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HomeMy WebLinkAbout29308-Z i FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-29760 Date: 10/07/03 THIS CERTIFIES that the building ACCESSORY Location of Property: 775 MULFORD CT ORIENT (HOUSE NO. ) (STREET) (HAMLET) County Tax Map No_ 473889 Section 14 Block 2 Lot 3 .26 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated APRIL 14, 2003 pursuant to which Building Permit No. 29308-Z dated APRIL 18, 2003 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 INGROUND SWIMMING POOL WITH FENCE TO CODE IN THE REQUIRED REAR YARD AS APPLIED FOR. The certificate is issued to RONALD KRIEB (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. 7832C 07/29/03 PLUMBERS CERTIFICATION DATED N/A oe G" Authorized Signatur 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. 29308 Z Date APRIL 18 , 2003 Permission is hereby granted to: RONALD KRIEB 889 BROADWAY 47B NEW YORK,NY 10003 for INSTALLATION OF AN INGROUND SWIMMING POOL IN THE REQUIRED REAR YARD AS APPLIED FOR FLOOD PMT INCLUDED at premises located at 775 MULFORD CT ORIENT County Tax Map No. 473889 Section 014 Block 0002 Lot No. 003 . 026 pursuant to application dated APRIL 14 , 2003 and approved by the Building Inspector to expire on OCTOBER 18 , 2004 . Fee $ 250 . 00 Authorized Signature COPY Rev. 5/8/02 Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 ^^ww 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 unusual natural or topograpW 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 J 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 topograA* . :!'` features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupaacy is denied, the BuildingIt Spector shall state the,reasons therefor in writing to the applicant. r C. Fees 1. Certificate of Occupancy-New dwelling$25.00, Additions to dwelling$25.00,Alterations to dwelling$25.00, wimming pool $25. Accessory building$25.00, Additions to accessory building$25.00, Businesses $50.00. 2. ertt tcate o ccupancy 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 2 Date. q— 3� o New Construction: Old or Pre-existing Building: X (check one) Location of Property: " 75 ///(/���/ ��(j. Or,16'{77L House No. / Street jj Hamlet Owner or Owners of Property: 20129 d'/'7'rl[i Suffolk County Tax Map No 1000, Section/&-')e9 0 /S/—23 Block Lot 22— Subdivision CJ/O/�p��/iC La/ � Filed Map. '7 0 g 3 Lot: zz Permit No. Date of Permit. Applicant: Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate: X (check one) Fee Submitted: $ Applicant Signature COQ Electrical Inspection Certificate Issue Date Electrical Inspection Service, Inc. Application Number 07/30/2003 375 Dunton Avenue 78321C East Patchogue, New York 11772 (631)286.6642 Issued To: Ronald Krieb Street: 775 Mulford Court Village: Orient Zip: 11957 Town: Southhold Section: Block: Lot: Contractor: R. C. Electric Corporation Lic. # 1610-E Was examined and found to be in compliance with the National Electrical Code. ❑ CommercialX❑ NV Defects 0 Pool ❑ tat Floor ❑ Indoor ❑ Basement ❑ Hot Tub IX] Residential ❑ Det.Garage ❑ Attic ❑ 2nd FloorX❑ Outdoor ❑ Addition ❑ Survey Switches Receptacles Fixtures GFI Heaters A/C Fans 1 1 1 1 Dishwasher Washer/Amps Dryer/Amps Oven Range/Amps Microwaves Furnace Oil Gas Circulators Smoke Detector Bell Transformer Meter Amps Phase UG/OH Jacuzzi Television CO Detector Bldg. Permit: > Other Equipment V 1-Gas Heater 1-Pool Panel 1-Time Clock Hugo S. Surd! 1-Motor President Rough Inspection: 07/29/2003 Inspector: Ed Scavelli Final Inspection: 07/29/2003 Inspector: Ed Scavelli This certificate must not be altered in any manner. Inspectors may be identified by their credentials. TOWN OF SOUTHOLD PROPERTY RECORD CARD OWNER STREET 775 VILLAGE DIST.1 SUB. LOT nal fiOR�Af�ER OWNER N_f N E _ ACR. SE► 1� U. V CI21e. '5userib Arj Q!!D S W TYPE OF BUILDING RES. 2- o SEAS. VL I FARM COMM. CB. MICS. Mkt. Value LAND IMP. TOTAL DATE REMARKS IU . i &L - _ i 7 - r82 �C U 4u S � 8 - LItII S-) —��-u<enLurq f Ono bu✓ N C t4-co - J t40 12 1as // �7 D 63f' a7 3a L: � IDAn �, ems✓ - 400 4�n0 IZ 2 7 —L /z/? -1 �3 wiz Tillable FRONTAGE ON WATER Woodland FRONTAGE ON ROAD �Q Meadowkind t °��D DEPTH House Plot ` d I BULKHEAD Total New York State Department of Environmental Conservation Division of Environmental Permits, Region One Building 40 - SUNY, Stony Brook, New York 11790-2356 Phone: (516) 444-0365 FAX: (516) 444-0360 John P. Cahill Commissioner Letter of Non-Jurisdiction - Freshwater Wetlands Act Adele Dusenbury April 30, 2001 PO Box 28 Stony Brook, New York 11790 Re: Application #1-4738-02826/00001 Mulford Ct., Orient SCTM 1000-14-2-3.26 Dear Ms Susenbury, Based on the information you have submitted, the New York State Department of Environmental Conservation has determined that: Your proposed project to construct a new 30' x 40' single family dwelling with septic system and driveway as shown on the survey by John C Ehlers, dated 11/16/2000 and last revised 12/12/2000 is more than 100 feet from regulated freshwater wetlands. Therefore, no permit is required under the Freshwater Wetlands Act (Article 24 of the Environmental Conservation Law). Be advised, that all construction, clearing, and/or ground disturbance must remain more than 100 feet from the freshwater wetland boundary. In addition, any additional work, or modification to the project as described, may require authorization by this Department. Please contact this office if such are contemplated. Please be further advised that this letter does not relieve you of the responsibility of obtaining any necessary permits or approvals from other agencies. Sincere Rqg r Evans Pe - it Administrator cc BOH file C Mesiano Albert J. Krupski, President % �(�� Town Hall James King, Vice-President �� GG 53095 Route 25 Henry Smith o r1 P.O.Box 1179 Artie Foster - cn Southold, New York 11971-0959 Ken Poliwoda C O J , Telephone (631) 765-1892 f Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD February 15, 2001 Ms. Catherine Mesiano Catherine Mesiano, Inc. 12 Mill Pond Lane East Moriches, NY 11940 RE: Mulford Court, Orient SCTM#14-2-3.26 Dear Ms. Mesiano: The Southold Town Board of Trustees reviewed the survey dated November 16, 2000 and last amended December 12, 2000 and determined that the construction of a single-family dwelling to be out of the Wetland jurisdiction under Chapter 97 of the Town Wetland Code. However, any activity within 100' of the Wetland line would require action from this office. This determination is not a determination from any other agency. If you have any further questions, please do not hesitate to call. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees AJK:hns _ TOWN OF SOUTHOLD PROPERTY RECORD CARD OWNER STREET 775 VILLAGE DIST. SUB. LOT fiORw1ER OWNER I E5-60C,4 A SF I"IbtA ( N E ACR. dela �usenb��r� 0 sW U'�'• ; TYPE OF BUILDING RES. 2i o SEAS. VL FARM COMM. CB. MICS. Mkt. Value LAND IMP. TOTAL DATE REMARKS S 8 - LIII 3n — r no u� bur N C 14 p c� . v �� ,� qa �� 27 n P" a7 .3 a .� - _ fa viz Tillable FRONTAGE ON WATER Woodland FRONTAGE ON ROAD Q Meadowland ' �0� DEPTH House Plot 1 r a BULKHEAD Total New York State Department of Environmental Conservation Division of Environmental Permits, Region One Building - SUNY, Stony Brook, New York 11790-2356 Phone: (5151 6) 444-0365 FAX: (516) 444-0360 John P. Cahill Commissioner Letter of Non-Jurisdiction - Freshwater Wetlands Act Adele Dusenbury April 30, 2001 PO Box 28 Stony Brook, New York 11790 Re: Application #1-4738-02826/00001 Mulford Ct., Orient SCTM 1000-14-2-3.26 Dear Ms Susenbury, Based on the information you have submitted, the New York State Department of Environmental Conservation has determined that: Your proposed project to construct a new 30' x 40' single family dwelling with septic system and driveway as shown on the survey by John C Ehlers, dated 11/16/2000 and last revised 12/12/2000 is more than 100 feet from regulated freshwater wetlands. Therefore, no permit is required under the Freshwater Wetlands Act (Article 24 of the Environmental Conservation Law). Be advised, that all construction, clearing, and/or ground disturbance must remain more than 100 feet from the freshwater wetland boundary. In addition, any additional work, or modification to the project as described, may require authorization by this Department. Please contact this office if such are contemplated. Please be further advised that this letter does not relieve you of the respons--ty of obtaining any necessary permits or approvals from other agencies. Sincere Rqq/g r Evans Pei it Administrator SU/1 BOH file C Mesiano Albert J. dent James KingUVicaPresi'dent �S�fFDClr l 53095 Route 25 Henry Smith h o j P.O. Box 1179 Artie Foster cn Southold, New York 11971-0959 Ken Poliwoda ; Telephone (631) 765-1892 Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD February 15, 2001 Ms. Catherine Mesiano Catherine Mesiano. Inc. 12 Mill Pond Lane East Moriches, NY 11940 RE: Mulford Court, Orient SCTM#14-2-3.26 Dear Ms. Mesiano: The Southold Town Board of Trustees reviewed the survey dated November 16, 2000 and last amended December 12, 2000 and determined that the construction of a single-family dwelling to be out of the Wetland jurisdiction under Chapter 97 of the Town Wetland Code. However, any activity within 100' of the Wetland line would require action from this office. This determination is not a determination from any other agency. If you have any further questions, please do not hesitate to call. Sincerely, Albert J. Krupski, Jr. President, Board of Trustees AJK:lms Applicant! � � Date Owners Name: L _ se �r — _—_— Revie"ued: �11613 Architect/ Dale SCTh4 1l: Vi,ion I.ocaliou. Sin%le & separate Required ccrUricffiion. Yes l Nol -- - —.� — — — — — ---- -_ ftcy �/ Itcq. /oninp Oistricl���© �Lvr rizu_ _ _ _ Anual. �_� (Lot covcragc chl upu.iu<�a_W_ Req. Req. - �y� Req. r [I ron)Yaid .Vcgr sed —] [Side Yard 1/ _— Proposed [IlcarYard _1Q Proposed Project Description: A GENCWERirIITS Permit REQUIRED FOR_EREVIEYES Number Suffolk County Health Dept. New York State D. L. Town Trustees Town Zoning Board approval: Town Planning Board approval Flood Plane Flevation ??? Flood Zone: Notes'.s . �&0 i ,65.1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IN LATION [ ] FRAMING [ FINAL [ ] FIREPLACE A CHIMNEY REMARKS: �= r� DATE INSPECTO at, le,ile -, - Gy �ot� m� FIELD INSPECTION REPORT DATE CONIlViENTS O R FOUNDATION(1ST) y ae ---------------------- ----- C rn t+7 FOUNDATION OND) z 0 ROUGH FRAMING& G 3 PLUMBING INSULATION PER N.Y. `3 STATE ENERGY CODE ' s iii e FINAL ADDITIONAL comm ;Ts i O m c x d TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD, NY 11971 3 sets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 Survey www. northfork.net/Southold/ PERMIT NO. �2 93Uf d; Check Septic Form N.Y.S.D.E.C. Trustees Examined 1)l 1q ,2003 Contact: Approved__ __ /�'�I X ,2003, Mail to: Disapproved a/c `� Phone:/ Expiration_ 20 4 �Q--hflc�y/ z� 6�� 71 Building Inspector APPLICATION FOR BUILDING PERMIT K ( � 2003 Date 20 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 waterways. 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 issue a Building Permit to the applicant. Such a 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 what so ever until the Building Inspector issues a Certificate of Occupancy. f. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an addition six months. Thereafter, a new permit shall be required. 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 inspections. OCCUPANCY OR "IMMEDIATELY" ad ENCLOSE POOL TO CODE USE IS UNLAWFUL (Si e of applicanor name,if a corporation) UPON COMPLETION f E gl i 0,0e- �tvC� I C 7(n 3 WITHOUT CERTIFICATE UNDERWRPARS CEHIIFIGATE o(J (Mailing address of applicant) OF OCCUPANCYREQUIRED i State whether applicant s owner, lessee, agent, architect, engineer, general contractor, electrician,plumber or builder AF Name of owner of premises R nq e— (As on the tax roll or latest e If applicant is a corporation, signature of duly authorized officer FEE:-Q Ste. BY: f.� NOTIFY BUILDING DEPARTMENT' AT (Name and title of corporate officer) A I IUN SHALL 7651802 SAM TO 4 PM FOR THE MEET THE REQUIREMENTS OF THE FOLLOWING INSPECTIONS: Builders License No-7 O!�,rs_ CODES OFNEW YORK STATE. 1. FOUNDATION - Two REQUIRED FOR POURED CONCRETE Plumbers License No. 2. ROUGH - FRAMING & PLUMBING Electricians License No. 16 IQ — M I: 3. INSULATION Other Trade's License No. 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. 1. Location of land on which proposed work will be done: ALL CONSTRUCTION SHALL MEET THE Mi N REQUIREMENTS OF THE CODES' :NEWHouse Number Street H `OR COSTRUCTNJN ERR County Tax Map No. 1000 Section— Block—_,;:?, Lot 3, 070 Subdivision(�CmVteu) &c,-}O eeS -- Filed Map No.:JOV' Lot (Name) 2. State existing use and occupancy of premiss and int ded use and occupancy of proposed construction: a. Existing use and occupancy Cz�SideX7h b. Intended use and occupancy )q and lsid)l(11moqPDQ1 3. Nature of work (check which applicable): New Building Addition Alteration__ Repair Removal Demolition Other Workitfo �lijt(pfQj4 [Xr 0 (Descriptio 4. Estimated Cost( /)00,00 Fee (To be paid on filing this application) 5. If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of each type of 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 Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories 9. Size of lot: Front Rear Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation? YES_NO-V- 13. OEL13. Will lot be re-graded? YES ✓ NO—Will excess fill be removed from premises? YES ✓NO_, 14. Names of Owner of premisesRnn KeteV,� Addressal-1 muQxJ Cl Phone Q Name of Architect Address Phone No Name of Contractor ,n Gr ls Address 5-I' f( l4410 0%+ry rd Phone No.(pg8-4NR8 — Ckgorn 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES ✓ NO * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES NO IF YES D.E.C. PERMITS MAYBE REQUIRED r * t4 :iftlilA{` 16. Provide survey, to scale, with accurate foundation plain and3distahtced t45mproperty lines. U N a �c , f, 4, r .. 17. If elevation at an point on property is at 10 feet or befo 1 w w must ravide too a Iiical data oi3.s e t Y P p P Y � �;• P gr P „ tii�✓��U STATE OF NEW YORK) SS: COUNTY OF n�arr�r,� J� e t Yf1 being duly swom, deposes and says that (s)he is the applicant def' ' dual cl) bov e named, (S)He is e :; ,F Age orp6rate'Offiber;et'C.YJq —TWA"" , s('q sir .1:J G a.`, ...,r 7 .-•(�r, of said ow$8ror'otwners; and is duly authoi5zed tS} ff, )mpr;h MGrfoe said work and to make and file this application; that all statements'eontained in-tbisiapplication are true to the best of fiis Tcnow and belief; and that the work will be performetih--d+ie manner set forth ir0thAp#Iication filed therewith. Swo to efove'nie this T '3 .p day:of P 82067 _ �� tr 'A rPublic "" f �.rr Signature ofApplicant ROBERT S.RAO NOIRY 1P�oM01�PMb York cAprao ae`Yob7 J pd 1I T. TERRYn,n IA.11l. S}UVS nIJ111 N ItOJ ry ' TOWCLERK ^{ = r�• i� P.O. flus I17o . y. � cr t1� �< Suulhnld. Nc�� bark I I'171 REGISFRA7 OF VITA.STATisICS ✓� Ic7b `, Fax (516) 765. I F21 MARRIAGE OFrICI-R - . bO` Tcicpl... l$1(,, 765_1801 RECOR!)S MANAGEMENT OFFICER FREEDOM OF INFORdA-nON OFFICER OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION WAS ADOPTED BY THE SOUTHOLD TOWN BOARD AT A REGULAR MEETING HELD ON AUGUST 24, 1993 : RESOLVED that the Town Board of the Town of Southold hereby adopts two (2) new forms to be used under the Flood Damage Prevent regulations of the Code of the Town of Southold : "Floodplain Development Permit Application" [FDP(93) ] , and "Certificate of Compliance for Development in Special Flood Hazard Area [C/C(93) ] . —+ t TOWN OF SOSni !OLD �h �� Southold Town Clerk August 25 , 1993 • APPLICATION s PAGE I of a TOWN OF SOUTHOLD FLOODPLAIN DEVELOPMENT PERMIT APPLICATION This form is to be filled out in duplicate. SECTION 1• GENERAL PROVISIONS (APPLICANT to read and sign): 1. No work may start until a permit is issued. 2 The permit may be revoked if any false statements are made herein. 3. If revoked, all work must cease until permit is re-issued. 4. Development shall not be used or occupied until a Certificate of Compliance is issued. S. The permit will expire if no work is commenced within six months of issuance. 6. Applicant is hereby informed that other permits may be required to fulfill local, state and federal regulatory requirements. 7. Applicant hereby gives consent to the Local Administrator or his/her representative to make reasonable inspections required to verify compliance. 8. I,THE APPLICANT,CERTIFY THAT ALL STATEMENTS HEREIN AND IN ATTACHMENTS TO THIS APPLICATION ARE,TO THE BEST O MY KNOWLEDGE,TRUE AND ACCURA'T'E. (APPLICANTS SIGNATURE) I DATE .. SECTION 2: PROPOSED DEVELOPMENT (To be completed by APPLICANTI NAME ADDRESS TELEPHONE CAM Iop ( J 4 B s S41 M idle Cn6 ,-d 01-4198 ENGINEER PROJECT LOCATION: To avoid delay in processing the application, please provide enough information to easily identify the project location. Provide the street address, lot number or legal description (attach) and, outside turban areas, the distance to the nearest intersecting road or well-known landmark. A sketch attached to this application showing the project location would be helpfuh. PhI� fa2� -75 Mol-VI-4 Cif (n (/' �e-ien r e of FDP(93) APPLICATION ' PAGE 2 OF G DESCRIPTION OF WORK (Check all applicable boxes) A. STRUCTURAL DEVELOPMENT ACTIVITY STRUCTURE TYPE 10 New Structure Xa Residential (1-4 Family) 0 Addition O Residential (More than 4 Family) 0 Alteration 0 Noo-residential (Floodproofmg? O Yes) 0 Relocation O Combined Use (Residential & Commerdal) 0 Demolition R 0 Manufactured (Mobile) Home (In Manu- 0 Replacement factured Home Park? 0 Yes) ESTIMATED COST OF PROJECT S o or B. OTHER DEVELOPMENT ACTIVITIES: 0 Fill O Mining 0 Drilling O Grading 0 Excavation (Except for Structural Development Checked Above) 0 Watercourse Alteration (Including Dredging and Channel Modifications) O Drainage Improvements (Including Culvert Work) 0 Road, Street or Bridge Construction 0 Subdivision (New or Expansion) 0 Individual Water or Sewer System 0 Other (Please Specify) After completing SECTION Z APPLICANT should submit form to Local Administrator for review. SECTION 3: FLOODPLAIN DETERMINATION fTo be completed by LOCAL ADMINISTRATOR) The proposed development is located on FIRM Panel No. Dated The Proposed Development: 0 Is +EQT located in a Special Flood Hazard Area (Notify the applicant that the application review is complete and NO FLOODPLAIN DEVELOPMENT PERMIT IS REQUIRED). 0 Is located in a Special Flood Hazard Arca. FIRM zone designation is 100-Year flood elevation at the site is: - FL NGVD (MSL) 0 Unavailable 0 The proposed development is located in a floodway. FBFM Pancl No, Dated 0 Sec Scatan 4 for additional instructions. SIGNED DATE i APPLICATION # PAGE 3 OF 4 SECTION 4: ADDITIONAL INFORMATION REQUIRED (To he completed by LOCAL ADMINISTRATOR) The apphcartt must submit the documents checked below before the application ran be processed: ❑ A site plan sbowing (be location of all casting structures, water bodies, adjacent roads, loi dimensions and proposed dcvclopmc❑t. ❑ Development plans,drawn to scale, and specifications, including where applicable: details for anchoring structures, proposed elevation of lowest floor (including basement), types of water resistant materials used below the fust floor, details of floodproofmg of utilities located below the fust floor and details of coclosures below the fust floor. Also, O Subdivision or other development plans (If the subdivision or other development exceeds 50 lots or 5 acres,whichever is the lesser, the applicant must provide 100-year flood elevations if they are not otherwise available). ❑ Plans showing the extent of watercourse relocation and/or landform alterations. ❑ Top of new rtll elevation Ft. NGVD (MSL). ❑ Floodproofmg protection level (non-residential only) Ft.NGVD (MSL). For floodproofed structures, applicant must attach certification from registered engineer or architect. ❑ Certification from a registered engineer that the proposed activity in a regulatory floodway will not result in any increase in the height of the 100-year flood. A copy of all data and calculations supporting this finding must also be submitted_ ❑ Other: =10N S: PERMIT DETERMINATION (To be completed by LOCAL ADMINISTRATOR) I have determined that the proposed activity. A, ❑ Is B.❑ Is not in conformance with Provisions of Local Law t¢ , 19 . The permit is issued subject to the conditions attached to and made part of this permit, SIGNED , DATE If BOX A h checked, the Local Administrator may issue a Development Permit upou payment of designated fee. If BOX B is checked, (be Local Administrator will provide a written summary of deficiencies. Applicant may revise and resubmit an application to the Local Administrator or may request a bearing from the Board of Appeals. APPLICATION N _ PAGE G OF a APPEALS: Appealed to Board of Appeals? ❑ Yes ❑ No Hearing date' Appeals Board Decision --- Approved? ❑ Yes ❑ No Conditions SECTION 6: AS GUILT ELEVATIONS (To be submitted by APPLICANT before Certificate of Compliance is isissued) The following information must be provided for project strictures. This section must be completed by a registered professional cnginccr or a licensed land surveyor (or attach a certification to this application). Complete 1 or 2 below. 1. Actual (As-Built) Elevation of the top of the lowest floor, including basement(in Coastal High Hazard Areas, bottom of lowest structural member of the. lowest floor, excluding piling and columns) is Fr. NGVD (MSL). 2. Actual (As-Built) Elevation of floodproofmg protection is FT. NGVD (MSL). NOTE: Any work performed prior to submittal of the above information is at the risk of the Applicant. SECTION 7: COMPLIANCE ACTION (To be completed by LOCAL ADMINISTRATQ) The LOCAL,ADMINISTRATOR will complete this section as applicable based on inspection of the project to ensure compliance with the community's local law for flood damage prevention. INSPECTIONS: DATE BY DEFICIENCIES? O YES ❑ NO DATE BY DEFICIENCIES? 0 YES O NO DATE BY DEFICIENCIES? 17 YES ❑ NO SECTION 8: CERTIFICATE OF COMPLIANCE(To be completed by LOCAL ADMINISTRATOR Certificate of Compliance issued: DATE BY: Attachment S 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 (OWNER MUST RETAIN THIS CERTIFICATE) PREMISES LOCATED AT: PERMIT NO. PERMIT DATE OWNERS NAME AND ADDRESS: CHECK ONE: 0 NEW BUILDING O EXISTING BUILDING J VACANT LAND THE LOCAL ADMINISTRATOR IS TO COMPLETE A. OR B. BELOW: A. COMPLIANCE IS HEREBY_ CERTIFIED WITH THE REQUIREMENTS OF - LOCAL LAW #_, 19 SIGNED: DATED: B. COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF LOCAL LAW # , 19_, AS MODIFIED BY VARIANCE # DATED SIGNED: DATED: C/C (93 ) SURVEY OF LOT 22 SES ,L o0 MAP OF GRANDV I EN ESTATES rc, � c � , F, --111 FILD JUNE 8, Ici82, FILE No. 7083 x =,eoe SITUATE: ORIENT 20' of =e°t,c --= TOWN: SOUTHOLD a. 2 9 n e ° - m:� Tco�e- � . B 3 �o.er > . B . SUFFOLK GOUNTI', NY ed0 — s` °°° Cn 000ls se0[,c 'I SGT# 1000-14-2-3.26 B' aee�ll l /a- a er t:o��c o SURVEYED OG-25-OI 300ae:5ii AlIENDP II-13-01 Ai seo�a�a t3�or, grovr.� «neer NEW HSE 04-25-02 /V - GERTIFIIED TO, �, RONALD KRIEB c - FIDELITY NATIONAL TITLE s INSURANCE GOMPANY OF N.Y. -- w c-� LOT 21 OWNER JOANN 5ANTORA TAX LOT 1000-14-2-3.25 `� � DWELLING A emsnw _. _N68°45'20"B a FSS MFNr PFR F Ll- N,; 165A0' P ) V` app lam , pin°, o , QO�z�"��P off. 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