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Home My WebLink About13551-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-25354 Date: 11/12/97 THIS CERTIFIES that the building NEW DWELLING Location of Property: 755 SALT MARSH LANE PECONIC (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 67 Block 3 Lot 3.1 Subdivision Filed Map No. __ Lot No. __ conforms substantially to the Application for Building Permit heretofore filed in this office dated DECEMBER 30, 1982 pursuant to which Building Permit No. 13551-Z dated NOVEMBER 19, 1984 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 ONE FAMILY DWELLING WITH ATTACHED DECKS AS APPLIED FOR. The certificate is issued to RONALD & MADELYN ROTHMAN (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 13-SO-64 UNDERWRITERS CERTIFICATE NO. N-854501 PLUMBERS CERTIFICATION DATED 03/18/97 RONALD ROTHMAN 09/26/97 02/26/88 B~din~or Rev. 1/81 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) No 13551 Z Permission Is hereby gronted to: ..... ...-z.~..~:......7...~ ~ o ~ .7~ ...................................... .~.%....~,...,...~..:~.,....~ I.~.Z.I .......... ,o..~....~......~...;~.~....~...~.~ ....... ~......~~ · .~:. ............................ ;.7.....~.~.-.:~...:.....r~ .................. ~.2 .............. : .................... ot pr*m~s*~ Io~oted ot ..2 .......... GX....°~..~...~ ............ .L.....~ ................ CounW To× ~p No. ~ooo S~ct~o,, ...o...~..'7... ........... B~o~k ..... :~.~ ........ Lot No..~.A,.I.~.L,~ pursuant to appUcatio, doted ...(~.,&.~C~.e..(~A~ ....... ~I1.:t~. .......... , 119.~....~.., and approved by the Building Inspector. Fe~ ~.. Building Inspector Rev. 6/30/80 TOWN OF $OUTHOLD /~-~ BU%LDtNG DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY '~~ This application must be filled in by typewriter OR ink and submitted to the building inspector with the following: for new building or new usa: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of c6mpleted si~e plan requirements. For existing buildings (priog to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: i. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic features. 2. A properly completed application and a consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $25.00, Additions to accessory building $25.00. Businesses $50.00. 2. Certificate of Occupancy on Pre-existin~ Buildinm - $I00.00 3. Copy of Certificate of Occupancy - ~ ,4. Updated Certificate of Occupancy - $50.00 5.. Temporary Certificate of Occupancy - Residential $15.00, Commercial $i5.00 New Construction ........... Old Or Pre-existing Building ................. Eouse ~o. $tree~ Pe~it No. ('}J[~](~ .Date Of Pe~it.jjl J~.~q .. Applicant Health Dept. Approval.,,.-..,..~¢. ..... Unde~ri~ers Approva ................ Planning Board Approval ........................ Request for: Temporary Certificate ........... Final Certieate ........... Fee Submitted: $...~./.: ..................... APPLICA~NT Town Hall, 53095 Main Road P. O. Box 1179 Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1802 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD May 29, 1997 Madelyn Rothman Box 212 - Salt Marsh Lane Peconic, N.Y. 11958 To Whom This May Concern: We are unable to complete your Certificate of Occupancy because of the following reasons: An application for Certificate of Occupancy is not on file. (Enclosed) No Underwriters Certificate on file. The check is (not on file.)$25.00 No Health Department Approval on file. NO final inspection has been made. No Plumber Solder Certificate on file. (All permits involving plumbing being issued after April 1, 1984). BUILDING PERMIT # 13551-Z Please contact our office on this matter. cooperation. Thank you for SOUTHOLD TOWN BUILDING DEPT. Town Hall. 53095 Main Road P. O. Box 1179 Southold. New York 11971 Fax (516) 765-1823 Telephone (516) 765-1802 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD CERTIFICATION DATE: Building Permit No. / (please print) Plumber: (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. (Plumbers Signature Sworn to before me this /~' day of ,///62.4~ Notary Public, RLIDI A POLIWOOA Nora'/Publ~ ~ate of New York NO. Ouatil~edin ,?.,,ullolk County Oommisslon Expires June 3, 19 ?¢ County '" O . THE NEW~YORK BOARD F FIRE ELECTRICITY ~-~00 ]-093 --:'~s~ JOHN STREET,BUREAUNEwOF yORK, NEW YORK 1OO~8 'mgD"t* February 26, 1988 ~p.tlc~tlo. No.o. JiZe 386123/85 Ran Rout~an, Lakeview Avenue, Off Milt L~o, Peconic,- ' in t~followlng (ocation;. ~B~sement ~ Ist FI. ~ FI. ~s exatnined on February - 22, 1988 and found re be in co.~pHance with the require.tents FIXTURE OUTLETS ' SWITCHES 38 53 40 DRYERS FURNACE MOTORS FIXTURES RANGES COOKING DECKS OVENS' EXHAUST~[ FANS: TfME CLOCKS MULTI.OUTLET ' DIMMERS SYSTEMS ~: NO~OF'FEET ~' '~ERVIC~ DISCONNECT · Motors: 1-1 Jacuzzi =':'z 2~G.F,oCI ·, 2-SmoKe Detectors Track Lighting.- 20' O" .'/~0 Lites 2/0 ? , . rCu~chogue.t N.~. 11935 !This-certificate must~not be altered in a'n~:man~e~; return to the office of the F1E~ fN~I'ECTION FOUNDATION (1st) FOUNDATION (2nd) ROUGH FRAME & FLUMBING COMMENTS INSULATION PER N. Y. STATE ENERGY FINAL ADDITIONAL COMMENTS: Mr. Ron Rothman Box 878 Southold, New York 11971 February 8, 1983 Victor L'Eplattenier- ~ Mr. Rothman: determine N.Y.S.D.E.C. Jouris- diction over Suffolk County tax map numbers 1000-067-003 lots# 2,3,12 & 13. Loc~on= Autumn Lake, near Goldsmith's Inlet; Lakeview Ave. Dickenson Street, Village of Peconic, Town of Southold State Pepart~ o~ Environmental Con~,~vat~on h~ found greater than 300 feet from inventoried tidal wetlands. Rcgion~ P~bt Adm~tratsr D.lL:lOff: cz TOWN OF $OUTHOLD OFFICE OF BUILDING INSIq{CTOR P,O. BOX 728 TOWN tlALL SOUTHOLD, N.Y. 11971 TEL. 765-1802 This is to advise you that the job under building permit no. 13551~ issued to Roe Rothm~n on 11/19/84 for New Dwelling is completed and a final inspection has ( ) has not ( x) been done. An Underwriters Certificate is needed In order to complete this file, it is necessary ~hat a Certificate of Occupancy be issued. Please fill out the enclosed form, return same to the above office with a check for $25.00payable to the Town of Southold. Please indicate to Whom the Certificate of Occupancy is to be mailed, amd arrange with this office for an inspection date Occupancy or use is unlawful without a Certificate of Occupancy. Please help us to clear up this matter so that legal action does not have to be taken. Thank you for your prompt attention. Very~'~ t r u 1 y~, ~/~,__ Victor Lessard Exeeut lye Admln~strator VL:gar encl. FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N.Y. NOTICE OF DISAPPROVAL File No ................................ To ~.~ .~/~... ~.../~M3.~.~.~.. · .m3o~..P/.~. ..................... PLEASE TAKE NOTICE that your ~plication dated . .~.. ,~ ........., 19 ~ ~o~,~ ~o~o~ . . .o~. . ~ G. . d~/~ .................... ~oc~o~o~o~ ~... ~Z~. 4~ ......... ,~~,. ~ ~o~n~y ~x~ ~o.~ ~,~on.. ~.X..~. ~o~..O.~ ........ ~;, .O~S,~'d, O' V~ s~a~v~o~e~,~o~.. ~a u,~ ~o~. .......... cot ~o. ~: ~(..~.~/ ~~ ~C f~O --Zf Bu~d~g Inspector RV 1/80 APR-O?-lgg? 1S:OG CODES N¥S DEPT OF STATE P.01 "vne- and Tw~F~i, nily..:._ ings . ' .... [INC~,UDiNG FACTORY MANUFACTURED HOMES). - Ftr~SaInIy Requirements 402.1 (646.1) PREVENTION OF INTERIOR FIRE SPRE~,D General Requirements Buildings shaft be constructed, arranged and separated into fire areas so as to confine.and restrict tAe spread of fire, 402.2 Fire Wells The floor area of buildings shall be divided by fire walls into fire areas in accordance with section A 204 including, tabte A 204. A 402.2,1 (640.2n) ConstrecMon a--Fire walls shall lorn a continuous fire and smoke harrier be- t, veen fife areas from Inundation to or through the roof, and the removal or collapse of construction on one side shall not en- danger the support of coestroction on the opposite side. b--Fire walls shall be constructed d noncombustible materials and shall ealend not less than 6 inches above roofs of combusti- ble construction. Where a roof is of noncombustible construction for a distance of at least 1 g inches on each side of the wall, a lire wall may terminate at the underside of the mol providing the jundion al the wall aBd root is made smokedght. c~Fire wails strait be made smoketigh! al their jundion with ex- terior wails, in type 5 construclion, the exterior wa~s shall be pro- tected with noncombustible construction of the same fire- resisfance rating as the fire walls for a distance of at least 18 inches on each side of the fire wall, or the fire wall shall project through the exlerior wail at least 6 inches. d--Where combustible members, such as joists and beams, are framed into fire wafts, suc~l combustible members shall not tend tlirnugh the wall but shall have al least 4 inches of solid non- combnstible maletial' below and at the sides and ends al such members. (64~2b) Fin RealstaKe a--The fire-resistance rating of fire wafts in'one-slo~y one- and two-fhmily dwellings wilhoul a basement shall be at least 1 hour. b--The lire-resistance rafing of lire walls in one- and two-family dwelJings nme th~n one story in J~eJgl~ shall be at least 2 hours, except that in buiidin~ more than 2 stories in height the tile- resistance rafing faf that portion o~ the wall extending t~arough a basement, cellar, or the towest story of such buildings which do not have a basement o~ cellar sh~ be at leas[ 3 hours. A 402~ (646.3) A 402,3.1 (646.3a) Division by Fin Separations Separation Between Dwelli~-g Unils Separation between dwelling units shall have a lire.resistance rating otat least ~A flour. Fire.Safely Roqulmmento oA 402.~.2 Separation al Mixed Oooupanclas ....... (646.3b) Nonresidential occupancies in or attached to a one- or two- family dwelling, not accessory thereto, shall be separated Iron the dwelling occupancy by fire separatiors having fire-resistance ratings in confo~mily with the reqbirements of table A 402-3. t~er~ABtE A 402-3. (I-646)--MINIMUM FIRE SEPARATION REQUIRED BETWEEN OCCUfANCIES (Fire~reaisl~ace ratings in hours) O~e- and Two. Family Occupancy Dwellings Mercantile rndustrial Storage Assembly Institutional (C2) (c~.l) (C~.2) {C3.3) (C4.1) (01.2) (C$.1) (C5.3) (C5.4) (C5-5) (Ce.T) (C6.2l (C6.3) I 1 2 2 2' 2 np 2 4 2 2 Z~ 2~ 2 A 462-3,3 A 402-3A (e4e.3d) ConBtruc:tlon a--Fire separations and their supportifl6 construction ~all form a continuous fire and smoke harder. b . Fin separations between dwellin6 units and occupancies other than residential shall be continuous and any openings therein shall be protected with self-closin8 opening pretectives: Enclosure o! Exits end Stairways Exits, including stairways and passa§eways forming a part thereof, servia8 in common two dwelling units or passing through or adjoining another dwelling or any occupancy olher than residenlial shall be separated'therefrom by a li~e separation having a fire-resistance rating at' al least sa hoar. A 402-3.5 646.36) Enclosure al Heat Producing Equipment a--Heat pmdudn8 equipmenl'shall be mounted on. noncom. bustible Iloor construction, or on protected combustible floor 39 Fl~*Ssfelv consiruction, shall be iaslalled with sufficient cP,~nce from ad- jac~t wo~ and olher combustible mater~al to pre~nt thek igni* t~on; a~ when Ihe ceiEng above can be heat~ to temperatm~ in excess of 175°F., It sha~ be pmtect~ for a ~sta~e d 3 ~et o~ all sid~ el Ihe heat pmducin~ equlpmenl by noncombustible maed~ providing 10 minutes or ~re of fi~e p~lecUon, excepl when such ceiling is ~eslmcl~ el non~mbust~le materia~ and has a fire.resislance rating of at I~sl ~ hour. b .Whe~ fuel-bu reing heal p~ucing e~pmeot is I~aled at a I~d ~nl~ning hab~le-sp~e, I~ walls, flo~ and ceiling 3 ~e~ or ~s I~m~ s~b equicor ~ ~ a fire-~slance rating ~ ~ lea~ ~ ho~ and ~ inlerior finish pmvi~8 at least 10 minut~ of ~re p~ecfion to Ihe c~bes~e mem~ Such pro- I~l~n drawl eel ~ m~k~ ~eraBg accepled s~ndard sh~ l~at such ~ ~ucin8 ~{pment will no~ cma~e a buslible material above 175~F. Where doo~ are pro~d~ ior e~lo~ I~a~ rooms ~F~ shaft be cover~ ~ the imide ~1b noncom~stlb~ material. c--F~1 bum~g heat Woduc~ equ~t wRhln a s~ll be pmt~d from ~cal damage ~ v~le~ d--Roor~oun~d fuel ~rnin8 ~ ~,eq~e~ ~lhin a ~raga ~ocawd ~ grade or ~lhin a ~l~rade space op~i~ d~lly ~o a ~ge, s~ll ~ tnsl~d ~ a non~m~s~le pla~esm n~ I~ Ihan ~8 Inches ab~ the ~t. A 402-3.6 Separa#one of GafaGe~ in, of Attached to, (64&3f) One- and Two-Family Dwellings ~o a--Private garages ~n, or attached to, a dwe~n8 shall be sepa~a~d (rom olher spaces in the building by oonstruclion hav- ing a llreresistance ratingof at least ~ hour. Each opening in the separation between the garage and other space in the building sha]l be equipped with a seU-clasing door having a fire-resistance rating of at least 5.4 hour..~uch door shall not open directly into a room used for sleeping purposes. b-.-Roo[S in garages shall be of rmncombustible material that will not absorb flammable liquids and shaft be placed or a~ranged so that beavier-than-~ir flammable vapors cannot ~pread to fixed sources of ignition. c--Constmctlon of garages and arrangement of equipment statiations shall be such thai toxic gases originat[ngwithin garages shall not spread to the dwellings; nor shal~ air for heating or ven- tiTatioe be ckculated ~ougb garages to dwellings. d--For purposes of this Code, a caTport with no more than two enclosing walls, sha# not be deemed to be a garage. e--An open breezeway with at least 5 feet be~veen the dwell- lng and garage shall be acceptable as separatTo~ be[ween a garage and a one-~ or two-family d~aa~ll)ng providing, a fires~op is 4O Fire. Safety Requirements provided between the roof and ceiling at ihe garage end of the breezeway. f Where a breezeway is less than 5 feet belween the dwelling and garage, or is closed on the sides, the ~a~age shall be fire pro- tected as though In, or attached to the dwellil~g. A 402-3.? Openings In Fire Walls and Fire Separations Openings in fire walls and fire separations shall be protected by opening protectlves having, fire-resistance ratings as set ~rth in table A 402-3.7. TABLE A 402-3.7. (II-646)--OPENING PROT~C~IVES FOR INTERIOR WALL OPENINGS fire-resistance catit~ of wall or Rre-re~istance separafloe in ~a1~c~ oper;~ opeeinS pn>tect[ve, occ~zs, i~ llours in hours 2or more ..................... Ior~, ....................... A 4O2.4 t64g.4) A 402-4,1 (648.4e) A a02.4,2 (646~b) A 402-4.3 Fkesiopplng General Requlrement~ Concealed spaces within wall, partition, floor, stair, attic, or cornice cons~ruc~,(oo, ~nd areu~l chimney, pipe ami duct open. ings in such construction, shall be fir&stopped to prevent the passage of flame, smoke, fumes, and hot.gases. Materials a--Firestopping ar fill shall be of nonffannrable material which can be shaped, tilted and permanently secured in position. b--Noucorebustlbie rte stopping materials shall be used in buildings of type I and 2 construction, and also around fire- places, flues and chimneys in buildings of afl Iypes of construc- tion. o---Combustible firestopping materials may be used in buildings of Wpe 3, 4 and S construction, d--Flammable materials ~all not be permitted as insulation or fill in concealed or attic spaces. Location a Concealed vertical spaces in walls and partitions shaII be flrestopped at each floor love! and at the ceiling o[ the uppermost story so that such spaces will no[ be continuous for more than one story, or communicate with concealdd'hodzoatal spaces in the floor or roof construction. b----When combustible materials [orm a pad or the concealed 765-J,802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [/~/ROUG" PLBG. FOUNDATION 2ND [/~]~INSULATION [~FRAMING [ ] FINAL ./ DATE -~//~ / INSPECTOR 765-1802 BUILDING DEPT. INSPECTION FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND/~ INSULATION FRAMING [ ] FINAL DATE ,, / INSPECTOR 7(,5.xle2 BUILDING DEPT. INSPECTION FOUNDATION 'IST [ ] ROUGH PLBG. [ ] FOUNDATION ZND ~ INSULATION. FRAMING [ ] FINAL 76S-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [:L~/~] ROUGH PLBG. FOUNDATION 2ND [ ] INSULATION FRAMING [ ] FINAL REMARKS: ? 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION2ND [ ] INSULATION [ ] FRAMING [~FINAL C~ [ ] FIREPLACE & CHIMNEY REMARKS= Approved FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-180:~ 19~. x!. Permit No.]..~.~..~.~.. [.. Application No .................. Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT Date .~..2./.~.0. ........... , 19 82 INSTRUCTIONS 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. 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 com~nenced 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~e_c.ti~nj. _ (Signature of~l/plicant, or name, if a corporation) BOX 878~ Southold~ N. Yo 11971 (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ·..I~pla.t. ter~.e.r ................ ./ .......................... Name of owner of premises (as on the tax roll or lat.est ~eed) 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 ...................... Location of land on which proposed work will be done..P-. ~. 99.n. 5:. 9. ~.h.q~. ?.~., ............................... ............................ . ................ ?e. to. n t c. .................... House Number Street Hamlet County Tax Map No. 1000 Section ..... ~. 7 ........... Block ..... ~. ............ Lot.. 2 ~ 3.,fi..?._, .1.~. ...... Subdivision..~.e.c.°.n. ¢9..~.h.?.e.s...(~.!a.p..//. ?.). ....... Filed Map No..65.4. .......... Lot .. (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy Vacannt land b. Intended use and occupancy . . . ?_.~$.m.~.~.y....hp?!e. .................................................. 3 Nature of work (check which applicable): New Building .x.x, Addition ' Alteration Repair'. ............. Removal .............. Demolition .............. Other Wor~c ............... ~De.~ription) 4 Estimated Cost ~20~0001 , Fee .................................... (to be paid on filing this application) 5. If dwelling, number of dwelling Units...............°ne Number of dwelling units on each floor ................ one If garage, number of cars ..... i ................................................................... 6. If business, commercial or mixec~ 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 ....... .~..~ · ~., ..........Numb~of,~tories .......... ~13 .......... 8. Dimensions_9,f et3tire new constrUction: Front .4°. ,~.~.' ... Rear... P.., .~.~'. . D~vth . _.~ gu. Hei-ht pu z~ .... ;berof~ fie aa4 s~or£es ~nc±us'£ve bX']~'t' zzoor'oa's'~t~."' g ' "0' Ill,un ~[O S ......................... 9. Sizeoflot Front ~. ? 55'. ........ Re~ 4OO+ ' . ..... .i'.'/)eph~"~66'~'~0')~{'i .... upon app.~ova±'oz'u, u.' .................. , ....... 10. Date of Purchase .. I Name of Former Owner .V. iC~;pr.(~). ~..t~p~[~°q~911~-e~ 11. Zone or use district in which premises are situated ..................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: .. ,I.n.s.u..g.f.~.q~..e.n~..s..e.~..b.a. 9.k.s 13. Will lot be regraded ......... :. .................. Will excess fill be removed from premises: Yes 14. Name 6f Owner of premises ...i ................. Address ................... PhoneNo ................ Name of Architect ' Address Phone No Name of Contractor ! Address Phone No Locate clearly and distinctly alii property lines. Give street and block interior or corner lot. PLOT DIAGRAM buildings, whether existing or proposed, anti, indicate all set-back dimensions from description according to deed, and show street names and indicate whether STATE OF NEW YORK, 'S S COUNTY OF.._q:2q.~.o.~./~_. ...... ! · ... ~,a ~..~/....~7~.-.. ~ ~. ~.-. .................. being duly sworn, deposes and says that he is the applicant (Name of individual sighing contract) above, named. He is 'the ..................... (Contractor, agent, corporat~ officer,.etc.) of said owner or owners, and is duy authorized to perform or have performed the said work and to make and file this application; that all statements conl dined in this application are true to the best of his knowledge and belief; and that the work will be performed in the manm'r set forth in the application filed therewith. Sworn to before me this .... ... .......... day .... Notary Public, ....... Co~ LINDA F. KOWALSI'(I NOTARY PUB[rIC, State Of No. 52-4524711 ~ualified In S~flo[k Coun~ '-Cz ,,it s'nou~ be note6 that since this _~rope¢.¥ is'located in 6n agri~u~tura~ ~reo, the goss ~ ,fy SUFF¢ THE SYSTEM~ CO N FOf~ SUFFOL~ SUFFO~ SERVI1 CONSTR DATI[: _ H. S, APPRO~ SUFF: DIST. OWNER.~ ~EL 7~ DEED:I "It s~ou~ be no,'ea thc since i-his LOT ~O'S,~Ap ~ LA~< E NA~ ES ~ E'F;~ ~ TO "MAP MO.~ OF 2,~Z___Y_;._/~_ GREEN~RT NEW YORK 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 APPLICANT SUFFOLK COUNTY . DEPT,, OF H£ALTH SERVICES -- FOR APPROVAL OF CONSTRUCT IO, 1¥ ONLY DATE: "-{ p--t- \ ~-~ SUFFOLK CO. TAX DIST. SECT. BLOCK OWNERS ADDRESS: tEL 7~=J-816[ ~ BU.~,V6~-B'TTO. DEED: L.. ~., SEAL SUFrot. K co. N£AL'r..oErr. Aee%V^L STATEMENT ~tNTE~T THE WATER ~LY AND ~WAGE OIS~AL CONFORM TO THE ~ANDAROS OF T~E CONS~"UCT ION ONLY DA E:~ DIST. ~CT, ~K' KL. r i ~ cop~er lubing is used (or water distributing system; piping shall be of types K or L only PL-U~ ~'E~ C~R~7?[CATION ON LEAD CONTENT BEFORE CERTIJ~ICATE OF OCCUPANCY SOLDER USED [N ,SUPPLY' SY2TEM CANNOT £XCE~,TD 2/~0 o/ .J / I