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Home My WebLink About16194-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall 8outhold, N.Y. CERTIFICATE OF OCCUPANCY No Z18154 Date JUNE 28, 1989 THIS CERTIFIES that the building. ONE FAMILY DW~T~.ING Location of Property EAST END ROAD FISHERS ISLAND House No. Street Hamlet County Tax Map No. 1000 Section 01 Block 01 Lot 3.15 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JUNE 30, 1987 pursuant to which Building Permit No. i6194Z dated JULY 9, 1987 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 AS APPLIED FOR. The certificate is issued to CHRISTOPHER MILLIKEN (owner, ~Lv~) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 87-S0-120 JUNE 20~ 1989 UNDERWRITERS CERTIFICATE NO. NO41484-OCT. 24, 1988 PLUMBERS CERTIFICATION DATED MICHAEL J. BARONE JUNE 30~ 1988 Rev. 1/81 FOB~ NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. Y. BUILDING PERMIT (THIS PEP, MiT MUST BE KEPT ON THE PP, EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) ]6194 z Permission is hereby granted to: ,o ~t premises located at ........................................................................ County Tax Map No. I000 Section ......... .~.J. ........ Block ....... ..~...J. ........ Lot No....;~.....~..',/£" pursuant to application dated ........ ...~.~....~ ................ , 19..~...'/.., and approved by the Building Inspector. rev. 6/30/80 TOWN OF SOUTHOLD BUILDING DEPARTMENT SOUTHOLD, NEW YORK 11971 765 - 1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY NEW CONSTRUCTION ....... OLD OR PRE-EXISTING BUILDING ...... VACANT LAND ........ Location EastEnd Main Road FishersIsland of Property ........................................................ HOUSE NO. STREET HAMLET Mr. Christopher Milliken Owner or Owners of Property ................................... ~ ............. i 1 County Tax Map No. I000 Section ...... Block ....... Lot ......... Subdivision..n. qt.a. pg!i.c.ab.l.e ........... Filed Map . .N/.A .... Lot..N/.A ...... Permit No..1.6.17.4:.Z...Date of Permit ?.u!Y..9'.l. 9.8.7.Applicant Mr: ?.h.N.st.o.p.h?. ?I. il. li.k.e.n.. SO being forwarded Health Dept. Approval from Health Dept. Underwriters Approval E.n.elose.d Planning Board Approval n. qt.a-pg.li-e.ab.l.e ...... Request for Temporary Certificate ....... Final Certificate ~ ........... Fee Submitted: rev. 10/14/88 TOWN OF SOUTHOLD OFFICE OF BUILDING INSPECTOR P.O. BOX 728 TOWN HALL SOUTItOLD, N.Y. 119'/1 TEL. 765-1802 CERTIFICATION Building Permit No. Owner ~/~ (please print) Plumber ~ ~r / (please prird~ I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. STATE OF NEW YORK) COUNTY OF SUFFOLK) ss; Sworn to before me this 30thday of June 19 88 Notary Public, Suffolk County y Public MARY 8. PANKIEWICZ NO, 52.826711~0 - sUFFOLK UNDATION (1st) UNDATION (2ndl UGH FRAME & PLUMBING SULATION PER N. Y. STATE ENERGY CODE FINAL · ADDITIONAL COMMENTS FRANK A. KUJAWSKI, JR., President ALBERT J. KRUPSKI, JR., Vice-President JOHN M. BREDEMEYER, III JOHN L. BEDNOSKI, JR. HENRY P. SMITH BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, $3095 Main Road P.O. Box 728 Southold, New York 11971 June 28, 1989 TELEPHONE (516) 765-I$92 BLDG, DEPT. TOWN OF SOUTHOLD En Consultants 1329 North Sea Road Southampton, N.Y. 11968 Re: Application No. 5-5-89-86-2-69 Dear Mr. Haje: The following action was taken by the Board of Town Trustees during their regular meeting held on June 22, 1989 regarding the above matter: WHEREAS, En Consultants on behalf of John Dempsey applied to the Southold Town Trustees for a permit under the provisions of the Wetland ordinance of the Town of Southold, application dated April 21, 1989 and WHEREAS said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and WHEREAS, a public hearing was held by the Town Trustees with respect to said application on June 22, 1989 at which time all interested persons were given an opportunity to be heard, and WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of -the town, NOW, THEREFORE BE IT RESOLVED that En Consultants ON BEHALF OF John Dempsey BE AND HEREBY IS GRANTED PERMISSION UNDER THE WETLAND ORDINANCE TO: Construct 4' x 14' ramp, 4' x 60' catwalk, 6' x 16' float, install 16 pilings with the condition that boat tied at dock canl~et c~ d~ of-~k~ad~does not interfere with navigation. Property located on R.O.W. off Indian Neck Road, Peconic, N.Y. This permit will expire two years from the date it is signed if work has not commenced by said date. Fees must be paid and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified upon completion of said project. Please return to the Building Department for a determination on the need for any other permits which may be required for this project. Permit will be issued upon payment of the following fees for work to be done below Mean High Water Mark: $270.00 180 sq. ft. catwalk 84.00 56 sq. ft. ramp 144.00 96 sq. ft. float 300.00 12 pilings $798.00 total fees FAK:jas cc: Bldg. Very truly yours, Frank A. Kujawski, Jr. President Board of Town Trustees Dept. Conservation Advisory Council file FRANK A. KUJAWSKI, JR., President ALBERT ]. KRUPSKI, JR., Vice-President JOHN M. BREDEMEYER, III JOHN L. BEDNOSKI, JR. HENRY P. SMITH BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 June 28, 1989 TELEPHO~ (516) 765-1892 J.M.O. Consulting PO Box 361 Wading River, N.Y. 11792 Re: Application No. 4-11-89-26-2-25 Dear Mr. Just: The following action was taken by the Board of Town Trustees during their regular meeting held on June 22, 1989 regarding the above matter: WHEREAS, J.M.O. Consulting on behalf of Walter L. Fink applied to the Southold Town Trustees for a permit under the provisions of the Wetland Ordinance of the Town of Southold, application dated April 13, 1989 and WHEREAS said application was referred to the Southold Town Conservation Advisory Council for their findings and recommendations, and WHEREAS, a public hearing was held by the Town Trustees with respect to said application on June 22, 1989 at which time all interested persons were given an opportunity to be heard, and WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of 'the town, NOW, THEREFORE BE IT RESOLVED that J.M.O. Consulting ON BEHALF OF Walter L. Fink BE AND HEREBY IS GRANTED PERMISSION UNDER THE WETLAND ORDINANCE TO: construct 135' bulkhead above MHWM, backfill with 300 cu. yds. clean fill to be trucked in from an upland source. This permit will expire two years from the date it is signed if work has not commenced by said date. Fees must be paid and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified upon completion of said project. Please return to the Building Department for a determination on the need for any other permits which may be r~quir~d for this project. Very truly yours, Frank A. Kujawski, Jr. President Board of Town Trustees FAK:jas cc: Bldg. Dept. Conservation Advisory Council file S H O P E R E N O W H A R T O N A S S O C I A T E S ARCHITECTURE INTERIOR ARCHITECTURE December 12, 1988 Town of Southold Building Department Town Hall 53095 Main Road Southold, New York 11971 To Whom It May Concern: Re: Milliken Residence Fishers Island, NY Enclosed is our application for a Certificate of Occupancy for the Milliken Residence on Fishers Island, New York, along with our $25.00 application fee. We are very anxious to receive our C.O. and hope that we have supplied you with everything that is required. If there is anything missing, or you have any questions whatsoever, please do not hesitate to give either myself or Allan Shope of our office a call. We appreciate you help in processing this application as quickly as possible. Thank you. Sincerely, SRW ASSOCIATES Dorothy Hurta OFFICE MANAGER Enclosures 18 WEST PUTNAM AVENUE GREENWICH, CT. 06830 203 869-7250 TO SHOPE RENO WHARTON ASSOCIATES 18 West Putnam Avenue GREENWICH, CONNECTICUT 06830 (203) 869-7250 Town of Southold Southold, NY 11971 Attn: Helen (Telephone - 516-765-1802) - Sent Express M'ail - WE ARE SENDING YOU ~Attached [] Under separate cover via [] Shop drawings [] Prints [] Plans [] Copy of letter [] Change order [] June 26, 1989 Helen Milliken Residence Fishers Island, NY [] Samples the fo Iowi [] Specifications 11-11-88 Survey Map of 1~ Rev. 6-14-89 6-26-89 . #676, Application Fee Millken job Approved by Suffolk County Dept. Health Service~ for C.O. of $25.00 THESE ARE TRANSMITTED as checked below: [] For approval [] Approved as submitted [] Resubmit_ copies for approval ~]z~For your use [] As requested [] Approved as noted [] Returned for corrections [] Submit_ [] Return copies for distribution corrected prints [] For review and comment [] [] FOR BIDS DUE__ [] PRINTS RETURNED AFTER LOAN TO US REMARKS Dear Helen: As per our telephone converation today, enclosed is our approved site plan from the Health Dept. along with our check for,S25.00 for the application fee for our Certificate of Occupancy. You informed me that you have all of the other necessary information there in your office already. Please send the Certificate of Occupancy to our office as soon as possible. For our records we need the old check for the application fee; check #6249 returned to our office also. Thank you for your help. COPY TO JOHN W. HALLMAN, LTD WATER ANALYSIS BOX 423 SHELTER ISLAND HEIGHTS, NY 11965 (516) 749-0195 THE ENCLOSED WATER ANALYSIS FOR YOUR NEWLY CONSTRUCTED HOUSE INDICATES: ~ That the drinking water- is of good quality and meets all State and County Health Department standards. [ ] Coliform bacteria is present <follow 'the instructions om 'the enclosed card). [ ] Iron exceeds the standard of 0,3 mg/L. Either run the water ~nore to develop the well and retest for iron, or install a polyphoephate feeder- (Micro-Met) to satisfy the Health Department. [ ] Iron exceeds the star, dard of 0~3 mg/L. more to develop the well and retest for iron, softener or ion exchange treatment system. Either run the water or in~tall a water [ ] Manganese exceeds the standard of 0.3 mg/L. I~stall a polyphoephate feeder (Micro-Met) to satisfy the Health Department. [ ] Manganese exceeds the standard of 0.3 mg/L. softener or ion exchange treatment system. Install a water' [ ] Nitrate exceeds the standard c,f 10.0 mg/L.. Run the water n~ore and retest for nitrate, or install a reverse osmosis treatment syste~'~ under the kitchen sink~ [ ] The organic compound(s) exceeds the standard of ........... ug/L. Run the water more and retest for organics. If the organics do not decrease below the State or Co,inty standard, install a granuIar activated carbon system for who, lc h,:,use:.~ treatment. [ ] Aldicarb (Temik) exceeds the standard of 7.0 ug/L. The Suffolk Cour, ty Health Department will coordinate the installatior~ of a treatment system, if necessary. Please be advised that the Health Department ~nay require you to deepen the well if one or more of the parameters exceed the etandard. If the well is changed, a new water analysis must be tmke~. If a parameter exceeds a standard, and better quality water, i~ not available, you ~st get approval fro~ the Health Department to have treatment installed. If treatment is necessary, the Health Department will require you to have a covenant put on your deed and it must be filed with the County Clepk~ stating that the naturally occurring water supply exceeded the N. Y. State drinking water standard at ~he ti~e of sa~pling a~d that water treatr~er~t has specify ir, writl~g~ the expedited operatior, al life of the filter ~'~er,~brar, e or capbon~ based upo~ the raw water ar~alysis. Ar~ affidavit be ~ub~,~itted with ~r~ acceptable water ar~alysi~ of the filtered war,er. If you j~.~st hawe a polyphosphate ~eeder (Mi~ro-Met) you will r~eed a le~tte~, fro,'~'t the plu~'~ber or in.taller st;atir~g that has been installedk If I can be o~ further help, please call. ENVIRONMENTAL TESTING 377 SHEFFIELD AVE. · N. BABYLON, N~Y. 1].703 · (5].6) 422-5777 LAB NB. C882869/1 12/06/88 ATTN: John W. Hallman Ltd PO Box 423 Shelter Island Heights MY 11965 SOURCE OF SAMPLE: Milliken~c.,Fishers Island COLLECTED BY:. JH-EcoTest DATE COL'D:ll/23/88 RECEIVED:ll/23788 SAMPLE: Water sample~from c.w. tank, pump ran 1 hr ANALYTICAL PARAMETERS T. Coliform~MPN/100mL <2.2 Chloride as C1 mg/L 27 Iron as Fe mg/L 0.16 Nitrate as N mg/L 0.8 pH units 7.2 MBAS as LAS mg/L <0.1 Manganese as Mn mg/L <0.02 Ammonia as N mg/L <0.1 Spec. Cond. umho/cm 160 ANALYTICAL PARAMETERs Vinyl Chloride ug/L Methylene Chloride ug/L 1t Dichi'oroethane ug/L Chloroform ug/L 111Tri~hloroethane ug/L Carbon Tetrachloride ug/L 11Dichloroethene ug/L 12 Dichloroethane ug/L Trichldr9ethylene ug/L 12 Dichloropropane ug/L Tet~m~hloroethene ug/L Benzene ug/L Toluene ug/L m Xytene ug/L o+p Xylene · ug/L o. Dichlorobenzene ug/L p Dichlorobenzene ug/L <1 <2 <2 <1 <1 <1 <2 <2 <1 <2 <1 <1 <2 <2 <4 <2 <2 REMARKS: Ail values are within NY State and Federal standards for potable Water. ID# 87-S0-120, 20 gpm., untreated.//~ NEW ¥O~.K STATE DEPARTMENT OF ENVIRONMENTAL CONSER~ATIOH County COMPLETION REPORT :- LONG ISLAND WELL A D~P,E $ S ....~/ Ground Surface DE~H OFWE~'~[O~'UR P ~C[ ' / 'ft. DE~H TO GROUND WATER FROM~O~SURFACE fl. TOP OF SCREENS MAKC OPENINGS ~- PUMPING LL ~ ft. top of casing ~ tr. top of casing ~l, hfs rain. PUMP INSTALLED DROP LINE SUCTION LIN~ ' DIAMETER D~AMETER ~ ~ , , i"' LENGTH In' _ -, ,,-. LENGTH METHOD OF DRILLINg USE OF WATER ' ' *NOTE: Show Jo~ of well - m~terJals encountered~ w~depth below ~round surface, water bearin~ bed~ and water levels in each, casin~s, screens, pump, additional pumpin~ tests and other mailers of imerest. Describe re,ir job. See Inslructions as to Well DriHers'CerHficales of Registration ~ndReports. Pages 5 - 7. Locate well with respeCt to at. least two streets or roads, showing distance (rom corner and front o( ~ot. i the 1own in which'the p~oiect is located: Check Nassau county: ~ North Hemgstead ~] Hempstead Suffolk CountY: ~Babylon ~uotington ~Southo~d ~]Brookhaven ~]lslip ~]Smithtown Oyster Bay East HamptOn giverhead [~] Southampton November 11, 1988 To Whom It May Concern: I Frausini Plumbing & Heating, Inc. was the plumbing and heating contractor for the Milliken Residence on ~Fishers Island, New York, Building Permit Reference #87-S0-120. We hereby certify that less than 2/10 of 1% lead was used in all plumbing joints at the Milliken Residence as required by New York State Code. Frausini Plumbing & Heating FORM S-9 S.C. DEPT. OF PUBLIC WORKS, DiV. OF S~,NiTATION S.C. DEPT. OF HEALTH Purported Owner Name Mr. Christopher Milliken Address Fishers Island New York Telephone No. 516-788-7428 TO WHOM IT MAY CONCERN: Building Permit No. 161-94-Z Map Name Fishers Island Map No. Hamle~ of Township of Map No. 1000 Section 1 Fishers Island Southold Lot No. 3.5 The sanitary sewers and appurtenances, sewage disposal facilities and water supply for the above mentioned structure have been inspected by these departments and found to be satisfactory. Sanitary Sewers and Appurtenances Date Construction Administration Sewage Disposal Facilities Date Dept. of Public Works, Div. of Sanitation Water Supply Date Department of Health Department of Health PLEASE NOTE- IMPORTANT - Where required by contract, escrow deposits must be made to the Department of Public Works, Division of Sanitation, before Certificates of Occupancy can be issued, Please be advised that a minimum of three (3) business days are required to process this form. THIS FORM MUST BE SUBMITTED IN ,TRIPLICATE. S-9 SCDPW SCHD 6/81 42-169:6/85 SPEARHEAD CONSTR; 1017 Washington STAMFORD, CT 0690 (GE (203) 323-61:~3 TO Southold Town Building Dept. 8626 & 8627 6/30/87 Main Road A~Nr,ON Southold, New York 11971 ~telen DeVoe RE O'Brien & Milliken Permits Fishers Island, New York WE ARE SENDING YOU XX Attached Under separate cover via the following dems Shop drawings Prints Plans Speoffloahons Sarnples Copy o[ leder Change of dm Other~ ............. + ......... , ................ DESCRIPTION 6/19/87 12882 Milliken Health Department Approval - Original 5/29/87 12065 O'Brien Health Department Approval - Original THESE ARE TRANSMITTED as checked below' For approval Approved as submllted Resubmd cop,os for approval X X For yom use Approved as noted Submit copies lot dlStrlbuhon As requested corrected pnnts REMARKS FOR BIDS DUE/D,~TE: PRINTS RETURNED AFTER LOAN TO US COPY TO Allan P. Shope, A.I.A. SlG~EO ~¢~; j HENRY P. SMITH, President JOHN I~1. BREDEI~EYER, Vice-Pres. PHILLIP J. GOUBEAUD ALBERT KRUPSKI, JR. ELLEN M. LARSEN BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall, 53095 Main Road P.O. Box 728 Southold, New York 11971 TELEPHOI~FE (516) 765-1892 May 1, 1987 Mr. Glenn E. Just Land Use:Company N. Country Road Box 361 Wading River, New York 11792 Re: Milliken Property Fish-ers Island Dear Mr. Just: Pursuant to your letter of April 23, 1987 requesting a determination on the need of a Wetland Permit for the above referenced property, please be advised that an on site inspection was conducted and it has been determined that the projecg is out of the Trustees jurisdiction. Should you have any questions or concerns, please do not hesitate to contact this office at the telephone number listed above. Very truly yours, Henry P. Smith, President Board of Town Trustees HPS:ip cc: Robert A. Greene, D,E.C., Stony Brook Commissioner Henry G. Williams, D.E.C., Albany Stephen Mars, Army Corps of Engineers Thomas Hart, Coastal Management Conservation Advisory Council Bldg. Dept. Board of Appeals File S Pi O P £ R E N O W kt A R T O N A A RCHIT [CTURE INTERIOR ARC H I T£C TUI(E S S 0 C I A T L S NEW YORK STATE ENERGY CONSERVATION CONSTRUCTION CODE DATA BUll.DING ADDRESS: OWNERS NAIVI E: ARCHITECT: Fisher's Island, New York 06390 Block 3 / Lot 5 Mr, and ~Jrs. Christopher Milliken Shope Reno Wharton Associates 18 West Putnam Avenue Greenwich, CT 06830 (203)869-7250 I. BUILJ)ING TYPE Detached One Family Dwelling 2,400 Square Feet - Two Stories in Height - Building is Residentially Heated Il. ENERGY SYSTEM - lleating III. DESIGN DATA fleating Degree Days 6,000 D,D Ileating Design Temperatures Outside 5°F Inside 70°F Page 1 of 3 18 W [ S T P U T N A M AVENUE G R E £ N W I C H, C T. 06 8 30 Z03 869-7250 IV. BUILDING ENVEI~OPE DATA a) b) e) d) Walls, Overall Assembly Ao = 2947 1. Opaque wall (framing & cavity) Aw = 2355 2. Glazing Ag= 519 3. Windows % wall area 22% 4. Doors Ad: 69.75 Basement Walls- Insulated- tleated 1. Opaque basement walls, above Aw = 140 grade 2. Basement wails, below grade Aw = I120 Roof/Ceiling, Overall Assembl~ Ao = 1125 1. Opaqne roof (framing & cavity) Aw = 1125 2. Glazing N/A. Floors, Overall Assembly - All floors to be over,insulated spaces. Prop?ed Value Uo = .12 Uw = .04 Ug = .44 Code l{equirement Uo = Uw = .05 Ug =.58 Ud = .346 Ud: .40 Uw =.078 Uw = .09 R1 = 12.35 Uw =.044 Uw =.044 N/A N/A AIR a) b) LEAKAGE Infiltration Rate Windows Res. sliding glass doors Res. swinging doors Nonresidential doors Entrance doors (type) One and two family dwellings Entrance Door (Ud = .346) c) Caulking and sealants d) Exterior joints and openings Between wall and foundation Between wall and roof Between wall panels Weatherstripping of openings Fireplace Outside comubstion air ' Infiltration loss 20 cfm flue damper Code Requirements 0.5 cfm/I/near foot 0.5 cfm/square foot 1.0 cfm/square foot 11.0 elm/linear foot Yes X X X X X X X Value Specified (if different) .17 cfm/linear feet N/A .07 cfm/sqaare foot N/A Page 2 of 3 VI. MECIIANICAL EQUIPMENT PI:,tU:OFtMANCI': - Oil lleating Equipment 75% min. efficiency. x/Il. TIIEIii~IOSTAT lleating- only with a min. range of 45° - 75° VIII. :,',IF. CIIANICAL SYSTEM INSULATION E(40a.10) - Duct insulation exempt - insulated basement ~ualls. IX. PLOMBING SYSTEM E(404.0) , a) l)omestie water l~eater to meet ASHRAE 90-75 stut~durd. Type: Electric b) All water pipes to be insulated to safeg'uard' nffninst winter' ft'ee×in~& c) Water conservation: lavatories ~t 2 gph tubs ~ 20 gph ahowers ~t 30 gph clothes washel, 0 20 gph dishwasher @ 15 gph kite/mn sink ~1 10 gph X. EL ECTIUCAL DISTRIBUTION Elects'itel distribution design to conform to the ~tiom~l l':lectric C~de. '/'his is to certify thai to tho best of my knowledg'e these ch'~winff~ comply tvitt~ lhe New York St~Io Energy Coneervation Construction Code. AI,I,AN P. SII()IU~ LAURA E. KAEHLER STATE DEPAR~'~ OF ~.IVIP~iq~,7~qTAL COMS,ERVATIOt! Regulatory Affairs Unit Bldg. 40. SUre--Room 219 Stony Brook, ~ 11794 (516) 751-7900 bocation.. , ~ ' I ' ~ , / I I, ' , ~e ~ew York State D~partme:t of Environmental ~e~ation has dete~in~ that the above project is. ~ !1ore than 100' fr~ Freshwater wetlands. ~e Freshwater ~.'etlands present are tentatively mapped as less than 12.4 .... acres and ;have not been designated by the State as having unusual local importance a~ this time so are not currently regulated by ~e wetlands p~esent are Tidal and i~ appears that you need to apply for a Tidal Wetland Pe~it. I~erefore, no permit under Article 24 (Freshwater Vetlands) of the Envtroreaental Conservation Law is required. Very truly yours, Alternate Permit Administrator SUFFOLK COUNTY I ECTION SEW~GEDISPpSAi Applicant DEPARTMENT OF HEALTH SERVICES tT FOR SINGLE/TWO FAMILY /~ER SUPPLY FACILITIES I~ ~ //1'/5'~ ~,~. , Phone No. ~ces~o6] Map of iEnte~ed EXCAVATION INSPEC~ION'~: 1. Date /~ 1M~ ~ 3. DepthS 2. Inspected ~Y ~ ~/~ 4. Backfill~ ~~-~~~~~=~-m~=~=~=~-~-~~-~ ~SITE INSPECTION ~ WATER 5. Single Family ( ~-~) Two Family (, ,) 10. Pu6i!ic w~ter lin~talled 6. Faci!. to ~.1. ~u~lding ..... I~! 11.]:.Watem li~e ~o edge of,'facilit'ies ( .... ) 7. Dist. to o~her wells & p.ools ..... ~ ~ 8. Covers clear, walks & dr, ve, ..... (--~) 12. Well ioc~tio~ ~ ) 14. Casing -'I 9. safe distance to surface waters..(~ 13. Lateral ;]ihe ( ) Dia. , -::':::~::-::::-: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: SEPTIC TANK,INS:PECT~ION ' ', 21. Chimneys. ( ) 15. Mfr. ~, (, ~ gals.) 18. A~r space';,. 22. Liq. level...( 16; Shap~ ~::::' Mat's] pr~ ,, 19. Outlet T'S..{~ 23; Tank level...( 17; Waste line ?~ ze ~ 20. Covers...~,.,.(~ 24. Grade ..... ,..{._~ ............... ~ .......................................... ~ .... ; ................ ~ ................... LEACHING POOL INSPEC~FION' #I POOL #2 P.OOL ~3, POOL ' 25. Effective ¢,~pth/ ' " ~' diameter/tOp. ~-~-, ~ ~' ~-, ~ ~ 26. Waste line slze & "~ '· typb of material (, 27~ Chimney prOvided ( ) ' (~ , . ) ( ) ( 28: Covers approved I~ ( (~ (--~' (--) 29. Disl~ance to! fin. grade,__.__~ (------} (--., (__) (~ · Insp D~te Remarks Da~e Disposition NAL HOLD FOR COMPLETION WDC WA Inspecto~ Covenants Date Other ' ~ Supervisd, r: WWM~051 (Rev. 1~86) z~.z~8,.s/8~ Date _'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. 11971 TEL.: 765-1803 Approved ..~. ., 19~..~. Permit No..! ./-e. [ .~.q..~. Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH~- SURVEY .~.,~t~;.,., cHec~ ~ . ~./~. ?. . ~OTI~Y CALL ................ Date ................... 19. INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 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 strec or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this app cation. e. 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 peru 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 Occupan, 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 tl Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein describe The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and admit authorized inspectors on premises and in building for necessary inspections. ....~.~.¢.~.,e.,¥~-..~.,..~,~-r~e,.~r.,~. ~'~,e.. ......... (Signature of applicant, or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builde ...~,,~..~¢ae.~,. L/~),,,,-.~,.~.no~. ..................................................................... Name of owner of premises . ~ .Z..~.~.q · ·..--.<~.~..'?.~.~. /~"/~"~'*~/ ...* .................... (as on the tax roll or latest deed) If applica~poratij~gafr~f duly authorized officer. ......-- "' '' ............. (Nam~and title of corpoi~officer) ' ALL CONTRACTOR'S MUST 'Blg SUFFOLK COUNTY LIC]gNSED Builder's License No .......................... Plumber's License No .... ,2,,¢...,¢¢.': ./-'%.. ........... Electrician's License No...~./. ~.q :. ~.-~ ............ Other Trade's License No ...................... 1. Location of land on which proposed work will be done ................................................ House Number Street Hatnlet County Tax Map No. 1000 Section .......... / ...... Block ...... .~...../. ..... Lot .~ .?: ./.~.'.~. · · Subdivision ..................................... Filed Map No ............... Lot .............. (Name) 2. $tate existing use and ~ccupancy ~f premises and intended use and ~ccupancy ~f pr~p~sed c~nstructi~n: a. Existing use and occupancy.........'d:5)~,--' ~.-o~'.q. . .................................................... b. Intended use and occupancy ..... q4~.. ,~.~.. '/,~.~,v'c~.. ' . .......................... ature of work (check which applicable): New Building ........ ,,, Addition ..... ', [i.~. lA~tenltlon ,. ~ ~ ........ Repair .............. Remoyal .............. Demolition ............. ; Other Work ........ . ....... I ~1~ ~ ~scrip.tion) 4. Estimated Cost...'~.~'t q.o~.: .o.o!! ........................ Fee ............. ......................... i " (to be paid on filing this application) ' / Numbe f dw Iii its h floor 5. If dwelling, number of dwelling qnits ............... r o eng un on eac ............... If garage number of cars ~ r---- 6. If business, commercial or mixedi occupancY, specify nature and extent of each type of use ................... 7. Dimensions of existing structure% if any: Front ............... Rear .............. Depth ............. Height ............... Number of Stories ....................................................... Dimensions of same structure with alterations or addThons Front ................. Rear ................. ' ' Number of Stories Depth i. Height ........................................... $ Dimensions of entire new construction: Front ' Rear Depth Height Number of Stories ~.. 9. Size of lot: Front ...........i .......... Rear ...................... Depth ..................... 10. Date of Purchase ........... ~ ................. J~ame of Fenner Owner ............................ 1 1. Zone or use dTstrlct m which prelmses are situated... ~F4'~..q,~-~.~/,~.~, ........ / .......................... 12. Does proposed construction violate any zoning law, ordinance or regulation: . ./~., .......................... 13. Will lot be regraded ........ "~/~.,s ................. Will excess fill be removed from premises. Yes 14. Name of Owner of premises/'/~;~/'/*~ .alT.....~<~.~.~'.~?.. Address .~'~3;~r~.,~&.o~v~. Phone No.f~.73.474 :.~. 15. Is this property located 0tthin 300 feet of a tidal wetland? *Yes ..... No ..... *If yes, Southold Town TruStees Permit mavbe required. i PLOq' DIAGRAM and distinctly all !buildings, whether existing or proposed, and. indicate all set-back dimensions from Locate cleltrly 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 NEW YORK, S.S COUNTY OF ..... ~ ' ' ......... i ...... ' being duly swor~ deposes and says that he Ts the applica (Name of individual sigh'lng contract) above named. (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 thi~ application; that all statements contained in this application are true to the best of his knowledge and belief; and ttial thc work will be performed in the manner set forth in the application filed therewith, Sworn to before me this ..... County. I NOTARY PUeLIC, State:of New Ye~k -- , ~*~,-.;r/- I -, -' ' _ No. 4707878, Suffolk County~ o ' ! le~m Expires March 30,1~