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Home My WebLink About13711-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy No. Z14862 Date Sept. 10 86 THIS CERTIFIES that the building .... A..cc..e .ss. 9r.Y. ................................... 4365 WICKHAM AVE. MATTITUCK . Location of Property House No. Street Hamlet County Tax Map No. 1000 Section .. 1.0.7. ...... '.Block ....~ ........... Lot 1.4 Subdivision ............................... Filed Map No ......... Lot No .............. conforms substantially to the Application for Building Permit heretofore filed in this office dated ..... Feb,. 1.4 .......... 19.8.5. pursuant to which Building Permit No, ,. ,i .3.7.1.1.Z ............. dated Feb. 28 85 ............................ 19..., 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 ......... Accessory garage in rear of property. THEODORE J. CONLON The certificate is issued to ..................... [o~n'o;',~'t) ...................... of the aforesaid building. N/A Suffolk County Department of Health Approval .......................................... N761854 UNDBR~RITBRS CERTIFICATE NO .................................................. Rev. 1/81 · ~/ Building Inspector ' FOB, M NO. Jl TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) tO ........ ~./~~~~ ,~~ ...... ~/ ........................................................... County Tox Mop No. 1000 Section ....~..0...7 ......... Block ..... ..(~...~... ....... Lot No....~.~..,~.... ....... pursuant to application dat~ .... ~~..../.~., ,9~/and approv~ by the Building Inspector. "'~"~ Buildinj Inspector Rev. 6/30/80 FORM NO. 6 TOWN OF SOUTHOLD Building Department ~ Town Hall '~ Southold, N.Y. 11971 765- 1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted tor with the following; for new buildings or new use: V'I. Final survey of property with accurate location of all buildings, property Ii v/ 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 pz"operty 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 $i 5.00 3. Copy of certificate of occupancy $1.00 5.updated C.O. $15.00 Date .................... NewCons trhc tion ..... Old or Pre-existing Building ............ Vacant Land ............. Location of Property ........ , .............. ~ ..... ~J~I~.TF,~'~. L~C~' . . House No. Street Owner or Owners of Property ,"~C),~. ,0.~.~' ~'-- .(~p.l'~ County Tax Map No. 1000 Section .. lO.? Block .~.~ Lot. Subdivision ................................. Filed Map No ........... Lot No .............. Permit No. ~..[1~.... Date of Permit .~.~Z.~. l ~..Applicant . -~3... ~.O..~..0{~.~....~.;...~'.~.~ ./:~..~. ........ Health Dept. Approval ........................ Labor Dept. Approval ........................ Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate ...................... Fee Submitted $ ............................. Construction on above described building and pJ~rj~it m~t,s all/appl~cable codes and regulations. FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 11971 765- 1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted m ~ 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 disposai-(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 pZOperty 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 $1 5.0 0 3. Copy of certificate of occupancy $1.00 4.Vacant Land C.O. $5.00 5. Updated C.O. $15.00 Date ....... .~'..~ .'7~ ~ ........ Ne.w C o ~on., ..... Old or Pre-existing Building ............ Vacant Land ............. D~'r~qTC.~K~.~ .~ L~e) ....... Lc.:~rty ...~.~. h5 ...... ~.' .[..c~L~H' . .I~.U..(:;.- ..... .~. ~;'~.~..T{~..C~¥ ................ House No. Street Ham/et Owner or Owners of Property .... . . ."~l~.~)~.~ ..,. ................................ County Tax Map No. 1000 Section ..... [.0..~ ...... Block ...... ;~ ....... Lot .... .~.~ ......... Subdivision ................................. Filed Map No ........... Lot No .............. PermitNo. !~3.-~1[,7-... Date of Permit .~ .Z.~. pplicant ...... .."~..~...~{~__~..~..-...~,.L)...~..~... Health Dept. Approval ........................ Labor Dept. Approval ..................... ... Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate ....................... Fee Submitted $ Construction on above described building and p,~t mepW.~ ~1 ap~l'mable codes and regulations. Rev. I0~10-78 THE NEW YORK BOARD OF FIRE UNDERWRITERS 1~09"~0~' BUREAU OF ELECTRICITY [~i 85 JOHN STREET, NEW YORK, NEW yORK 1OO38 THIS CERTIFIES THAT : o~ly t~ electrical e~u[pment ~ ~eribed below and intr~uced by t~ applicant ~med on the a~ve appllcation nu tuber in the prem~es of Con[on~ Ted~ W~ckh~ Ave. (log cab~n)~ Ma~uck, N~Y. ~s examined ow ,.3~ l y Z4 ~1986 a"d fou"d t° be ln c°"tVlla"ce ~'ith tbe reqt'ire"~enis ~f tbls B°ard' FIXTURES RANGES OVENS DISH WASHERS EXHAUST FANS FIXTURE 21 20 DRYERS UNIT HEATERS MULTI.OUTLET SYSTEMS NO. OF FEET OTHER APPARATUS: 2- Smoke Detectors S E NO OF HI-LEG AWG NEUTRAL 1 Independent Elect. Systems 112 Prospect Street Babylon~ N,Y,, 11702 lic.#3264 This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors COPY FOE BUILDING DEPARTMENT. THIS COPY OF GENERAL MANAGER may be identified by their credentials. IN ANY MANNER. TO~;N OF SOUTHOLD OFFICE OF BUILDING INSPECTOR P.O. BOX 728 TOWN HALL SOUTHOLD, N.Y. 11971 TEL. 765-1802 CERTIFICATION Owner'~o~O~ ~' ~ (please print) Plumber ~ ~ ~ ~' ~/~l%)' (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. (plumber' s signature) Sworn to before me th~s ~-~ d~y o~ ~ , 19~'~ · Notary Public, ~~ County FIELD INSPECTION ~ COMMENTS FOUNDATION FOUNDATION (2nd) 2. ROUGH FRAME & PLUMBING INSULATION PER N. STATE ENERGY qO~E Y. ~Ok" ADDITIONAL COMMENTS__k__ 765-18~2 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION ZND [ ] INSULATION [ ] FRAMING [ ] FINAL RE:MARKS: ---~~~. MANUFAC~'URER.e. OF EARLY AMERICAN LOG HOMI~ I~IVERSIDE DRIVE ® CtiESTERTOWN, NEW ¥ORR 12517 ® (.~]~) 494-;t4~ C U S T OM E R N O T I C____E C E R T IF I C A T I O N : RE: Conformance to %he State of New York~ Public Service Commission Order & the Energy Conservation Construction Code. Lincoln LOgs Std., hereby certifies to __/~__~ ~6~4~d~ __ '(name of purchaser) that the Basic DO9 Home Buildin9 Package, ~~,~.~ '~ ~ ~ [name of model) Model, when cor~tructed in accordance with the Specifications and RecommendationS herein attached, {4eets &/or Exceeds the minimum insulation and energy conservation standards as established by the STATE OF Nfl~ YORK - PUBLIC SERVICE CG,~LSSION~ CASE ~269%3 & ORDER ~76-16(A) and the ENERGY CONSERVATION COr~3TRUCTION CODE~ as amended to-date° Linc~[nLogs Ltd., also certifies that the above-named Model & any Modifica%ions &/or Addit~ons~ has not been altered subsequent to review by the Engineer~ whose Meat Loss or Thermal Studies were the basis for approvals &/or acceptance. Lincoln Logs Ltd. by: Richard Considine President GEORGE KUROSAKA Chief of Engineering NEW YORK ENERGY SUBMISSION (cit~T-- --'~r66t--no--~~ ~-treet name,) MAP # SECTION # BLOCK CODE FORM (%-E~'~')'- ' ----~£~-T---- DESIGN CONDIT I_____ONS :, Outd~ Design Temperature: /o oF Indoo~ Design~ Temperature: 70°F Annuali De~ree-Days. ~ d-d d-d or per ASHRAE: _ oN Degree~ North Latitude: ~ Building Type: 78OF Detached 1 or 2 P~ily Dwelling Other Residential (3 stories or less) Other Buildings Heated yes no % yes no METHOD OF CO~ORMANCE: Cooled Envelope Compliance E302o~ Alternate Building Design ~ Syst? AnalysiS E502.2 Bidg DeSign by Acceptable Practices WINTER DESIGN TEMPERATURE DIFFERE~E.:._ ~ or ~ °C °Fo~ ,~, ~ °c A.SoH.RoA.E CoA.BoOo E N E R G Y C 0 D E SUBMISSION FORM: CGMBINED GRO~ WALL THE~3P~%NS!~ITTANC,E.,.VALUE (u) CALCULATIONS: Glass dbl-glzg dbl-glzg tri-glzg u - 0.46 u - 0.55 U - 0.30 Door 1. 3/4"Foam-filled Wall 6" ,,loqs" EWP Framing x , Fr~g 2"x6"~24"c~ /~-x.~0 wall Attic-R~m ~ x 0.85 .~ . ~sed ~t Walls/~x2' ~ ~s~ent Gi~s ~1~1~ u = 0.55 ..... Bas~ent ~r fo~-filled Area (A~) Resistance (R) ~. 2 o 17,4 ........... ~0.52 21. 05 . 12.28 39.81. 8.56 22.58 1.0.84 ~[.818 Uo wall = A Uo wall Cod~ Limit = ! ~Meets Code [[] Does ~t Meet Code C~BI~D GROSS R~/CE~ T~ T~M~A~E V~UE R~='Ce~n~m~nen~~z ~rr r~ ~ ~ea (A) Resistance (R) ~n~ath~ / Cathedral Ceiling Fr ~ming (u) CAI~iULAT1ONS: T 0 T A L S Uo roof = A = ' u Code Limit = ~ o roof ~tS Code ~ Does ~k~t Meet Code '.C~B~ ~S F~R Till T~A~E V~UE (u) CA~TIO~: Floor C~ ~ Res~ta*=e (R~ TOTALS UO flor = ' ~ = UO flor Code'L~m~t ~ ~ .~,. ~ ~ ~es Not Meet Code A/R ~9. 6~ btu=h/ft2_°F N E '.~; Y 0 F, l( E N E R G Y' C O D E T}SiRMAL RESISTIVITY C~ SIAB-ON-GRADE FLOORS: Insulation Type:2" ex ded-~oly-s~rene Foam-Board (EPS) ~ R ~ 4o17/" ~4" in or down R ~ 8.34 ~1 24" in & down R R mino Code w ~ Meets Code ~] Does Not Meet Code ALTERNATE ME~HOD _- ' TOTAL ENVELOPE CO~Ot~ANCE:, Component ~.~ __Gr°ss Area_ Total A/R WalI ..... Non-cathedral Roof/Ceiling ~ _ , Cathedral Roof/Ceiling Floor (1) GRAND TOTAL [] Mee~s Code U C__ode°Limit. AXU Limit_° (2) TOTAL [] Does NOt Meet Code If the GRAND TOTAL (~) of the Wall~ Roof/Ceiling and Floor A/R values is S~_t__oor.------------less than the TOTAL (2) of the A x U Code Limits for the Wall~ Roof/ Ceiling and Floo~, the TOT~.,ENVE~OP__E - Meets the even though individual Components may not. If the TOT.AL ENVELQP~ Calculation still indicates that' the proposed construction does not meet Code Require~ ments~ changes ~n the building must be made to reduce glass areaS~ use additional layers of glazing~ increase amount of insulation in components~ until structure 'meets the Code Requiremen~So INSULATION STANDARDS & SpSIi!FICATIONS - USED ~i~ CALCULATIONS: M~nimum Insulation to meet a/or exceed all current requirements of the N~; York State Public Service Commission Insulation Standards & the Energy Conservation Construct- ion code. ]- ~ .... ~ q~4"hi~h X 6"ave. thick, #2(min) - machine-shaped, % side - fla~, bottom - dotfole-grooved; air-dried still air 0.68 6" Pine Log O.S. Air ~5mph )0o~7 Eastern White Pine (Adirondack-Northern) 1 side - rounded; top - double-tongued~ = 1,86/" or 6" = ~1.~5 12o00 u = 0.083 TOTAL R 2"x6" Stud Walls - 2,'x6" ~ 24"c-c~ 6" fiberglass harts w/Kraft-Paper ~ R = gypsum wall-board - interior; and 5/8" plywood siding (R B&B) - exterior, still air 0.68 ~, gyp. hd. 0~45 6" f-g' ~9.00 5/8" plywood 0.75 OoS. Air ~5mph 0.%7 TOTAL R : 21.05 u = 0.048 insulate with ~2" fiberglaSS along with ceilings} wood-framing Attic-Room Walls, %,, gypsum wall-board - interior ( R = 38); v. atlate attic space. still air .0.68 ½,, gyp. bdo 0.45 12" f-g 38.00 still air 0.68 TOTAL R = 39.8~ u = 0.025 cEILINGS/ROOF.:.. Ventilated A~tic: 12" fiberglaSs harts interior ceiling still air up 0.6~ ~, gyp. hd. 0.45 12" f-g 38°00 still air up 0.61 TOTAL R = 39.67 w/Kraft-Paper; ~' gypsum wall-bo~r~ - u : 0.025 RIM JO/STS: ~ension lumber around perimeter of · exterior & 6" fiberglass batts w/Kraft-Paper' - insulation dwelling, w/ 5/8- plywood siding R = ~9 still air 0.68 6" f-g ~9.00 2',.-lumber 5/8" plywood 0~75 O.So Air ~lSmph TOTAL R = 22.58 u 0°044 Wood-Framed over crawl-space, unheated garage or space, 3/4" tongue & grooved plywood flooring, w/6" fiberglaSs still air down 0.92 3/4" plywood 0.93 6" f-g 19o00 still air down 0.92 &/or outside Air batts w/~r. aft-Paper R = i9 TOTAL R T 21.77 U ,' 0~046 SLABS .'~ 4" concrete floor slab, w/6x6, 10/~0 w.w.f.; 6 mil poly vapor-barrier & 2" expanded~poly-styrene foam-board (EPS)~ R ~ 8.34 24" in or d°wn ~ R = 8.34 '24" in a -.down ~ R = %6.68 ,. ' ' , , Above-grade -~%-&0" hollow-core~ concrete blocks, w/2" expanded-poly-styrene foam-board (EPS) from top of masonry Go 2' below-grade (reco~end to basemen% = ~' gypsum wall-board for thermal barrier° or 2" poly- floor) at R 8.34 ~ urethane foam-board ~ R = &6.0 still air 0°68 0.6'8 ~' gyp. bdo 0.45 0~45 2" EPS 8.34 2" PU 16°00 10" conc. blk 1.20 %20 O.S. Air ~15mph 0.17 0.17 TOTAL R = 10o84 18.50 u = '. 0.092; 0.054 Below. grade - assume no insulation from 2' below-grade ave. u = 0.%07 BASEMENT FLOOR: Below-grade - 4" concrete grade-slab, assume w/no insulation ave~ u = 0.03 5/8" insulating glass u = 0°46 ,T2~lple-glazi~g u = 0.30 1/2" insulating glass u = 0.55 triple-glazing u = 0.34 " EXTERIOR DOORS,: - , & 3/4" metal-clad; wood-framed; foam-filled; insulated; ~terior door~ w/ or 5 s.f. lite; completely weather-stripped, ~ R = ~0.52 u = 0.095 THERMAL RESISTIVI~"f OF WHITE PINE by A. J. Nanassy and T. Szabo - July 1978 Ihf~ER~.~ REPORT (EFPL - 6-3-307) Eastern Forest Products Laboratory, Canadian Forest Se/iv!ce, Department of Fisheries & Environmei~ - Ottawa KiG 3Z5 (currently: Fornitek-Canada Corp.) All%~alculations per current N.E.M.Ao & A.S.H.R.A.E. Energy CalcUl~tion Me%hods, using the Component, Overall Stuctural Performance or Alternate Systems Confor~ mance or other approved methodology, u & UoS' equal~to or less than &/or Rs equal to or more than; Code Limits. C O M P A R I S O~4 Component or System ROOF OR CEILING EXTERIOR WAT,T-~ FLOORS CONSRETE SLAB BASEMENT BASEMENT FLOOR GLAZ INS Descrip. 12" "logs" . "studs" ,,attic-room" over/unhtd space 2" EPS above-grade below-grade . dbl-glzd '~ri-glzd Lincoln Logs R oru u- 0.025 u = 0.083 u = 0o077 u = 0.025 u = 0.044 R = 8.34 u = 0.092 ave. u = 0.%07 ave. u = 0.03 u = 0°46 u = 0~30 Fi~TERIOR DOORS foam-filled u = 0.095 NE%; yORK STATE - u & R VALUES VS DEGREE-DAYS degree-days exterior walls roofs/clgs floors slabs 5,000 0.24 0.05 0.08 5.0 6,000 0.22 / I 5.0 7,000 0.21 5.5 8,000 0,19 0.05 6.2 9,000 0.18 0.04 0.08 6.8 New York R or u u~ 0.04 o u = 0.18 o u= 0.08 R= 6.8 u = 0.08 u = n/a u = 0.69 u = 0~40 'FORM NO. 1 ToWN OF SOUTHOLD BUILDING DEPARTMENT · TOWN HALL ~ ~ ,~OUTHOLD, N.Y. 11971 TEL.: 765-1802 )isapproved a/c ...... ~..~v75.._~.~.~ ........ ~ ......... (Building Inspector) APPLICATION FOR BUILDING PERMIT Re( elved .... , 1 Date.· .2/1! ~ .......... 19 8.5. INSTRUCTIONS a. Tiffs application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, x4i~h 3 ~ts 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 ,r areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- ation. 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 hall 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 hall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department ~br the issuance of a Building Permit pursuant to the luilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or ~egulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. ?he applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to ~dlnit authorized inspectors on premises and in building for necessary inspe~ . ,~.. ~ (Signature of applican~, or name, if a corporation) · ' ' m~.rl-t~,r-g., .O.,y,... :i ' , (Mailing address of applicant) State whether applicant is ~lessee, agent, architect, engineer, g~neral contrac{o-~, electrician, plumber or builder. Name of owner of premises ..... '~eoB.o.e.~...,~..,..C.o .~.L~. ........................................... (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 ....... ,~2 ......,'' ' "' ' ',,':: ' Electrician's License No. ~11:5.6~.Te.i.c...8..~.q.-.E.. Other Trade's License Nc~; '} i. Location of land on which proposed work will be done: ................. ?. ..................... ? ............. ..... q .t,.5 ......... ........ ................................ House Number Street Hamlet County Tax Map No. 1000 Section ..... ~.O.~/ ......... Block .... ,14 ............ Lot ..... ~.~ ............ Subdivision ........................ 'L',', .......... Filed Map No ............... Lot ............... (Name) 2. State ex/sting use an~ 9ccupancy of premiaes and intended use and occupancy of proposed construction: .. ...... r- a. Existing use ani~ occupancy ......................................................... b. Intended use and occupancy ~.1~001~/0~0.1~. ~.~..IB.I..~. ~)~l~Aig~/~.l~...~, .... ~/~.~.~.~..~?~..C~.... 3. Nature of work (check which applicable).'. N~w Building '..., io' Addition ......... Alteration ......... Repair .............. RemOval... ~., ]'.. i .... ~ Dem01if ..... ......... Other Work ............... ':~" e .'~.../~...--~. ~ (Description) 4. Estimated Cost .............. ' · e ................ q' (to be paid on filing this application) 5. If dwelling, number of dwelling units .... ~E ...... Number of dwelling unit~ on each floor ............... If garage, number of cars ......... ~O ...................................... * ..................... 6. if business, commercial or mixed occupan¢y, specify natu~ and extent of each ty~e of use ........ ~ ............. 7. Dimensions of existing structures, if any: Front ............... Rear .............. Depth./i; ........... Height ............... Number of Stores ............................ ~ ............................ Dimea~i0ns of same structure with~alterations or additions: Front ;. :.: ....... ~ ..... Rear .................. Depth ...................... ~eight ............ , .......... Number of'Stories ...................... 8. Dimensions of entire new construction: Front ............ Rear .. ¢ ..... ....... Depth ........... Height ... l~~.~ ~.* ...... Nmnber of Stories ....... [ ~ .................. ~ ............................ 9. Size of lot: Front ...... l.q~ ............ Rear ..... [~.~ ............. ~epth . ~.~ [... .............. 0. Date of Purchase [fi~ ~ ............ Name of Fomer Owner .!.~.~ ........ 1. Zone or use district in whi~¢~e~ige~e sitfia ,a?:: .... ................ 2. Does proposed construcl~q¢ ~i~la[~ guy zoning law, ordinance or regulation: .... ~ ...................... 3. Will lot be regraded .. ;':':... y~'~.'~... ~.~..... ,... Will excess fill be [emoved from premises: Yes 4. Name of Owner of premises . .~ ~.~. ~dd~ss ~q[~ ~. Phone No..~: ~.~ Name of Architect . ·; ........................ Address ............... ~ ....Phone No ................ Nmne of Contractor .......................... Address ............... ~ ....Phone No ................ PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from roperty lines Give street and blocknumber or description according to deed, and show street names and indicate whether lterior or corner lot. suRu y , TATE OF NEW YORK, S.S 'OUNTY OF ................. (Name of individual signing contract) bore named. · being duly sworn, deposes and says that he is the applicant is tile ...................................................................................... (Contractor, agent, corporate officer, etc.!) said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this pplication; that all statements contained in this application are true to the best of his knowledge and belief; and that the :ork will be performed in the manner set forth in the application filed therewith. .worn to before me this ........... ./.t/.~. ..... day of...~" .r~.. .............. , 19 .~-~'-.. ,Iotary Public, . .~..~. ..... ~..4~...~.~... County... ...~... ,~. · SUFFOLK CO. HEALTH DEPT. APPROVAL .; ., ,~. ......... ,, H.S. NO. STATEMENT OF ~ENT O~ t' ~/~ ~/V/~Z~ ~/ ~/~ THE WATER SUPPLY AND SEWAGE DISPOSAL ~ ~ ~ ~;~'F~ ~ : ~ ~ SUFFOLK COUNTY DEPT. OF HEALTH . ~ ~ . . .. '. . SERVICES -- FOR APPROVAL OF ' ~FFOLK CO. TAX MAP DESIGNATION: ~ , ~ ~;~ ~ , ~ . DIST. SECT. BLOCK PCL. : -, .' ,. ~ . .~- , ,., ~ ~ ~ ~NERS ADDRESS: ,~ I_"' ~~~ ~ ~U, ~ ,, - - ' ~" DEED: L. ~ P' ~ LICENSED LAND SURVEYORS : le [ GREEN~RT NEW YORK SUFFOLK CO. HEALTH DEPT. APPROVAL -STATEME~ SY$~EM$~ ,~R %Ht$~ RESIDENCE WILL CONFORM TO ~HE.'S~ANDARDS OF THE SUFFOLK cOUNTY ' DEpT, Of HEALTH .-SERVICES. ~. FOR ..A~PROVAL OF CONSTRUCTION ONLY DATE! ' APPROVED: ; I ~ TEST HOLE STAMP SEAL /70.0 ] ~e sewa~ disoo~al s~g ~:'ater su~ y fac~itie~ for thi: location hav~./D b'een inspected b~ this d~:~c'tment ~fo~d ~ , ~- ~ .... Oh~P oP ~ener~l En~in~gi~ ~erviee8 , t RODERI~CK VAN TUYL, P.C. LICENSED LAND SURVEYORS GREENPORT NEW YORK