFFICIAL NEWSPAPER OF LOCALITY WHERE pROPOSED WORKS ARE LOCATED: ~OMPLETE? 14, IS ANY PORTION OF THE ACTIVITY FOR WHICH A PERMIT IS SOUGHT NOW BEGUN [~] YES J~] NO If "YES", explain tn addenda, giving reasoes aJld dates, and show existlr~g work on drawings or maps. 15, PROVIDE SEPERATE LIST OF NAMES, ADDRESSES, AND PHONE NUMBER5 OF OWNERS OF PROPERTY ADJOINING THE WORK (~'CORP5'~ PERMITS ONLY). NOTE that the CORPS OF ENGINEERS CANNOT process applications lacking this information. 16, CERTIFICATION: o-' ', I hereby affirm under penalty of perjury that information provided on this form and all attachments submitted herewith is true to the best of my knowledge and belief. False statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the State penal Law. As a condition to the issuance of a permib the applicant accepts full legal responsibility for all damage, direct or indirect, of whatever nature, and by whomever suffered, arising out of the p~oiect described herein and agrees to indemnify and save harmless the State from suits, actions, damages and costs of every name a~d description resulting from tbe said I~-oject. In addition, Federal I~w, 18 U.S,C. Section 1001 provides for a fine of not more than $t0~000 or ~Jsonment for not more lhan f ye years, or both, where an applicant knowingly and willfully falsifies, conceals or covers up ~or uses a false, flctJUous or fraudulent statement SIGN! 95-19-3 -SEE REVERSE SIDE-- NEW YORK STATE DEPARTMENT OF ENVIRON~gNTAL CONSERvAtION Building ~,0, State University of New York Stony Brook, New York 11794 51~-751-7900 P.& C. Construction Inc. 69 Durkee Lane East Patchogue,N.Y. 11772 August 1,1983, Re:10-83-0774 Dearsir: In conformance with the requirements o the State Un~form Procedures Act (Article 70, ECL) and i~s ~mplement Lng Reghlations (6NYCRR Part 621) we are enclosing your pgrmi~. P Lease read all conditions carefully. If you are unable tb comply ~ith any eondi- tions~ please contact the Regio~ial RegUlatory Affairs Off,ce. NYS Department of EnvirOnmental Conaervatioa, ~State Un~versity of New york at Stony Brook, Building 40, Stony B~ook, Ne~i¥ork 11794. Also enclosed is a permit sign which:you are ~o conspicuously post at the project site, protected ~r~m the weather. Regional~erml~ Adm~ ~strator · EnclS. New York State Department of Environmental Conservation NOTICE The Department of Environmental Conservation (DEC) has issued permit(s) pursuant to the Environmental Conservation Law for work being conducted on this site. For further informa- tion regarding the nature and extent of work approved and any Departmental conditions on it, contact the Regional Permit Administrator listed below. Please refer to the~ ~ _ ~-..,~pctr~FCJ~/b, er shown when contacting the DEC. ~¢'~/¢',,~,,~ Regional Permit Administrator Permit No. 10-83-0774 Expiration Date 95-20-1 (11/82) September 30,1984 NOTE: This notice is not a permit SUPpLE~E?~TAP~f SP~CIAL COk~OITIOS~S The following conditions apply to all permits~ If any of the permit conditions are unclear, the permittee shall contact the Division of Regulatory Affairs at the address and telephone noted below. A copy of this permit or approval and supplementary conditions shall be available at the project site whenever authorized work is in progress. The permit sign enclosed with the permit or a copy of approval letter shall be protected from the weather and posted in a conspicious location at the work site until completion of authorized work. D. At least 48 hours prior to commencement of the project, the permittee shall complete and return the top portion of the enclosed receipt form certifying that he is fully aware of and understands all provisions and conditions of this permit. Within one week of completion of the permitted work the bottom portion of that form shall also be completed and returned. E. For projects involving activities to be accomplished over a period or more than one year~ the permittee shall notify the Regional Permit Administrator in writing at least 48 hours to the commencement of resumption of work each year. F. If project design modifications take place after permit issuance, the permit- tee shall submit the appropriate plan changes for approval by the Regional Permit Administrator prior to undertaking any such modifications. The permittee is advised that substantial modification may require submission of a new application for permit. G. All necessary precautions shall be taken to preclude contamination of any wetlands or waterway by suspended solids~ sediment, fuels, solvents~ lubric- ants~ epoxy coatings~ paints~ concrete~ leachate or any other environmental- ly deleterious materials associated with the project work. Mo Any failure to comply precisely with all of the terms and conditions of this permit~ unless authorized in writing, shall be treated as a violation of the Environmental Conservation Law. The permittee is advised to obtain any permits or approvals that may be re- quired from the U.S. Department of Army Corps of Engineers~ New York District~ 26 Federal Plaza~ New York~ NY 10007, (Attention Regulatory Functions Branch), prior to commencing work authorized herein. The granting of this permit does not relieve the permittee of the responsib- ility of obtaining a grant~ easement, or other necessary approval from the Division of Land Utilization, Office of General Services, Tower Building, Empire State Plaza, Albany~ NY 12242, which may be required for any encroach- ment upon State-owned lands under water. Regional Permit Administrator NYS Department of Environmental Conservation Bldg. 40~ SUIqY--Room 219 Stony Drook~ NY 11794 (516) 751-7900 DEC #10-83-0774 76S.1802 BUILDING DEPT. INSPECTION DATE INSPECTOR z6~-z.oz · BU ILDI NG ~ DEPT. ~ INSPECTION :DATE 7ss-z8o;~ BUILDING DEPT. ~ INSPECTION' FOUNDATION 1ST ROUGH PLBG,~~ FOUNDATION ZND [ ] INsUlaTION [ ] FRAMING [ ] FINAL REMARKS: DATE ,'/..×4 S ~,oE -, ¢_.,¢vL~s4 t(mo.c) z-z,4 P~T~/" '~B e,oX rrA~.r~.oc~ t4.-o0S8." -- ,~ Cc OT~IC~. 'I l /Z-I- O' 'I I 'F' -" ' COY~LETE APPLICATION ~tECKL,I, ST SUBIiIT 1~I~ F~ESl~ATER I~TLANDs, TIDAL T.~TLANDS & PRDTECTION OF UATERS ANVLIC~.TION. To avoid delay be sure all inforru~tion indicated below is included (where able) with your submittal. If you trove questions call (516) 751-7900. SUBMITTED 1. "APPLICATION FOR~fS" (in triplicate) Instructions om reverse; must include pro- Ject desc~iPtion-~state type of structure(s) or work proposed & specific areas, a~unts, etc. involved. It also must be signed. 4. "AUTIIORIZATIOM LETTER" (if a~plicant is 6thor than o~er) 5. ~t~0CATi~N ~P'*'"(in triplicate) mp of general location of project site su~ ient to locate the site; name roads, bodies of water, laud~rks, telephone pole street address, etc. Copy of tax section ~p ~s ~8~lly cl~rest. 6. "LONG ENVI}IO~NT~ ASSESS~,~NT FO~" If you're aware your project is a ~pe I action as defined in SEQR. Art. 8, Part 617 request this fo~ complete Part I & submit with application. ~is ~y be required on such u~lis~ed actions as Subdi~ tsions~ Coud~iuiums, Co~ercial Development, ~Jor Beach Control l, fork, ~jor Dred- ging, Roads, Bridges .... 7. "P~S" (in triplicate) (five sets for projects listed i~ #6 above). Plane need to show area of wetland/wate~ay directly afl.ted. Attach a 8tat~eut as to fees- able alter~ative8. Provide as much data as possible go clearly delineate project. Show: dimensions, distances from fixed objects (~nument8, adJoi~ng structures, eenterline of road, otc.) Elevatio~s (existing & proposed); distances from regulat- ed wetlands & watercourses, mean high water (~5,~). ~ditional data needed accord- ing to type of structure(s), work or action proposed as listed below: A. ~NSTRUCTION/WORK i~ adJac~t area e.g. b~ldimgs, accesso~ structures such as pools, decks, tennis courts, etc.. filling, excavatiou (for excavation ~elow see dredging below) grading~ clearcutting~ roads~ subdivisiones condomini~s. On a recent plan you must show: (1) ~-~1 line and/or wetland line, state how this was dete~ined. **(2) Specific locatto~ tn ou~li~e of pr~osed 8tructure(s)s work area(s) proposed subdivisions line, etc. **(3) Show on plan: sanita~ system(s) & dry well location with recent test holq; & distance to ~IW or wetland edge; data to show groundwater l~el. **(4) If filling (a) amount in cubic yards; type of ~terial & source, k ~ {"~ ~. (b) existin~ & proposed elevation must be sho~ on plan. %~.(i~i (5) ~e lot on plans lms be~ ~n, single & separate o~ership since= (6) Submit flood zone desig~tion; name~ n~ber and date of ~p. B. B~KH,~ REVE~-~NT~ RETAINING U~L OR G~ION sh~ on a recent su~ey: .... *F('I) Location of proposed-structure(s), ~J or wetland edge; state distances existinz structure(a) e.g. house, road~ property ltne~ ~n~ent. (2) Cross-sect. & Plan view of structure(s); type of ~ter~al; )~I, existing & proposed elevations seaward & landward of proposed structure according to USGVD. Show construction detail~ state specific di~eusion~. (3)Outline of excavation &/or fill, State ~t., t~e & source of fill. C% ~CK~ CA~,I~K~ PIER,, BRIDGE~ ROAD STRUC~RES on ~ite plan or survey: **(1) Location of proposed structure(s) ia relation to ~--or wetland edge, dis- tances to existing structure(s) i.e. house, road, property line. (2)Cross-sect. & planview, shew dimensions & cloy. above ~ & wetland. D. D~ING (removal of ~terial k. elow }~ to establish or i~crease water depth) (1) ~ plan: limits of dredging referenced to lands adjacent to wate~ay. *~(2) On plan: outline limits of propo.ed spoil site. (3) Spoil site o~er's authorization If differ~t fr~ applica~t. (4)Cross-sect. view of area to be dredged & spoil ar~ with dimens~ons & 'e'iev- atioms of existing & proposed depths referenced to USGS. (5)~unt iR cu. yds. type of ~terial to be dredged (sand, silt, muck) (6)~ns of dredging (hydraulic, bucket, etc.) E. JE~IES, G~INS~ B~ATE~S~ FILLip ~CKS (1)~lan view showing location, of structure(s), dimensions & distances to latent land areas & existing structures within I00' of m~n high w~ter. (2)Cross-sect. view of structure: dimensions, elev., ~N~, (3)Profile el~. of 8t~cture relative to existlng lamdfo~ using USGS, 8. eRECFi~T PHONS OF PROJECT ~" are requ~ed (label w~th o~er's ~me) **NO~: L~ITS OF l~ ~ST BE ST~D, ~ S~W~D STA~S AT SITE PRIOR TO DEPT's FIELD IMSPECTION~ INDI~ BELOU ~T SITE }ILS B~N OR NOT B~ STUD. A FInD INSPECTION WILL NOT BE ~E ~TIL ~I~EN NOTICE IS ~CEIV~. SHOW ST~ LO~TION ON P~NS. STUD NOT ST~D, ~I~EN NOTICE SE~ AT ~TER 'DATE ~PLICATION IS INCOMPLETE ~TIL ST~S ~i~ & .~I~EN NOTICE ~CEI~D. ' ..... 12. -2- NOT KNOWN d) Does'project involve any excavation or placing of fill in the navigable waters of the State and adjacent wetlands? 9. ~l,,~etlands Permit I. Will project be located: a) in tidal waters? b) within 300 feet of either the land- ward edge of a tidal wetland boundary or a tidal body of water? II. Will there be any subdivision of land or physical alterations of land or water? Exemptions to the above regulation location if: 1) Project will be located at a ground elevation of 10 feet or higher above mean sea level (excepting on the face of a bluff or cliff). 2) A substantial, man-made structure (such as a paved street or bulkhead) 100 feet or longer exists between the project site and tidal wetlands or tidal water. (Consult D.E,C. Regional Office if unsure). 10. Freshwater Wetlands Permit a) Will project area be within, or within 100 feet of a freshwater wetland or freshwater body of 12,4 acres or larger? b) %;ill project involve draining, dredging, filling, excavating, erecting structures. roads, utilities or other alterations or placing any form of pollution in a wetland? (Consult D.E.C. Regional Office if unsure). 11. ~,eCti9~ 4~l-TWater qgality Certification ,Letter Does project or activity require a Federal Pet-mit or License? If so, this State certification may be required prior to Federal approval. State Pollutant Dischar~e E%lminatlon System-- (SPDES) Permit Does Project involve: a) A proposed subdivision of five or more t,nits? c) d) e) b) A proposed or existing discharge of 1,000 gallons per day of sewage or any discharge of industrial or other wastes to ground waters? ..... V Any discharge of sewage, industrial or other wastes to surface water? , Any disposal of stormwater containing sewage industrial or other wastes? ,, Any storage and ~ispoaal of potentially toxic or hazardous wastes? 13. The following additional required D.E.C.pel~ite have been applied for: Type of Application A~plication Permit Num~e~ Filing Date _A.%r:.l_!c.a.~nl_:'s__N:~_~_e' (if different on 14. List all other pet./ts, licenses c,.' .,~ ,j. ~'/,:ts a~.:.,.~f.{/: ;,:" ',,'",,'~.' ~-':.~.n.~.,:..;s of govern~nt Typ9 of Pe~it ~,ve~mental or approval I cerCifF t~ the above ~nfo~tion is correct ~o ~ best of my ~wled~e. ' NEW ¥0,,.~, ,STATE, ,DEPAKT~NT OF ENV!RON~NTAL CONSERVATION FKOJECT PEFcO%IT REqUIREmeNT, qUESTIONNAiRE The purpose of this questionnaire is to assist the applicant in determining what, if any, Department Permits or approvals must be obtained before starting work on a proposed project. If you are not sure if the action proposed is a regulated activity or is within an area subject to Department regulations (tidal wetlands, freshwater wetlands, etc.) contact our regional office for clarification. A pre-application conference with our staff to obtain guidance in the Department's permit application review process can be arranged. ANSWER ALL qUESTIONS NAME OF APPLICANT: ~ET~I.LED PROJECT DESCRI,PT~ON & LOCATION: 1. Realty Subdivision Approvals i~,Nassau County Does project involve subdivision of land into 5 or more residential lots that will be served by a public or community s~age disposal system? 2. ~nins Permit Does project involve the mining and commercial sale or off-site use of 1,000 tons of mineral within 12 calendar months (excepting excavat- ion or grading in connection with on site con- struction or farming)? 3. Air Conta~ination Permit ............. ~_,N,ew ~,,Ho, dified Sources: .... Does project involve the construotion~ mod- ification or operation of a boiler greater than 1 million BT~/hr rated heat input, an incinerator or an industrial process? b) Indirect Source: 'Does project involve construction or modif- ication of a hig~ay, airport or a parking facility with 250 or more spaces? 4. Sol,id Waste Mana~,ement Permit Does project involve the storage, transfer processing or disposal of solid waste? 5. Wi!d~ Scenic & Recreational Rivers Permit Only applies to certain lands within a ½ mile of the Ce~ana Riwer. Consult D.E.C. Regional Office for exact dete~nation, 6. Water Supply Does project involve the acqu~sltion of land or construction of facilities for water sup- ply or distribution purposes? 7. Lon~ Isl~nd Well Permit, a new well or deepening or increasing the capacity o~an existing well to withdraw water at a rate greater than 45 gallons a minute? b) Will project require the temporary lower~n~ of groundwater levels fo~ construction purposes? 8. Frotect$on of Waters a) ~ill project chauge~ modify or othe~rlse disturb the course, cha~mel or bed of any stream classified C(T) or higher? (Consult the Regional Office for cla~sificaZions). b) Does project involve the temporary or permanent artif~cial obstruction of a nat- ural stream or Water course? ¢) Does project involve the construction or repair of a permaneut dock~ pier or wharf havi~s a top surface area more than 200 square feet? NOT YES NO KNO~fN I~YSDF-C Reg, Permit Admi~istrator Bldg. 40, Room 219 SUNY Campus Stony Brook, N.Y. 11794 Permit No. Issued to (Agent) ......... Dear Sir: Pursuant to General Condition No. 1 of the above referenced pemmit you are hereby notified that the authorized activity shall commence on This notice is to be sent a~ least two days ia advance of com- ~ncemen~ of the project. The permit sign will be posted at tile site and copy of permit will be avail- able at site for inspection. Submitted by, ,, Failure to notify or post sign will leave owner and/or contractor subject to applicable penalties for non-compliance with permit conditions. NYSDEC Reg. Permit Administrator Bldg. 40~ Room 219 SUNY Campus Stony Brook, N.Y. 11794 Permit NO, Issued to (Agent) ........ Pursuant to General Condition No. 1 of the above referenced permit you are hereby notified that the authorized activity was completed on Submitted by (~lis notice is to be sent to above address promptly upon completion of project). Failure to notify will leave o~,mer and/or contractor ~ubjec~ able penalti~m,.fnr,.non-eompli~,nae with permit .condf~ion. FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y, 11971 TEL.: 765-1803 Approved ..........~.~ ~ .~.., 19~. Permit No.}..~.k..~.'3. .~... Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date ~./"?-/ a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Hot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a deta'ded description of layout of property must be drawn on the diagram which is part of tiffs appli- cation. 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 issued 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 Zone 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 building for necessary inspections~/--4-~ , ~ ~ ~ ~ / ........ ..~..~..~.~c...~' ~'" '-" ................... ex> tOe.- ~: ~'~(~ ~ C ~ '~ (S~atur~'ofapplicant, or name, ifa corporation) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. .......... c.~..?.~ .............................................. Name of owner of premises ........... ~...m-~. ...................................... (as on the tax roll or latest deed) If applicant is a corporation, si. gnature of duly authorized officer. / ' (Name and title of corporate officer) Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done ................................................... ............... : ....... ........ House Number Street Hamlet ?D I 6 County Tax Map No. I000 Section ........ .,,: ...... Block ................... Lot ........ .~ ........... Subdivision... ~...~,..~.0~....../~.O,.ZLL.. Filed Map No .... ,~, .~. ....... Lot ./.~....~ ......... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ......................................... ~ ........................... b. Intended use and occupancy ~ 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work ............... ~ (Description) 4. Estimated Cost.. Fee : (to be paid on filing this application) 5. I f dwelling, number of dwellingiunits ............... Number of dwelling units on each floor ................ If garage, number of cars .... [ .................................... ............................... 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 ......... , ..... Rear ............... Depth ............... Height ............... Number of Stories ........................................................ 9. Sizeoflot: Front .......... ; ........... Rear ...................... Depth ...................... 10. Date of Purchase .......... i .................. Name of Former Owner ............................. 11. Zone Or use district in which premises are situated ..................................................... 12. D6es proposed construction violate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ........ , ................... Will excess fill be removed from premises: Yes No 14. Name of Owner of premises .. i ................. Address ................... Phone No ................ Name of Architect ........................... Address ................... Phone No ................ Name of Contractor ........ r ................. Address ................... Phone No ................ PLOT DIAGRAM Locate clearly and distinctly ali buildings, whether existing or proposed, and. indicate all set-back 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. STATE OF N~ EVfY~2~RK, .~, SS COUNTY 0 t:~'~r~,~'~ .... ~' (Name ofindMdua s~gning contract) above named. being duly sworn, deposes and says that he is the applicant 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 and to make and file this application;, that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manne'r set forth in the application filed thei2ewith. Sworn to before me this ........ ~./..~..:. :': .... day of.. Notary Publil~, . ............ · (J I~,l~'~ilZ~8~l}l~:l~?t~o~}I llew "/0*~ .... . , .~,"~TfiT. f ...... ~...~-' ......................... . ~0' .~'~o,'.-~< ~a// ,~ ' (Signature ofapphcant) I SUFFOLK CO. HEALTH DEPT. At~PROVAI. ~ ~-- ~_ ~'~- ..~, STATEMENT OF INTENT , ' ...... ~ ........ THE WATER SUPPLY AND SEWAGE DISPOSAL ~' ,~ '" ':~-M' CONFORM TO THE STANDARDS OF THE 7~ ' ~" ; .... c ' '-- c ..... , ~x:~: SUFFOLK CO. DEPT. Of HEALTH SERVICES. ~:¢d 'D , ' SUFFOLK COUNTY DEPT. OF' HEALTH 50.0 :, i SERVICES -- FOR APPROVAL OF : CONSTRUCTION ONLY DATE: ~ ~ , ,~ SUFFOL CO. TAX MAP DESIGNA LICEN~D LAND ~EVEYORS GREENPORT NEW YORK X b RODERICK YANSUYI~. LAND SURVEYORS ~=REENPORT NEW YORK jSUFFOLK CO. HEALTi~I' DEPT. APPROVAL~ H.S. NO. STATEMENT OF INTEN-~ THE WATER SUi~LY AND ~I~'WA~ DISI~OSAL l~ CONFORM TO THE STA~AR~ OF TH~ SUFFOLK COUNTY OkPT. ~" mALTH( SERVICES -- FOR APPROVAL OF CONSTRUCTION ONLY ~ / ~ ' ~FFOLK ~O. TAX MA~ DESIGNATION: TEST HOLE SUFFOLK CO. HEALTH DEPT. APPROVAL No+e: ho+ ,*~u;~s ~hown ~ +o H.S. NO. ~ EL~:~E~ f"' , , - z .... '- STATEMENT OF INTENT ~_g~.~C~:~ ~ ~''~; 7 '~ * ;~ _ THE WATER SUPPLY AND SEWAGE ~o, ,~ ~ SYSTEMS FOR THIS RESIDENCE WiLL ~n .... ' " ,~ : ~ "~,~/~/t~-~/' CONFORM TO THE STANDAR~ OF THE - ¥ -, ~ ,, A~LICANT 0 ~. ~ '~ ~ ':,, SUFFOLK COUNTY DEPT. OF HEALTH ~ ~ ~ ~ ----- ~ ~ ,.,. SERVICES -- FOR APPROVAL Of j ~ ~ ~ , ~ CONSTRUCTION ONLY [ ~ ~ ~ Ht ~ ~k'. DATE: [ ~: ;. k', H. $. REF. NOn j .' ~ L ~ ~ X ', ~[~: ~0 '= /" suFFOLK CO. TAX MAP DESI~AT[ON: h ~. ~ , ~, ~r-~ =~B,G~ ~.~(~ +~ ,~.~) mST. SECT. SL~ ~L. U-- ' "' / '~ ~ '~ ~' ' ' Ag, ~-~ ~ ,, DEED:. L~ RODERiCK VAN TUYL. P.C. ~ ~ LICEN~D LAND S~VEYORS ~--'k GREEN~RT NEW Y~K