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Home My WebLink About12555-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy No. Z13205 Date Feb. 8 ...... 19 ~.5. THIS CERTIFIES that the building New Dwelling 675 Cedar ~oint Dr. East Southold .................................. Hamlet Location of Property 80 Lakeside Dr. House No. Street County Tax Map No. 1000 S~ction ... 9.9.0. ..... Block .....0.3 ......... Lot ...,Q.1.4. .......... Subdivision Cedar Beach Park .Filed Map No..9.0. ..... Lot No. 81 conforms substantially to the Application for Building Permit heretofore filed in this office dated .... .J.U.].y ...... $ .4 .....19 ~ .3. pursuant to which Building Permit No....~ .2.5.5.5. Z. ............ dated ...... .~.u.q .. .... 2. .7 ........... 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 ......... New Private One Family Dwelling ................ THOMA~ &..A.N.N.E..H.I.G. qI..N~ ................ The certificate is issued to .............. ic;~na'r, of the aforesaid building. 13-SO-90 S ffolkCo tyDepartm¢ tofH App I · · '" ' u un n ealth rova .................................... UNDERWRITERS CERTIFICATE NO ................. N674764 ...... Rev. 1/81 Building Inspector FO~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y, BUILDING PERMIT (THIS PERMIT MUST DE KEPT ON THE PI~EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) ...; ~- ~T°. 12555 Z Dote ................. ~ .......... , 19...~..% Permission is hereby grante~?_ ~ . ~ ~10~ ~ I~ ........................................ '_~"~Z.-'; ......................... ..~.....~.~..~....~ ........................ ~~.....~.....~..:~..~...~..~..~.~ .~~~...~.. ~.....~ ................ ~ ~..~.~.~ ..... ~ .... ,~,,,, ~o~,a o~.~..~~.~.~..~....~.~.~...~...t..~...~....~ County Tax Map No. 1000 Section~......~.....~..~ .~'-' ......... Block ...... .~....~...?.,:-, ,-~L°t No....~....~ ............... ~ Building Inspector. Fee SJ.~:..~k,--,.. Btfi~d~g Inspector Rev. 6/30/80 FORM NO. 6 TOWN OF SOUTHOLD Building 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 natural 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 p~operty showing all property lines, streets, buildings and unusual natural or topographic featu res. 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 3, Copy of certificate of occupancy $1.00 4.Vacant Land C.O. $5.00 $15.00 Date ...F..e.b......8.,.1.9..8.5 ......... New Building ...X. ......... Old or Pre-existing Building ............ Vacant Land ............. 675 Cedar Point Dr. East Location of Property 80 Lakeside Dr. Southold House No. Street Ham/et Owner or Owners of Property Thomas Higgins & Anne County Tax Map No. 1000 Section ...... .0.9. q .....Block ... ,0.3. ......... Lot... 014 Subdivision ...C.e.d..a.r..B.c..a.c.h...P.a.r.k. ........... Filed Map No.. ,9.0 ....... Lot No...8.1 .......... Permit No..1.2.5.5..5.Z... Date of Permit .8[.2.7,/. .8.5..Applicant .................................. Health Dept. Approval .1.3.LS..O.-.9.0. ........... Labor Dept. Approval ........................ Underwriters Approval. N674764 . .Planning Board Approval Request for Temporary Certificate ..................... Final Certificate ... X Fee Submitted $ ............................. Construction on above described building and permit~neets all applicable codes and regulations. Applicant ..... ~ .... ~.-~ ................. . ,, YORK' STATE DEPARTi~NT OF ENVIRO~,,~.NTAL CONSERVATION ~gulato~ Affair~ Unit Bldg~ 40, SUKY--Room ~ ........ Stony ~. ~' 11794 ............... ~516) 751-7900 A review has been made of your proposal to: York State Department of Environmental Conservation has found the Ne~ parcel~proJect to be: ~Greater than 300' from inventoried tidal wetlands. --. Landward of a substantial man-mede structure greater than 100' in length oonstructed prior to September 20, 19~7. Landward of 10' contour elevation above mean sea level on a gradual, nat- ural slope. .... Landward of topographical crest of bluff, cliff or dune in excess of 10 feet in elevation above mean sea level. Therefore, mo permit under Article 25 (Tidal Wetlands of the Environmental Conservation Law) is required at this time since the current proposal is beyond State mandated ~.Hrisdiction pursuant to this act. However, any additional work or modifications to the projectmay require a permit. It is your responsibility to notify this officer in writiHg, if such additionalwork of modifications are contemplated. Very truly yours,i Regional Supervisor of Regulatory Affairs DJL:RNT:cz FIELD INSFECTION FOUNDATION (1st) ~OMM~ L FOUNDATION 2. (2nd) ROUGH FRAME & PLUMBING INSULATION PER N. STATE ENERGY FINAL ADDITIONAL COMMENTS: FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N.Y. NOTICE OF DISAPPROVAL File No ................................ ....q.y...q. ~, .~....~..: .......... ~...~....~... ~,,. ~ :.~.,...~../~-~.o.... PLEASE TAKE NOTICE that your application dated ....... .~. · .O'A~... 3..~ ....... , 19 .~.q.. Location of ProperW Hou~ No, Street Hamlet County Tax Map No. 1000 Section .... .~ ~ .~... Block .... ~. ~ ..... Lot ... ~.l.q ...... s,~ai,i~io, 5¢~& .~.~ F,~d ~ap No ....... ~0 ....... rot ~o .... ~. t ........... , ,. ) p ........ . ................. '~ ................. "O'.G ..... ~ .......... ~ ..... E~"~: ............... Building Inspector RV 1/80 765-'~802 BUILDING DEPT. I NSPE/C~Ir.ON [ ] FOUNI~ATION 1ST [ ] ROUGH PL.BG. FOUNDATION 2ND ~"' INSULATION FRAMING [ ] FINAL REMARKS: loooa~ THE NEW YOR~ BOARD OF FIRE UNDERWRITERS ~- ol . BUREAU OF ELECTRICITY 85 JOHN ~TREET, NEW YORK, NEW YORK 10038 O. te ~,.n,~ zs, ~5 ~,~.,o.~o.o.~,~~~m~/~ N 674764 THIS CERTIFIES THAT only the electrical equipment ~ ~scribed be~w and ~nt~oduced by t~ applicant named on the above application number in the premises of was exat.ined on ~ 'l > 1DSfi and found to be in compliance with the requirements of this Board, FIXTURE RANGES COOKING DECKS OVENS EXHAUST FANS OUTLETE SWITCHES INCANDESCENT DRYERS FURNACE MOTORS FUTURE TIME CLOCKS UNIT HEATERS MULTI*OUTLET DIMMERS SYSTEMS NO~ OF FEET SERVICE DtSCONNEC'~ S E R - OF CC. CONO. 310 C NO, OF HI-LEG NO, OF NEUTRALS A, WG OF NEUIRA~ Charles ~. Ilall Elf~c~ri Dong Ore~k Cdouthold, N Y 11971 Lie 657 E This certificate must not be altered in any manner; return to the office of the 8oard if incorrect. Inspectors may be identified by COPY FOR BUILDINQ DEPARTMENT. TH!S (~OP¥ OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 Examined.."y'/~....oN .k~..'~...~.~., 19~..~. Approved ~ .k~..~-...g..~., 192 .~. Permit No. ! ..x:..~.~.~..~..~q. Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Application No. } ~L_~ ~--~. Date ............ '7/.~.~, 19.~.~. a. This application must be completely filled in by Wpewriter or in ink and submitted 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 of property must be drawn on the diagram which is part of this 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 ail applicable laws, ordinances, building code, housing code, and regulation_s, and to admit authorized inspectors on premises and in building for necessary~krffpections. J/ ~- ~ (Signature ~cant,.o£~ ' _ff=~) X', (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ......... ........................................................................... Name of owner of premises .... '~..~dL~. ~.S. ~...~.~/.~ .ff.... ,t~j/.' (4'/2~. ~. ................................ (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No... ~ .~..[ ..-~. ............... Pluinber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... ~ .~a. y r~-,~-'7, 1. Location of land on which proposed work Will be done. ~..~.~.~ ./iff&.-'.. ~,. ~.1 ff,~...~.~.' .ff,,~ .~. ~.~.//fi. 7'. ~/g~ ~YJ'r House Number Street Hamlet County TaxMap No. 1000 Section .... ~ .... .~.'.t~.... Block . . . ~).-~ .......... Lot....(~.{. · ./4W. ......... Subdivision.. ~P~:~.."...~ .~..'-...76M4C..~,, .... Filed Map No....~7) ........ Lot...~../. ......... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ... ff~.Q/,¢, zg. ~ .... ./~.z~,,? ............................................... b. Intended use and occupancy . 2.~.1.*'~...1~?:... ~.~,~/A'~..A. ./d'.t/.~.; ....................................... Repair .............. Removal ............ 4. Estimated Cost .......... . .~. ~.~./~ &O.~. .... Nature of work (check which applicable): New Building /'""/ Addition . l' Alteration · Demolition .......... , ....Other Work ............... -' ~;~ i J (Description) ......... Fee (to bq paid on filing this application) 5 If dwelling number of dwelling units /. Number of dwelling un'its on each floor If garage, number of cars ..................................... i ............................. 6. If business, commercial or mixed occupancy, specify nature and extent of each t~pe of use ..................... 7. Dimensions of existing structures, if any: Front ............... Rear ...... ........ Depth ............... Height ............... Number of Stories ........................... i ............................. Dimensions of same structure with alterations or additions: Front ........... i ...... Rear .................. ~,~_epth ...................... Height ...................... Number olf Stories ...................... imensions of entire new construction: Front ............... Rear .... i ..... Depth ........ Height ............... Number of Stories ......... i ................. ................... t/~ Size of lot: Front ...................... Rear ...................... i Depth ................... ~ Date of Purchase .... ~1~. ~.~/~&.. ~../~,.~ ........... Name of Former Owner, i ...... -.%~6r~ t/.~. TT.~ ...... " 11. Zone or use district in which premises are situated ................. ' ....... ............................. 12. Does proposed construction violate any zoning law, ordinance or regulation: . .~.,~ .................. ' ....... 13. Will lot be regraded ...... ~v~...; ~ .... :,. ,~ ,..,.. Will excess fill be removed from premises: Yes (~ 14. Name of Owner of premises~O.~./d)',~.~.l~.L".~.if[l~ddress ~.g flT, fld#q~, f14~ ..... Phone No.'7 ~. ~..~/~../. Name of Architect '. ......... Address .~'./t'.~.~..i~..~/?~..l(~'~hone No ......... i i i Name of Contractor . .7't~.at.~./~ $../-~9a'~.~,,¢~'. ..... Address .. :~ 4,,~?~ .A,5 .t~V~ Phone No..~4'~..'*~/~f~... PLOT DIAGRAM I Locate clearly and distinctly all buildings, whether existing or proposed, and. ihdicate all set-back dimensions from property lines. Give street and block number or description according to deed, and interior or corner lot. STATE OF NEW ~)R/j~/~/~' S S COUNTY 7~ .... · ......... ~(Name of in~~ia'c~i .......... being duly sworn, deposes and above named. says that he is the applicant He is the ......................................................................................... (Contractor, agent, corporate officer, etcl) 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 h s knowledge and belief; and that the work will be perforated in the manner set forth in the application filed therewith· Sworn to before me this o nt, JUDITH T. TERRY ~lo~a~ PubliC, State o~ New ¥o~ ..... F .......... I~1~. 52-0344963 Suffolk ~ourttF~ ~omm'~sLon Expires Maroh ,'t0~ (Signature of applicant) 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 Examined ................ , 19... Approved ................. 19... Permit No ............ Disapproved a/c ..................................... Received ........... ,19... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. Tkis 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. 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 of property must be drawn on the diagram which is part of.this 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 i¢ 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 applicablb laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary insp~ections. ............... (Signature of applicant, orVr~me, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, en~neer, general contractor, electrician, plumber or builder. Name of owner of premises ..~..~0..~./~.-~.' ~.{ .~..~..{.~4'.~...~.'..~.. ~ .N)..~.~. ~'l[Cd-~'~,- f~.cz} (as on the tax roll or latest deed) If applicant is a corporation, signature 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 ...................... Id d~ /~)f12. Jo, Location of land on which proposed work will be done... -- q:k~.q'· ............................................................ ~..? g...vy[ ~q ......................... House Number Street Hamlet County Tax Map No. 1000 Section ....~. ~ ........... Block ..... :~ .......... Lot .... J.L:~. ........... Subdivision. ~ .~....~.o,4~. ........ Filed Map No...¢~. ......... Lot .... ?.[ ........ (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: · . a. Ex~stmg use and occupancy .......... .... ....... - ............ :~. ............................. b. Intended use and occupancy ~ '~ ..... 8..'qr... C.~.. ~ ~..'bg. property lines. G~ve street and block mtmber pli ' ' ' ' 3. Nature of work (check which ap cable): New Building .......... Add,hen .......... Alteration ........ Repair .............. RemOval .............. Demolition .............. Other Work~).~..~.~. .. . .. i (Descr/ption) 4 Estimated Cost . Fee i "~ (to be paid on filing this application) 5. If dwelling, number of dwelling nits ............... Number of dwelling units on each floor ................ If garage, number of cars ..... 'I :-:'~:~' ............................................................... 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ...~7~ .TTT.. ............. 7 ..... if any' Front Rear Depth i · D~mens~ons of ex~st~ng structure~,, . ........................................... Height ......... Number of Stories ................................................ Dimensions of same structure with alterations or additions: Front ~ Rear Depth ...................... Hmght ...................... Number of Stories ...................... 8. D~mensions of entire new construction: Front ............... Rear ............... Depth ............... Height~ ............... Number of Stories ................................................... 9. Size of lot: Front ...........i ........... Rear ...................... Depth ...................... 10. Date of Purchase ........... i .................. Name of Former Owner ............................. 11. Zone or use district in which premises are situated .................................................. ... 12. Does proposed construction violhte any zoning law ordinance or regulation: 13. Will et be regraded ........ .. ........ ~., .......... Will excess fill be ten,eyed from premises: Yes No 14. Name of Owner of premises .-~i.~.rd.~ ~[..~ ~ ~ .~.(.K} ~ddress ~ ~,~.mq~; ~.~ ,.~... Phone No. ~.~ ¢ .~. ~T.I.~-. l... Name of Architect .......... i ................. Address . .m~..~..~-~...~. ~.; .~.-.~..~.. Phone No...~: ........... Name of Contractor...~..4~-.!) ................ Address .... .~.~..,-~ ....... Phone No... PLOT DIAGRAM Locate clearly and distinctly all ibufldings, whether existing or proposed, and, indicate all set-back dimensions from or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, COUNTY OF ................. LS ......... ; ................... i .................... being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. , He is the ...................... ~ ................................................................... (Contractor, agent, corporate officer, etc.) of said owner or owners, and is dui authorized to perform or have performed the said work and to make and file this application;:that all statements cent; ined in this application are true to the best of his knowledge and belief; and that the work will be performed in the manne ': set forth in the application filed therewith. Sworn to before me this Notary Public, ........ .... day ofi... 4~..~.. ............. , 19 ~.? 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL ~OUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined ................ , 19 .. App?ved ................ , 19... Permit No ............ Disapproved a/c ..................................... Received ........... ,19... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely tilled in by Wpesvriter or in ink and submitted 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 of property must be drawn on the diagram which is part of this appli-, cation. c. The work covered by this application m~y 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 ia 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 instep' ns. /~fi/ ' , .....~-~,.,., :.~.~o.... c,,W...~7...-~..~ ....... (Signature of applicant, or name, lit a'corporation) '" ......... i~'aili.g address of ap~li~t, W:/r::: ~ State whether applicant is owner, lessee, agent, architect engineer general contractor, electrician, plumber or builder. ~.-. ~ ~ .~ :' .~...{..~.o..~>.~:...~.'. .................. . ..... Name of owner of premises . :..-~..~..~...~..~:.~.~. ..... .~..{. ~ ~ !. ~xJ._~. ................................... (as on the tax roll or latest deed) If applicant is a corporation, signature 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 .................................................. ...¢...m. .... ~. ~.~':..:?~ .~..~.~..:. :...~.¢.7. l~ .......... C.:. ~.~ e.~... ~. >.-..~.: ..... House Number Street Hamlet County Tax Map No. 1000 Section ..... c~ ~) Block ~ Lot. I ~ Subdivision .~c~O,~/-..... ~_~..~ .... FO,~,,~. ,. Filed Map No ..... .~..O. ...... Lot...-- ~.l ........ (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupanc .. ........................................ -...~.. ........... b. Intended use and occupancy ........................................................ 3. Nature of work (check which applicable): New Building ..... ' ..... Addition .......... Alter~io~n~t~ ........ Repair ............. Removal ......... Demolition ........... Other Work '...~r'2~...'q. ~ (Description) 4 Estimated Cost i .... Fee ,l ~'. (to be paid on filing this application) 5. If dwelling, number of dwelling units....flY...m-A-~.. ..... 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 us~ ..................... 7. Dimensions of existing structures, ifany: Front Rear Depth Height ............... NurOber 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 Size of lot: Front ' Rear Depth 10. Date of Purchase .......... ~ ................... Name of Former Owner ............................. 11. Zone or use district in which p~emises are situated ..................................................... iol ' g 1 · · 12. Does proposed constructionv ate anyzonm aw, ordlnanceorregulatlon: ....... ......................... 13. Will lot be regraded · · .;. Will excess fill be removed from premise: Yes No 14. Name'ofOwnerofpremises .... Address .... PhoneNo. Name of Architect i Address Phone No Name~of Contractor ........ . .................. Address ................... Phone No ................ Locate clearly and distinctly al property lines. Give street and block interior or homer lot. PLOT DIAGRAM buildings, whether existing or proposed, and, indicate all set-back dimensions from number or description according to deed, and show street names and indicate whether STATE OF NEW YORK, !S.S COUNTY OF ................. .................. .' ' .' '. ..... .' i.' ................... being duly sworn, deposes and says that he is the applicant (Name of lnd~wdual s~gmng contract) above named. He is the ..................... ~ ~ (Contractor, agent, corporate officer, etc.) of'said owner or owners, and is du y authorized to perform or have performed the said work and to make and file this application;that all statements cent ~ined in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in th~ application filed therewith. Sworn to before me this / ' day of Notary Public ........................... .... County (Signature of applicant) SUFFOLK CO. HEALTH DEPT. APPRO>~AL STATEMENT OF INTENT ~ J ~Y~EMS FOR THIS RESIDENCE WILL ~j CONFORM TO THE ~ANDARDS OF THE g'~ ~'..F~l~t~, ~]~.., SUFFOLK CO. DEPT. OF HEALT~'~ERviCES. SERVICES -- FOR APPROVAL ~ - ~ tU~ T~T HOLE ~rv~/ 3'! ~.. , ~ RODERICK VA~ TUYL, P.C. LICENSED LAND SUR~ORS SUFFOLK CO, HEALTH DEPT. APPROVAL ~i H.S. NO. STATEMENT OF INTENT ~:;~IC~:~L~T~ THE WATER SUPPLY AND SEWAGE DISPOSAL ~ SYSTEMS FOR THIS RESIDENCE WILL ..... ~ ~ CONFORM TO THE STANDARDS OF THE . t~ %~ <?' SUFFOLK C~Em. OF~AL~H ~EEVICES. (s~ ~ ~/~ ~ A~LICANT ~~,~.~ SUFFOLK COUNTY DEPT. OF HEALTH SERVICES -- FOR APPROVAL Of: '~t ~ ~ ~ ~t ~ ~ CONSTRUCTION ON~ ~t~ su~ly .~ contal~ ~~ ~ ~ ~ tl SUFFOLK CO. TAX M~SIGNATION: .... TEST HOLE ~TAMP SEAL RODERICK/VA~ TUYL. P.C. LICENSED LAND SU~YO~S ~T~~ GREEN~ NEW YORK RODERICK VAN TUYL, P.C, LICENSED LAND SUR~ORS NEW YORK SUFFOLK CO. HEALTH DEPT. AP?P~OVAL 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. DEFT. OF HEALTH SERVICES. {si APPLICANT SUFFOLK COUNTY DEPT. OF HEALTH SERVICES -- FOR APPROVAL OF CONSTRUCTION ONLY DATE:. H. S. REF. NO.: APPROVED: SUFFOLK CO. TAX MAP DESIGNATION: DEED: L. ~OfO P. ~¢~ ('~_.~ t~.J~ TEST HOLE STAMP ' I SEAL L , El NOTIF'r' TM IILDING DEPARTME:'NT AT 76518?? 9 AM TO 4 PM FOP, 'THE rFOU nV-F~G INSPEC'T[ON£. '1. Fr~lF'- ~TION - TWO RE,~UIRED CODES. NOT RE£PONSI[~I E FOP, DESIGN OR CONSTF. UCT[ON i