HomeMy WebLinkAbout27398-ZFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
NO: Z-29663 Date: 08/27/03
THIS CERTIFIES that the building ALTERATION
Location of Property: 370 FISHERM3kNS BEACH RD CUTCHOGUE
(HOUSE NO.) (STREET) (HAMLET)
County Ta~ Map No. 473889 Section 111 Block 1 I~Dt 13.1
subdivision Filed Map No. __ Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated MARCH 8, 2001 pursuant to which
Building permit NO. 27398-Z dated JUNE 13, 2001
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 ALTERATION AND SHED D2DDITION TO AN EXISTING ONE FAMILY DWELLING AS
APPLIED FOR.
/~ne certificate is issued to LAUREN PRAUS
of the aforesaid building.
(OWNER)
SL~FFOLK COLSK~Iqf DEP~R~T OF ~-~AL~{ ~PPROVD~L N/A
ELECTRIC3kL CERTIFIC-~TE NO. 1159451 08/19/03
pLL~MBERS CERTIFICATION DA'£~O N/A
Rev. 1/81
FORM NO. 4
TOWN OF SOUTBOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-29664 Date: 08/27/03
THIS CERTIFIES that the building ACCESSORY
Location of Property: 370 FISHERM3~NS BEACH RD CUTCHOGUE
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 111 Block 1 Lot 13.1
Subdivision Filed Map No. __ Lot No. __
conforms substantially to the Application for Building Permit heretofore
filed in this office dated MARCH 8, 2001 pursuant to which
Building Pezmit No. 27398-Z dated JUNE 13, 2001
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 SHED AS APPLIED FOR.
~e certificate is issued to LAUREN PR-AUS
of the aforesaid building.
( OWNER )
SUFFOLK COIFA~UY DEPARTMENT OF P~ALTH APPROVA~ N/A
ELEL-£RICAL CERTIFICATE NO. 1159451 08/19/03
PLUMBERS CERTIFICATION DATED N/A
~/hor~ed Signature
Rev. 1/81
FORM NO. 3
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)
PERMIT NO. 27398 Z Date JUNE 13, 2001
Permission is hereby granted to:
MARIAN J PP~AUS
425 SLEEPY HOLLOW LANE
SOUTHOLD,NY 11971
for :
ALTERATION TO A SINGLE FAMILY DWELLING WITH NON HABITABLE ATTIC
SPACE AND ACCESSORY SHED AS APPLIED FOR. INCLUDES FLOOD PERMIT, 2 CO'S REQUIRED
at premises located at
County Tax Map No. 473889
pursuant
Building
Fee $
370 FISHERM3~NS BEACH RD CUTCHOGUE
Section 111 Block 0001 Lot No. 013.001
to application dated MARCH 8, 2001 and approved by the
Inspector.
300.00
Authorized Signature
COPY
Rev. 2/19/98
Form No. 6
TOWN OF SOUTHOLD
BUILDING 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 Department with the following:
A. For new building or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and nnusual natural or
topograpl'fic 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 completed site plan requirements.
B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses:
1. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic
features.
2. A properly completed application and 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 ot~Occupancy on Pre-existing Building - $100.00
3. Copy of Certificate of Occupancy - $.25
4. Updated Certificate of Occupancy- $50.00
5. Temporary Certificate of Occupancy- Residential $15.00, Commercial $15.00
Date.
Old or Pre-existing Building:
House No. Street
Owner or Owners of Property: L ~ (,///~ ~,) f~/~/'G/ ,~
New Construction:
Location of Property:
l I I Block
Filed Map.
Applicant:
Underwriters Approval:
Suffolk County Tax Map No I000, Section
Subdivision
Permit No. ~ 7 5 Date of Permit.
Health Dept. Approval:
Planning Board Approval:
Final Certificate:
(check one)
Hamlet
Request for: Temporary Certificate
Free Submitted: $ % 5 - 0 0
Lot
Lot:
~ (check one)
/
Applicant Signature[~'~
BY THIS CERTIFICATE OF COMPLIANCE THE
NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
40 FULTON STREET ~ NEW YORK, NY 1OO38
CERTIFIES THAT
Upon the application of
upon premises owned by
ROSLAK ELECTRIC
P.O. BOX 164
CUTCHOGUE, NY 11935-2453,
LAUREN PRAUS
375 FISHERMAN'S BEACH ROAD
CUTCHOGUE, NY 11935
Located at
375 FISHERMAN'S BEACH ROAD CLJTCHOGUE, NY 11935
Application Number: 1159451
Certificate Number: 1159451
Section: Block: Lot: Building Permit: BDC: NS11
27398
Described as a Residential occupancy, wherein the premises electrical system consisting of
electrical devices and wiring, described below, located in/on the premises at:
First Floor,
was inspected in accordance with the National Electrical Code and the detail of the installation, as set forth below, was
found to be in compliance therewith on the lgth Day of August, 2003.
Name QTY Rate Rating Circuit Type
Miscellaneous
FINALED 8-15-03
INSP. R. RICHERT
Wiring and Devices
Outlet 3
Receptacle 7
Switch 4
Fixture 1
Fixture 2
Dimmers 1 60 W
Fixture
General Purpose
General Purpose
Incandescent
Fluorescent
seal
1 of 1
This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated.
Mark K. Schwartz, AIA - Architect, PLLC
P.O. Box 933
Cutchogue, New York 11935
Phone: (~3i) 734 - 4185
Fax: (631) 734 -4185
TRANSMITTAL
Date:
To:
From:
Re:
August 21, 2001
SouthoM Building Departmem, Arm: Mr. Gary Fish
Mark Schwartz
Praus House
375 Fisherman's Beach Road
Cutchogue, N.Y. 11935
(Permit# 27398)
I have inspected the wall insulation prior to sheet rock installation and found it was
stapled to the studs adequately. I have also observed the floor insulation that has metal
insulation supports installed as necessary. Please call this office if you have any
questions or require any additional information.
Mark K. Schwartz, AIA - Architect
P.O Box 135
Southold, New York 11971
June 13, 2001
Southold Building Department
Main Road
Southold, New York 11971
Re: Praus House
375 Fisherman's Beach Road
Cutchogue, New York
To whom this may concern:
I have marked up the submitted plans (dated February 27, 2001) to indicate omission of the
proposed third story work. Please call this office if you have questions or require additional
information.
Very truly yours,
Prausl.doc
BUILDING PERMIT REVIEW CHECK LIST
APPLICANT NAME:
DATE REVIEWED: ~ /2 13
DATE SUBMITTED: 2 /~
SCTM#--- DISTRICT: 1,000 SECTION: ?// BLOCK: / LOT:
PROJECT LOCATION
STREET: 325' tmT.~t~,.,,,.v..~, ~9,.,,.~ /o~ CITY: ~..~,~_
~CHITECT / ENG~EER: ~ ~
S~GLE & SEP~TE CERTWICATION-~QU~D: YES o~OTES:
ZONING: PERMIT~MATE AMOUNT: $ ~ .00
ZO~G DISTRICT~ R80, AC, - COlOr,G: YES o~ NO ~QU~D LOT S~E: SQ
~E~ACTU~LOTS~EFROM?TAXCA~ ~o<~ b~ /~/~ ACTUAL LOTS~E: /~ SQ
~Q~D ~Q~D ~Q~D
FRONT:~' PROPOSED: ' SIDE YD: /~ '/ ~' PROPOSED: '/ ' ~:~ 'PROPOSED: :
LOT COVE~GE: ~LOWED: ~ % EXIST~G: /sf % ~W: ~ sf % TOT~k~sf
CO--R? YES o~AT ER FRONT~ NO DESC~TION:
~TS 40,000SF --100-24. ~t reco~ition. (C~ATED before June 30, 1983), ~ERS~ED LOTS FROM
J~.1997 100-25. Merger. (A nonconfo~ing at ~y time after July 1, 1983.)
SUBDW. NAME:
FAST TRACK~oR
PROJECT DESCRIPTION: ADD~------~CC OR N/D: ~'~'~,~,~
AGENCY PERMITS REQUIRED FOR REVIEW
NEEDED
TOWN SPETIC PERMIT: YES or
SUFFOLK COUNTY HEALTH DEPT: YES or~Q)(BED #): DTE: / / PERMIT #:R10-
NEW YORK STATE DEC: Pm~-*)ec 9aris YES or~
SOUTHOLD TOWN TRUSTEES: YES or~]~
TOWN ZONING BOARD APPROVAL: YES
TOWN PLAN. BOARD APPROVAL: YES or~.Q.)
FLOOD COMPLIANCE ZONE: PRE-FiRM MIS/S0 PANEL #:J~ FLOOD ZONE: ,,$~"'~,
NYS ENERGY. Y[~ES)OR NO' :-'~ EGRESS: VENT: LIGHT:
FEE STRUCTURE:
FOUNDATION: ~ SF
FIRST FLOOR : 8-~O ~ SF
SECOND FLR : ,4 ~0 SF
TOTAL: /.~0, SF
SF)-( o~.~-) SF)= ~,3'O SFX$,.2o =$
INIT OTHER
FEE FEE
TOTAL
FEE
3oo --
APPLICATION
PAC;E ! or 4
TOWN OF SOUTHOLD
FLOODPLAIN DEVELOPMENT PERMIT APPLICATION
This form is to be filled out in duplicate.
SECTION 1: GENERAL PROVISIONS (APPLICAJNW tO read and sign):
L No work may start until a permit is Lssued.
Z The permit may be revoked il' any fal~e statemcnt~ are made herein.
3. If revoked, all work mtmt cease tmtil permit is re-issued.
4. Development shall not be u~cd or occupied until a Certificate of Comptiaace i~ kssucd.
5. Thc permit will cxpixe i/' no work is commenced within six months of i~suance.
6. Applicant is hereby informed that other permits may bc required to fulffull local, state and federal regulatory
requh-emcnta.
7. AppLicant hereby gives consent to the Local Administrator or his/her representative to make reasonable
inspections required to vcrlfy compLiance.
8. I, THE APPLICANT, CERTIFY THAT ALL STATEMENTS HEREIN' AND IN ATTACHMENTS TO
_ THIS APPLICATION AR.E, TO THE BE~'I~ OF.,M¥ If-.N(0~EI~, TRUE AND ACCURATE.
SECTION 2: PROPOSED DEVELOPMENT (Th be completed by APPLICA/x_q3
NAME ADDRESS TELEPHONE
APPLI~ .,
BU..oE O-'tr-44v4,4",. //? 3f
ENGINEER / '
To avoid delay in processing thc application, please provide cnou_13h information to easily Mcutlfy thc project
location. Provide the street address, lot number or legal description (attach) and, outside urban areas, the
distanee to the nearest intersecting road or wcli-k~ovn~ landmark. A sketch attached to this application showing
the project location would be helpful.
FOP(g3)
A.PPLICAT]ON ~
PAGE 2 OF d
DESCRIPTION OF WORK (Check ail appl~cablc boxes)
A STRUCTURAL DEVELOPMENT
~TRUCTURE TYPE
[] New Structure
U] Addition
RAJteration
elocation
[] Demolition
121 Replacement
[] Resident/al (14 Family)
[21 Residential (More than 4 Family)
ID Non-residential (Floodproofing* [] Yes)
[] Combined Use ('Resident/al & Commercaxl)
[] Manufactm-ed (Mobile) Home (In Manu-
factured Home Park7 [~ Ye.s)
ESTIMATED COST OF PROJEC¥ 5~}]~.l'~'~t"J
B. OTHER DEVELOPMENT ACTIVITIES:
[] F'dl F1 Mining [] Drilling FI Grading
[] Exoneration (Except for Structural Development Checked Above)
' [] Watercourse Alteration (Including Dredging and Charmel Modifications)
[] Drainage Improvement~ (Including Culvert Work)
[] Road, Street or Bridge Construction
[21 Subdivision (New or Expansion)
Iondividualwater or S~er Systole '
ther(PeaseSpecffy) [ .l~.~ ~t'~ ' ,,~6..T"~. t . ~.,~l/J /__ fi)~_~,/ ~(~7l'~ '
After completing SECTION 2, APPLICAb~ shouJd submit form to Loc~! Administrator for re~4ew.
SECTION 3: FLOODPLAIN DETERMINATION (To be completed by [~OCAL ADMINISTRATOR)
The proposed development i~ located on F'IR_M Panel No. , Dated
The Proposed Development:
FI I,~ NOT located in a Special Flood HuTard Azea (Notify the applicant that the application
review i~ complete ~nd NO FLOODPLAIN DEVELOPMEN'F PERM1T IS REQUIRED).
Fl I~ located in a Special Flood Hazard Area.
FIRM zone dezignation is
100-Year flood elevation at the site k: Ft. NGVD (MSL)
[] Unavailable
O The proposed development is located ia a floodway.
FBFM Panel No, Dated
[] See Section 4 for additional instructions.
SIGNED
DATE
,NPPLICATION #
PAGE 3 OF 4
SECTION .t: ADDITIQNAL INFORMATION REQUIRE_I) (To be. completed by LOCAL ADMINISTRATOR)
The appLicant must submil the documents checked below before tLie appLication c2m bc proc~scd:
[] A site plan showing thc location of all cxSsting structctrcs, water bodies, adjaccnt roads, lot
dimeusioms and proposed development.
Devclopmem plans, drawn to scale, and spedfications, including where applicable: details for
anchoring structures, proposed elevation of lowest floor (including basemeot), types of water
reslstznt materials used below the l-u'st floor, detaiE o£ floodproo£mg of utilities located below
the In:st floor z. ud details of endnstrres below the lust floor.
AL~o,
[]
[]
[2]
Subdivision or other development pierre (I[ the subdivZmion or other development exceeds 50
lots or 5 acres, whichever is the lesser, the app[icam must provide 100-year flood elevations
ff they are rmt otherwise available).
Plans showing the extent of watercourse relocation and/or landform alterations.
Top of new [-dl elevation
Ft. NGVD (MSL).
Floodproo£mg protection level (non-residential only) Ft.'NGVD (MSL). For
floodproofed structures, applicant most attach certification from registered engLneer or
architect.
Certification from a registered engineer that the proposed activity in a regulatory floodway
will not result in any ~crease ha the height of the 100-year flood. A copy of all data and
calculations supporthag this fmdLng must also be submitted.
[] Other:
SECTION 5: PERMIT DETERMINATION {'1'9 be completed bY LQq;AL ADMINISTRATORI
I have determined that thc proposed activity:. A. FI Is
B. Fl Is not
in conformance with provisions of Local Law 4~ , 19
attached to a. nd made part of this permit.
__. The permit is issued subject to the conditions
SIGNED , DATE
If BOX A is checked the Local Administrator may issue a Development Permit upon payment of designated
If BOX gili checked., the Local Administrator will provide a written summary of deficiencie& Applicant may
revise and resubmit an appfication to the Local Administrator or may request a hearing from thc Board of
Appeals.
APPF~',~.5 Appealed to Board of Appeals7 [] Yes C~} No
He~mg date:
Appeals Board Decision -- Approved7 [] Yes
Conditious
[] No
APPLICATION
PAGE '~ OF ~
SECTION 6: A.5-BI~IILT ELEVATIONS (To be submitled bv APPLICANT before Cert~cate o(C0mpliance
is issued).
The following i~ormation must be pro',4ded for projecl structures. This section must be completed by a
registered professional engineer or a liceused land surveyor (or attach a certification to this application).
Complete 1 or 2 below.
1. Actual (A~-Built) Elevation of the top of the Iowe...st floor, inducting ba-~emcnt (in Coastal High Hazard
.Areas, bottom of lowext struct'ttral member of thc lowest floor, excluding piling :md colttmas) is:
FT. NGVD (MSL).
2. Actual (As-Built) Elevation of floodproo£mg protection is FT. NGVD (MSL).
NOTE: A~y work performed prior to submittal of the above information ks at the risk of the Applicz~nt.
SECTION 7: COMPblA~CE ACTION (To be completed ~v I~}CAL, ADMINISTRATOR)
The LOCAL ADMINISTRATOR will eomple~'g tl:~ section ax apl~licable based on iztspection of the project to
e~ure compliance with the commtmity's local law for flood damage prevention.
INSPIECTIONS: DATE BY DEFICIENCIES7 [] YES [] NO
DATE BY DEFICIENCIES? El YES [] NO
DATE BY DEF'[CEE. NCIES? [] YES [] NO
SECTION 8: CERTIFICATE OF COMPLIANQE(To be c~,mpleted bv LOCAL ADMINISTRATOR'}
Certific. ate of Compliance issued: DATE: BY:
Attachment B
SAMPLE
CERTIFICATE OF COMPLIANCE
for Development in a Special Flood Hazard Area
TOWN OF SOUTHOLD
CERTIFICATE OF COMPLIANCE
FOR DEVELOPMENT IN A SPECIAL FLOOD HAZARD AREA
(ov~rI',FER MUST ILETAIN THIS CERTIFICATE)
PREMISES LOCATED AT:
PERMIT NO.
PERMIT DATE
OWNERS NAME AND ADDRESS:
CHECK ONE:
[] NEW BUILDING
[] EXISTING BUILDING
U] VACANT LAND
THE LOCAL ADMINISTRATOR IS TO COMPLETE A. OR B. BELOW:
COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF
LOCAL LAW # ,19
SIGNED: DATED:
B4
COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF
LOCAL LAW # , 19__, AS MODIFIED BY VARIANCE # ,
DATED
SIGNED: DA'I'ED:
C/C(93)
STATE OF NEW YORK )
) SS:
r ~, ~¢J~- ~ . l~../~/#¢'lT~being duly sworn, deposes and says:
That deponent is over the age of 18 years and resides at
That on the ~7/~.day of /~. ~1~...- , 2001 deponent architect/engineer,
licensed by the State of New York, hereby states that s/he accepts full
responsibility for the accompanying plans compliance with the New York State
Fire Prevention and Building Code (9 NYCRR); said plans pertain to property
located at SCTM# 1000- /~ -- ¢//-- ~t3o / ,
address~?)" ~'/flY~fZ.~¢,¢4~ ¢¢,¢-.4'¢¢Pf'M'.~ .
street
...¢.¢/
Architect/Engineer
Sworn to befor..r¢ me this
~2~ day of ./!/,,~--/~, 2~01.
ol~ry PuBlic -' -
ELIZABETH A STATHIS
NOTARY PUBLIC, State of New York
No. 01ST6008173, Suffolk Coun~l~f
Te,"m Expires June 8, 20~---~..~
cc: Applicant
765-~.802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST
[ ] ROUGH PLBG.
[ ] FOUNDATION 2ND
[ ] FRAMING
[ I INS~i, fl. ATION
[ t~INAL
[ ] FIREPLACE & CHIMNEY
DATE
INSPECTOR~~/~
765-1802
BUILDING D£PT,
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION2ND [ ]INSULATION
[ ] FRAMING [ c.~NAL
[ ] FIREPLACE & CHIMNEY ~
DAI~
INSPECTOR
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] RO~GHPLBG.
] [~"] INSULATION
[//~)UNDATION 2ND
[ ~1 FRAMING [ ] FINAL
[ ] FIREPL_A~CE & CHIMNEY
REMARKS:~05~ C,~0 ~L
DATE ~// / / INSPECTOR/~~
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST
[ ] FOUNDATION 2NO
[ I FRAMING
[ ] FIREPLACE & CHIMNEY
]
//]"INSULATION
[ ] FINAL
ELD INSPECTION 1U;IPORT DAT~ COI~NTS
~S~TION ~R N. Y.
FINAL
BUILDING DEPART~IENT
TOWN HALL I ·
$OUIHOLD, NY 11~1'
TEL. 765-1802
Examined ~/~r_.~ .200/,
Approved ~1//~ ,20~0 /
Disapproved a/c
Building Inspector
HUIJ.~IiNk/FP_,I<IVIII Ai~FLICA'I'ION CHECK.LIS
Do you have or need the following, before applying
Board of Health
3 sets of Building Plans
S~¢y
Check
Septic Form
N.Y.$.D.E.C.
Trustees
Contact:
Mail to:
APPLICATION FOR BUILDING PERMIT
Date ,20.
INSTRUCTIONS
a. This application MUST be completely filled in by iypewriter or in ink and submitted to the Building Inspector with3
sets of plans, accurate plot plan to scale. Fee according to scl/edule.
b. Plot plan showing location of lot and of buildingS .o..n"premises, relationship to adjoining premises or public streets or
areas, and waterways.
c. The work covered by this application may not be commenced before issuance of Building Perrmt.
d. Upon approval of this application, the Building l~ector will issue a Building Penn/t to the applicant. Such a permit
shall be kept on the premises available for inspection througho.ut'the work.
e. No building shall be occupied or used in whole or i~ part for any purpose what-so-ever until a Certificate of Occupan
is issued by the Build~ng Inspector.
APPLICATION/S HEREBY MADE to the Buildi~. g. Deparlment for the issuance cfa Building Permit pursuant to the
Building Zone Ordinance oftbe Town ofSouthold, SUffolk, Cotinty, New York, and other applicable Laws Ordinances or
Regulations, for the construction ofbuildinl~, additions or'alterations or for removal or demolition as herein described. The
applicant agrees to coinply with all applicable laws, ordinandes, building code, housing code, and reg?~ations~, and to admit
auth,'°rized inspect°rs °npremises'andinbuilding f°rneces...~.'Y, inspecti°ns'i/¢/////~,F~(/~... .
, .. ' ~.. (Sigl~aturo ofa~plieant o~/~ame, ifa corporation)
:.,
' '. (Mailing address of applicant)
State whether applicant is owner, lessee, age ,~t//~arct~it¢ci~gineer, general contractor, electrician, plumber or
builder
Name of owner of p~'emises (~ ~'&'ff~-~t~ P~r./~"
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer
(Name and title of corporate officvr)
Builders License No.
Plumbers License No.
Electricians License No.
Other Trade's LicenSe No.
1. Location of land on which proposed work will b~ done:
House Nmber S~,et -
Co~ty T~ M, No. !000 S~fion ~ ~ ~ "Block ~ ~ Mt
Subdivision
Filed Map No. Lot
(Name)
~^~mLl~ u~c ~,Lu uuuupancy Ol premises arid intended use arid occupancy ofpropo~
Existing use and occupancy .., ~/,~t~r.4,' ~t:?,,/.,,~ t,- ~, /"~ ~'/~---J c.~ff [.~//~ .J.
b. tntended use and occupancy ~. ,~'/~---- ~-/~
Nature of work (check which applicable): New Building
Repair Removal D~molition
Estimated Cost eC~z9
if dwelling, number of dwelling units
If garage, number of cars
Fee
(Description)
(to be paid on filing this application)
Number of dwelling units on each floor
If business, commercial or mixed occupancy, specify nature and extent of each type of use.
Dimensions of existing structures, if any: Front ~> ~ ~/~- (,,'f'J.~ Depth
Height. Number of Stories
/
Dimensions of same structure with alterations or additions: Front ,~C'~__~ ..~'cJ/~c/~,ear
Depth Height Number of Stories
:. Dimensions of entire new construction: Front
Height Number of Stodes
Rear .Depth
,. Size of lot: Front Rear Depth
0. Date of Purchase Name of Former Owner
1. Zone or use district in which premises are situated ~ - ~
2. Does proposed constmcti0n violate any zoning law, ordinance or regulation:
3. Wilt lot be re-graded AJ ~ Will excess fill be removed from premises:
4. Names of Owner of premises/~4~,/'8K~
Name of Architect
Name of Contractor
aaress~l~llone 1~o.
Address Phone No
Address Phone No.
YES(~
5. Is this property within 100 feet ora tidal wetland? *YES ~/-~'/ NO
· IF YES, $OUTHOLD TOWN TRUSTEES PERMITS MAY BE REQ~D
6. Provide survey, to scale, with accurate foundation plan and distances to property lines,
7. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey.
TATE OF NEW YORK)
SS:
, - V?t&f,'u~ ~' ~>/,,-t~,/,,.-,,/,~7. being duly sworn, deposes and says that (s)he is the applicant
('Name of individual signing contract) above named,
' ' (0~2ontr~ctor, Agent, Corporate Officer, etc.)
f said owner or owners, and is'duly authorized to perform or have performed thc said work and to make and file this application;
mt all statements contained in this application are true to the best of his knowledge and belief; and that the work will be
,rformed in the manner set forth in the application filed therewith.
wo~,to, before me thi~ A ,~
(--'/ / ~tary Public
LYNDA M. BOHN
NOTARY PUBLIC, State'of New York
No. 01 BO6020932
Oualified in Suffolk County
Te~m Expires March 8, 20 ~
' ~'Si~ant