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26625-z
FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-27589 Date: 03/23/01 THIS CERTIFIES that the building ADDITION Location of Property: 760 OAK AVE SOUTHOLD (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 77 Block 1 Lot 3 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 5, 2000 pursuant to which Building Permit No. 26625-Z dated JUNE 29, 2000 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 ADDITION & DECK ADDITION TO EXISTING ONE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to JAMES W. KOPHEN (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. N-550747 02/14/01 PLUMBERS CERTIFICATION DATED 03/14/01 ROBERT VANETTEN ut rized 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. 26625 Z Date JUNE 29, 2000 Permission is hereby granted to: JAMES W & WF KOPHEN 760 OAK AVE SOUTHOLD,NY 11971 for CONSTRUCTION OF A NEW ADDITION AND DECK TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. FLOOD PMT. INCLUDED. at premises located at 760 OAK AVE SOUTHOLD County Tax Map No. 473889 Section 077 Block 0001 Lot No. 003 pursuant to application dated MAY 5, 2000 and approved by the Building Inspector. Fee $ 175.00 Authorized Signature ORIGINAL Rev. 2/19/98 Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR,CERTIFICATE OF OCCUPANCY A. This application must be filled in by typewriter OR ink and submitted to the building inspector with the following: for new building 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 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 a consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. - Fees 1. Certificate of Occupancy - New dwelling $25.003 Additions to dwelling $25.00, Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $25.00, Additions to accessory building $25.00. Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Buildinc - $100.00 3. Copy of Certificate of Occupancy - .2 .0 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential )J $15.00, Commercial $15.00 Date .-.I�uC�d�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Construction.. . . .. . . . . . Old Or Pre-existing Building. . . . . . . . . . . . . . . . Location of Property. . 7G0. . . . . . . . . . . . . . . . . . . . . .(0C.'x.AVI .. . . . . . . . . . . . . doMn9.1� . . . . . . . . House No. �( Street Hamlet Onwer or Owners of Property..'Tf'ynff . . . . l:a P: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . County Tax Map No 1000, Section. . . . . . . . . . . . . .Block. . . . . . . . . . . . . . . .Lot. . . . . . . . . . . . . . . . . . . . . . Subdivision. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . .Filed Map. . . . . . . . . . . L t. . . . . �+ . T . . . . • •� n��l• ISCLieY �al� Permit No.7-" zS.�. . .Date Of Permit. G/Z h �q . . . . .Applicant. Ki 6V µq�.�.a.•. . . . . . . . . . . Y Health Dept. Approval. . . . . . . . . . . . . . . . . . . . . . . . . .Underwriters Approval.�� . . . . . . . . . . . . . . . . . . . . Punning Board Approval. . . . . . . . . . . . . Request for: Temporary Certificate. . . . . . . . . . . Final Cer icate. .�. . . . Fee Submitted: $. . . . . . .d.. . . . . . . . . . . . . . . . . . . . y . . c9��.c.,sq X01 . . . . . . . . . .��.'�'�C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o� y� Town Hall,53095 Main Road N Z Fax(631)765-1823 P.O.Box 1179 1� �•F Telephone(631)765-1802 Southold,New York 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD To Whom This May Concern: We are unable to complete your Certificate of Occupancy because of the following reasons: X An application for Certificate of Occupancy is not on file. (Enclosed) X No Underwriters Certificate on file. X The check is (not on file). No Health Department Approval on file. No final inspection has been made. X No Plumber Solder Certificate on fil . (All permits involving plumbing being i ed after Ap ' - , 1984). BUILDING PERMIT # 26625 Z �- Please contact our office on this matter. Thank you for your cooperation. SOUTHOLD TOWN BUILDING DEPT. o Y-A; ��4-t-, OftGa-� IJJf �\G�s � Fax (516) 765.1823 7olophon© (516) 765 180'1_ T �fJlam Ft N Town Hall, 530950 y P. O. Box 1179 ' Southold, NOW YOf1C 11971 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD C E R T I F I C A T I O N DATE: Building Perini t No owner: � � . ple se print) Plumber. rint) (please P I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. (Plumbers Signature) ' Sworn o before me this day of �pL,< County Notary Public, ELIZABETH A STATHIS NOTARY PUBLIC,State of New York No.01 ST6008173,Suffolk k CovO Terns Expires June 8, ?2—' ENERGY CODE CALCULATIONS (ror Non-Electric Iieat) Design Criteria 6,000 Vegree'.Days // / O.A. LUOr L.A. 7U'r• raft: (/��h�1 PJ ll V `d e PER: ��t �°A �� �^ 1jv DATED: Rev -3 /! po DESIGN TIIERMEL REMARKS SUBSYSTEM AREA "U" RAPING Exterior. walls (Opaque) fC p L1L Glaziny ~ / 17 , 3 'L ZZ ham e 4 c l Doors — Ceililsy/Itoof (Opaque) . 05 v Skyliytits $ rloor 11 U� Foundation Walls Slab Insulation TOTAL + Z L Notes: Building Envelope Systems Lo meet requirements of 7015.2 IIVAC Equipement to meet requirements of 7015. 11 IIVAC Systems to meet requirements of 7015. 1`2 Duct Systems to meet requirements of 7015.13 Ventilations Systems to meet requirements of 7015. 19 Insulation of Pipiliy Systems to meet requiremenL"s of 7015. 15 Service Water Heating Systems & Equipment: to meet- requirements of '1015. 21 Electrical & Lighting Systems & Equipment to ineeL- requiremenL-s of 7015. 31 To the best of my knowledge, OF NEW-J, & professional �P�� uE T�0 judyemenL, these plans are in compliance with the code. ,► �� c � r Uj Am J � �F 032254-1 �V oA�OFESSIOIA Jj MAY -IAN so 2 NofKl 00 WWJJ Ifo0 sF_ G 4( H "30L*416AD tS No Tri DM �r4>e- GAN2.p '�D 0 19101 A6 04CM IF'OV 5t CCe. 0 � D06 Rel( F►SO o N t o Trt OF 99 �a 04 �a -Ai�,r, 00 4tO u�o WM)ft�P 4 >E . 4f-: VAP C�N`D�Tio►�S_ = �� u�OVLD �SE ���� 50RV E 6f00 I N(9 y WA6 FSA N + moo f3M� C)kAW V 4SFMf-5 Of'--)L . !�iAdD Mt( 0L,vj;)rr�aNl5 ujf5RE F NI�'-- 'Fi Llf ROP Ili o Q f Tt7219f k(Cf 100 ( tCF�r N t4a_Pp__R --�- _ JKAk- M SIV tWK I k) To Ate- �S -9,OeP WAW O,t rc Fe l two R W . o� mg STS i croo 5L)696 625-(fP S}DU OD Town Hall, 530V5 Main Itnacl ;JUDITH T. TERRY 1 P.O. Box 11711 1 TOWN CLERK ~ � �•'-•t'�'% � Scruthcilcl. New York I 1971 y ( l• � Fax (516) 765-1821 REGISFRAR OF VITAL STATIS ICS �'� � AIARRIAGF OFFICER _ Tcicphoric (516) 7(6-1 X(11 RECOR[)S MANAGEMENT 01-FICEIZ ��� .a FREEDOM OF INFORMATION 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) ] . D : a .1 I TOWN OF SOi1 i FiOLD Judith T. Terry Southold Town Clerk August 25. 1993 APPLICATION # PAGE 1 of 4 TOWN OF SOUTHOLD FLOODPLAIN DEVELOPMENT PERMIT APPLICATION This form is to be filled out in duplicate. SECTION I• GENERAL PROVISIONS (APPLICANT to rcad and sign): 1. No work may start until a permit is issued. 2. The permit may be revoked if any frlse 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. 5. 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 OF MY KNOWLEDGE,TRUE AND ACCURATE. (APPLICANT'S SIGNATURE) DATE SECTION 2: PROPOSED DEVELOPMENT (To be completed by APPLICANTI NAME ADDRESS TELEPHONE APPLICANT BUILDER 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 urban areas, the distance to the nearest intersecting road or well-known landmark. A sketch attached to this application showing the project location would be helpful. FDP(93) APPLICATION` r PAGE 2OF4 DESCRIPTION OF WORK (Check all applicable boxes): A. STRUCTURAL DEVELOPMENT ACTIVITY STRUCTURE TYPE O New Structure ❑ Residential (1-4 Family) ❑ Addition ❑ Residential (More than 4 Family) ❑ Alteration ❑ Non-residential (Floodproof-mg? ❑ Yes) ❑ Relocation ❑ Combined Use (Residential & Commercial) ❑ Demolition ❑ Manufactured (Mobile) Home (In Manu- 0 Replacement factured Home Park? ❑ Yes) ESTIMATED COST OF PROJECT S B. OTHER DEVELOPMENT ACTIVITIES: ❑ Fill O Mining O Drilling O Grading ❑ Excavation (Except for Structural Development Checked Above) O Watercourse Alteration (Including Dredging and Channel Modifications) O Drainage Improvements (Including Culvert Work) O Road, Street or Bridge Construction O Subdivision (New or Expansion) ❑ Individual Water or Sewer System O Other (Please Specify) After completing SECTION 2, APPLICANT should submit form to Local Administrator for review. SECTION 3 FLOODPLAIN DETERMINATION (To be completed by LOCAL ADMINISTRATOR) The proposed development is located on FIRM Panel No. Dated The Proposed Development: O Is NOT located in a Special Flood Hazard Area (Notify the applicant that the application review is complete and NO FLOODPLAIN DEVELOPMENT PERN41 T IS REQUIRED). O Is located in a Special Flood Hazard Area. FIRM zone designation is 100-Year flood elevation at the site is: Ft. NGVD (MSL) ❑ Unavailable O The proposed development is located in a floodway. FBFM Panel No. Dated ❑ See Section 4 for additional instructions. SIGNED DATE APPLICATION # PAGE 3OF4 SECTION 4 ADDITIONAL INFORMATION REQUIRED (To be completed by LOCAL ADMINISTRATOR) The applicant must submit the documents checked below before the application can be processed: ❑ A site plan showing the location of all existing structures, water bodies, adjacent roads, lot dimensions and proposed development. ❑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 floodproofing of utilities located below the fust floor and details of enclosures below the first floor. Also ❑ 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 fill elevation Ft. NGVD (MSL). ❑ Floodproofing 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: SECTION 5: PERMIT DETERMINATION (To be completed by LOCAL ADMINISTRATOR) I have determined that the proposed activity. A. O Is B. O Is not in conformance with provisions of Local Law , 19 . The permit is issued subject to the conditions attached to and made part of this permit. SIGNED DATE If BOX A is checked, the Local Administrator may issue a Development Permit upon payment of designated fee. If BOX B is checked, the Local Administrator will provide a written summary of deficiencies. Applicant may revise and resubmit an application to the Local Administrator or may request a hearing from the Board of Appeals. _ APPLICATION # PAGE 4 OF 4 APPEALS: Appealed to Board of Appeals? ❑ Yes ❑ No Hearing date: Appeals Board Decision --- Approved? ❑ Yes ❑ No Conditions SECTION 6: AS-BUILT ELEVATIONS (To be submitted by APPLICANT before Certificate of Compliance is issued The following information must be provided for project structures. This section must be completed by a registered professional engineer 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: FT. NGVD (MSL). 2. Actual (As-Built) Elevation of floodproofing 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 ADMINISTRATOR) 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. INSPP,CTIONS: DATE BY DEFICIENCIES? ❑ YES ❑ NO DATE BY DEFICIENCIES? ❑ YES ❑ NO DATE BY DEFICIENCIES? ❑ YES ❑ NO SECTION 8: CERTIFICATE OF COMPLIANCE(To be completed by LOCAL ADMINISTRATOR) Certificate 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 (OWNER MUST RETAIN THIS CERTIFICATE) PREMISES LOCATED AT: PERMIT NO. PERMIT DATE OWNERS NAME AND ADDRESS: CHECK ONE: ❑ NEW BUILDING ❑ EXISTING BUILDING ❑ 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 # , 19AS MODIFIED BY VARIANCE # DATED ' SIGNED: DATED: C/C(93) .. .-_ T -..y. - - - :> : _ .. " j - - ` - _ ... . p t� v _ 'i.1 _ k.A �.c ( ,(,, y - . . 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' ... _'#i - '•: .!. ., .. :. ,.-.r,' :y r. -_..,.,. �h ...,r �.'a, -f�. 3 _k't_ syi r�. ,w-s&,a 3,: .y . .,7y. k /..,� c� br .` iRr ' r - x r �.lR.t'lk'�C�. a YO�If , t ,r2M!�/ "'+.-r;.i T. a.•..�... . .a.a. .e'.;-.. r i.. c .. -<3_ •-n-; .a.;;r ... ... 'r, �.. ..-,�. 1tsi�w ,�:.d.,.555'.. �-i. -/.�/�r�.f wd-� < i,.. .r!� - •` : _ .. . FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0077 NATIONAL FLOOD INSURANCE PROGRAM Expires July 31, 2002 ELEVATION CERTIFICATE Important: Read the instructions on pages 1 -7. SECTION A-PROPERTY OWNER INFORMATION For Insurance Company Use: BUILDING OWNER'S NAME Policy Number BUILDING STR ET ADDRESS(Including Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Company NAIC Number Qak Avenue CITY STATE ZIP CODE qnilt- NY 11971 PROPERTY DE CRIPTION(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.) 1000-77-01 -03 BUILDING USE(e.g.,Residential,Non-residential,Addition,Accessory,etc. Use Comments section if necessary.) LATITUDE/LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: L_l GPS(Type): ( ##°-##'-##•##" or ##.###W) L_l NAD 1927 L_l NAD 1983 L-1 USGS Quad Map L_L Other: SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION B1.NFIP COMMUNITY NAME&COMMUNITY NUMBER B2.COUNTY NAME B3.STATE Southold 360813 1 Suffolk I New York B4.MAP AND PANEL B5.SUFFIX B6.FIRM INDEX B7.FIRM PANEL B8.FLOOD B9.BASE FLOOD ELEVATION(S) NUMBER DATE EFFECTIVE/REVISED DATE ZONE(S) (Zone AO,use depth of flooding) 36103CO166 G 05/04/98 X & AE El. 8 1310. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in B9. 1_I FIS Profile IX I FIRM 1_1 Community Determined I_I Other(Describe): B11. Indicate the elevation datum used for the BFE in B9:1 x 1 NGVD 1929 I_I NAVD 1988 (J Other(Describe): B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? 1J Yes P_Cj. No Designation Date: SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) C1. Building elevations are based on: 1_1Construction Drawings* 1JBuilding Under Construction* IX 1Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Building Diagram Number 2 (Select the building diagram most similar to the building for which this certificate is being completed-see pages 6 and 7. If no diagram accurately represents the building,provide a sketch or photograph.) C3. Elevations—Zones Al-A30,AE,AH,A(with BFE),VE,V1 430,V(with BFE),AR,AR/A,AR/AE,AR/A1-A30,AR/AH,AR/AO Complete Items C3a-i below according to the building diagram specified in Item C2.State the datum used. If the datum is different from the datum used for the BFE in Section B,convert the datum to that used for the BFE.Show field measurements and datum conversion calculation. Use the space provided or the Comments area of Section D or Section G,as appropriate,to document the datum conversion. Datum Conversion/Comments Elevation reference mark used RM l 9 Does the elevation reference marts used appear on the FIRM? I-XI Yes 1-1 No ❑ a)Top of bottom floor(including basement or enclosure) 5 7 ft.(m) ❑ b)Top of next higher floor 13 1 ft.(m) ❑ c)Bottom of lowest horizontal structural member(V zones only) _ft.(m) o ❑ d)Attached garage(top of slab) _ft.(m) E cc L1e)Lowest elevation of machinery and/or equipment u, servicing the building _ft.(m) E ❑ f)Lowest adjacent grade(LAG) 5 ft.(m) 2.5 ❑ g)Highest adjacent grade(HAG) 10 .;ft.(m) 8 E3 h)No.of permanent openings(flood vents)within 1 ft.above adjacent grade 8 ❑ i)Total area of all permanent openings(flood vents)in C3h sq.in.(sq.cm) SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation information. I certify that the information in Sections A,B, and C on this certificate represents my best efforts to interpret the data available. 1 understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. CERTIFIER'S NAME LICENSE NUMBER 49618 I President PecPonicA Surveyors, P.C. ADDRESSP.0. Box 909 CITY Southold STATE NY ZIP CODE 11971 SIGNATURE DATE TELEPHONE ( 631 ) 765-5020 FEMA Form 8 3 ,AUG 99 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS IMPORTANT: In these spaces,copy the corresponding information from Section A. For Insurance Company Use: BUILDING STREET ADDRESS(Including Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Policy Number CITY STATE ZIP CODE Company NAIC Number SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED) Copy both sides of this Elevation Certificate for(1)community official, (2)insurance agent/company,and(3)building owner. COMMENTS Check here if attachments SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(WITHOUT BFE) For Zone AO and Zone A(without BFE),complete Items E1 through E4. If the Elevation Certificate is intended for use as supporting information for a LOMA or LOMR-F, Section C must be completed. E1. Building Diagram Number (Select the building diagram most similar to the building for which this certificate is being completed— see pages 6 and 7. If no diagram accurately represents the building,provide a sketch or photograph.) E2.The top of the bottom floor(including basement or enclosure)of the building is LL-1 ft.(m)LLIin.(cm) Lj above or LJ below (check one)the highest adjacent grade. E3. For Building Diagrams 6-8 with openings(see page 7),the next higher floor or elevated floor(elevation b)of the building is I—LI ft.(m)LLlin.(cm)above the highest adjacent grade. E4. For Zone AO only: If no flood depth number is available,is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? I Yes I No LI Unknown. The local official must certify this information in Section G. SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION The property owner or owner's authorized representative who completes Sections A,B,and E for Zone A(without a FEMA-issued or community-issued BFE)or Zone AO must sign here. PROPERTY OWNER'S OR OWNER'S AUTHORIZED REPRESENTATIVE'S NAME ADDRESS CITY STATE ZIP CODE SIGNATURE DATE TELEPHONE COMMENTS LJ Check here if attachments SECTION G-COMMUNITY INFORMATION(OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A, B,C(or E),and G of this Elevation Certificate. Complete the applicable item(s)and sign below. G1. Lj The information in Section C was taken from other documentation that has been signed and embossed by a licensed surveyor, engineer,or architect who is authorized by state or local law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2. LJ A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE)or Zone AO. G3. LJ The following information(Items G4-G9)is provided for community floodplain management purposes. G4.PERMIT NUMBER J G5. DATE PERMIT ISSUED G6. DATE CERTIFICATE OF COMPLIANCE/OCCUPANCY ISSUED G7.This permit has been issued for: Lj New Construction L1 Substantial Improvement G8. Elevation of as-built lowest floor(including basement)of the building is: _ft.(m)Datum: G9.BFE or(in Zone AO)depth of flooding at the building site is: _ft.(m)Datum: LOCAL OFFICIAL'S NAME TITLE COMMUNITY NAME TELEPHONE SIGNATURE DATE COMMENTS Check here if attachments FEMA Form 81-31,AUG 99 REPLACES ALL PREVIOUS EDITIONS INSTRUCTIONS FOR COMPLETING THE ELEVATION CERTIFICATE The Elevation Certificate is to be completed by a land surveyor, engineer, or architect who is authorized by law to certify elevation information when elevation information is required for Zones Al-A30,AE,AH,A(with BFE),VE,V1-V30,V(with BFE), AR, AR/A,AR/AE, AR/A1-A30, AR/AH, or AR/AO. Community officials who are authorized by law or ordinance to provide floodplain management information may also complete this form. For Zones AO and A (without BFE), a community official, a property owner, or an owner's representative may provide information on this certificate, unless the elevations are intended for use in supporting a LOMA or LOMR-F. Certified elevations must be included if the purpose of completing the Elevation Certificate is to obtain a LOMA or LOMR-F. In Puerto Rico only,elevations for building information and flood hazard information may be entered in meters. SECTION A-PROPERTY OWNER INFORMATION This section identifies the building, its location, and its owner. Enter the name(s) of the building owner(s), the building's complete street address,and the lot and block number. If the building's address is different from the owner's address,enter the address of the building being certified. If the address is a rural route or a Post Office box number, enter the lot and block numbers,the tax parcel number,the legal description,or an abbreviated location description based on distance and direction from a fixed point of reference. For the purposes of this certificate, "building"means both a building and a manufactured (mobile) home. A map may be attached to this certificate to show the location of the building on the property. A tax map, FIRM, or detailed community map is appropriate. If no map is available, provide a sketch of the property location, and the location of the building on the property. Include appropriate landmarks such as nearby roads, intersections, and bodies of water. For building use, indicate whether the building is residential, non-residential, an addition to an existing residential or non-residential building,an accessory building(e.g.,garage),or other type of structure. Use the Comments area of Section F if needed. If latitude and longitude data are available, enter them in degrees, minutes, and seconds, or in decimal degrees, taken at the center of the front of the building. Enter arc seconds to two decimal places. Indicate the horizontal datum and the source of the measurement data(for example,taken with GPS,scaled from a USGS Quad Map,etc.). SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION Complete the Elevation Certificate on the basis of the FIRM in effect at the time of the certification. The information for Section B is obtained by reviewing the FIRM panel that includes the building's location. Information about the current FIRM,and a pamphlet titled"Guide to Flood Maps,"are available from the Federal Emergency Management Agency (FEMA)website at http://www.fema.gov or by calling 1-800-427-4661. If a Letter of Map Amendment (LOMA) or Letter of Map Revision(LOMR-F)has been issued by FEMA,please provide the letter date and case number in the Comments area. Item Bl. NFIP Community Name & Community Number. Enter the complete name of the community in which the building is located and the associated 6-digit community number. For a building that is in an area that has been annexed by one community but is shown on another community's FIRM, enter the community name and 6-digit number of the annexing community. For a newly incorporated community, use the name and 6-digit number of the new community. Under the NFIP, a "community" is any State or area or political subdivision thereof, or any Indian tribe or authorized native organization, that has authority to adopt and enforce floodplain management regulations for the areas within its jurisdiction. To determine the current community number, see the NFIP Community Status Book,available on FEMA'swebsite at http://www.fema.gov or by calling 1-800-427-4661. Item B2. County Name. Enter the name of the county or counties in which the community is located. For anunincorporated area of a county,enter"unincorporated area." For an independent city,enter"independent city." Item B3. State. Enter the 2-letter state abbreviation(for example,VA,TX,CA). Instructions—Page 1 Item B4. Map and Panel Number. Enter the 10-digit number shown on the FIRM panel where the building or manufactured (mobile)home is located. The first six digits will not match the NFIP community number: 1) when the sixth digit is a"C" in which case the FIRM panel is in a countywide format; or 2) when one community has annexed land from another community but the FIRM panel has not been updated to reflect this annexation.If the sixth digit is a"C,"it is followed by a four-digit map number. For maps not in countywide format,enter the"community panel number"shown on the FIRM. Item 115. Suffix. Enter the suffix letter shown on the FIRM panel that includes the building's location. Item 136. FIRM Index Date. Enter the effective date or map revised date shown on the FIRM Index. Item B7. FIRM Panel Effective/Revised Date.. Enter the map effective date or the map revised date shown on the FIRM panel. This will be the latest of all dates shown on the map. The current FIRM panel effective date can be determined by calling 1-800-427-4661. Item B8. Flood Zone(s). Enter the flood zone,or flood zones, in which the building is located. All flood zones containing the letter"A"or"V"are considered Special Flood Hazard Areas. The flood zones are A, AE,AI-A30,V,VE,V1-V30,AH, AO, AR,AR/A,AR/AE,AR/Al-A30,AR/AH,and AR/AO. Each flood zone is defined in the legend of the FIRM panel on which it appears. Item B9. Base Flood Elevation(s). Using the appropriate Flood Insurance Study (FIS) Profile, Flood Elevation Table, or FIRM panel, locate the property and enter the BFE(or base flood depth)of the building site. If the building is located in more than one flood zone in Item B8,list all appropriate BFEs in Item B9. BFEs are shown on a FIRM or FIS Profile for Zones A1- A30,AE,AH, V1-V30,VE,AR,AR/A,AR/AE,AR/A1-A30,AR/AH, and AR/AO; flood depth numbers are shown for Zone AO. Use the AR BFE if the building is located in any of Zones AR/A, AR/AE, AR/A1-A30, AR/AH, or AR/AO. In A or V zones where BFEs are not provided on the FIRM,the community may have established BFEs or obtained BFE data from other sources. For subdivisions and other developments of more than 50 lots or 5 acres, establishment of BFEs is required by the community's floodplain management ordinance. If the BFE is obtained from another source,enter the BFE in Item B9. Item B10. Indicate the source of the BFE that you entered in Item B9. Item Bll. Indicate the elevation datum to which the elevations on the applicable FIRM are referenced. Item B12. Indicate whether the building is located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA). Federal flood insurance is prohibited in designated CBRS areas for buildings or manufactured (mobile) homes built or substantially improved after the date of the CBRS designation. An information sheet explaining CBRS areas may be obtained on FEMA's website at http://www.fema.gov or by calling 1-800-427-4661. SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) Complete Section C if the building is located in any of Zones Al-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, AR/A, AR/AE, AR/Al-A30, AR/AH, or AR/AO, or if this certificate is being used to support a LOMA or LOMR-F. If the building is located in Zone AO or Zone A(without BFE),complete Section E instead. Item Cl. Indicate whether the elevations to be entered in this section are based on construction drawings, a building under construction, or finished construction. For either of the first two choices, a post-construction Elevation Certificate will be required when construction is complete. Item C2. Select the diagram on pages 6 and 7 that best represents the building. Then enter the diagram number and use the diagram to identify and determine the appropriate elevations requested in Items C3a-g. If you are unsure of the correct diagram, select the diagram that most closely resembles the building being certified, or provide a sketch or photograph of the building and enter all elevations in Items C3a-g. Item C3. Indicate whether the elevation reference mark(benchmark)used during the field survey is an elevation mark on the FIRM. If it is not, indicate the source and datum for the elevation. Vertical control benchmarks other than those shown on the FIRM are acceptable for elevation determinations. Show the conversion from the field survey datum used to the datum used for the BFE(s) entered in Item B9. All elevations for the certificate must be referenced to the datum on which the BFE is Instructions—Page 2 based. Show the datum conversion, if applicable, in this section or in the Comments area of Section D. For property experiencing ground subsidence, the most recently adjusted reference mark elevations must be used for determining building elevations. Enter elevations in Items C3a-g to the nearest tenth of a foot(in Puerto Rico,nearest tenth of a meter). Items C3a-d. Enter the building elevations indicated by the selected building diagram(Item C2) in Items C3a-e. Elevation for top of attached garage slab (d) is self-explanatory and is not illustrated in the diagrams. If the building is located in a V zone on the FIRM, complete Item C3c. If the flood zone cannot be determined, enter elevations for all of Items C3a-g. For buildings in A zones,elevations a,b, d, and a should be measured at the top of the floor. For buildings in V zones, elevation c must be measured at the bottom of the lowest horizontal structural member of the floor(see drawing below).If any item does not apply to the building, enter "NIA"for not applicable. BUILDING ON BUILDING WITH BUILDING ON PILES, SLAB BASEMENT PIERS,OR COLUMNS A ZONES V ZONES a A ZONES V ZONES a A ZONES a C c BASE FLOOD ELEVATION C BASE FLOOD ADJACENT ELEVATION GRADE E)JACENT .'-dKADE Item C3e. Enter the lowest elevation of machinery or equipment in an attached garage, enclosure,or open utility platform that provides utility services for the building. If the machinery or equipment is mounted to a wall, pile, etc., enter the platform elevation of the machinery and/or equipment.If this item does not apply to the building, enter "NIA"for not applicable. Items Cif-g. Adjacent grade is defined as the elevation of the ground, sidewalk, patio, or deck support immediately next to the building. Use the natural grade elevation, if available. This measurement must be to the nearest tenth of a foot if this certificate is being used to support a request for a LONA or LOMR-F. Items C3h-i. Enter the number of permanent openings (flood vents) in the walls supporting the building that are no higher than 1.0 foot above the adjacent grade. Determine the total area of all such openings in square inches (square cm, in Puerto Rico),and enter the total in Item C3i. If the building has no permanent openings (flood vents)within 1.0 foot above adjacent grade,enter"0"(zero)for each of Items C3h and C3i. SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION Complete as indicated. This section of the Elevation Certificate may be signed by only a land surveyor, engineer, or architect who is authorized by law to certify elevation information. Place embossed seal and signature in the box next to elevations in Section C. A flat stamp is acceptable only in states that do not authorize use of an embossed seal over the signature of a professional. You are certifying that the information in Sections A, B, and C on this certificate represents your best efforts to interpret the data available and that you understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. Use the Comments area of Section D, on the back of the certificate,to provide datum, elevation, or other relevant information not specified on the front. Instructions—Page 3 SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO &ZONE A(WITHOUT BFE) Complete Section E if the building is located in Zone AO or Zone A(without BFE). Otherwise,complete Section C instead. Item E1. Select the diagram on pages 6 and 7 that best represents the building; then enter the diagram number. If you are unsure of the correct diagram, select the diagram that most closely resembles the building,or provide a sketch or photograph. Item E2. Enter the height in feet and inches (meters and centimeters, in Puerto Rico) of the top of the bottom floor (as indicated in the applicable diagram)above or below the highest adjacent grade(HAG). For post-FIRM buildings in ZoneAO, the community's floodplain management ordinance requires that this value equal or exceed the base flood depth on the FIRM. Buildings in Zone A(without BFE) may qualify for a lower insurance rate if an engineered BFE is developed at the site. Item E3. For Building Diagrams 6-8 with "proper openings" (see page 7), enter the height in feet and inches (meters and centimeters, in Puerto Rico)of the next higher floor or elevated floor(as indicated in the applicable diagram)above the highest adjacent grade(HAG). Item E4. For those communities where this base flood depth is not available, the community will need to determine whether the top of the bottom floor is elevated in accordance with the community's floodplain management ordinance. SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION Complete as indicated. This section is provided for certification of measurements taken by a property owner or property owner's representative when responding to Sections A, B, and E. The address entered in this section must be the actual mailing address of the property owner or property owner's representative who provided the information on the certificate. SECTION G-COMMUNITY INFORMATION(OPTIONAL) Complete as indicated. The community official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A, B, C (or E), and G of this Elevation Certificate. If the authorized community official completes Sections C,E,or G,complete the appropriate item(s)and sign this section. Check Item G1 if Section C is completed with elevation data from other documentation that has been signed and embossed by a licensed surveyor,engineer, or architect who is authorized by law to certify elevation information. Indicate the source of the elevation data and the date obtained in the Comments area of Section G. If you are both a community official and a licensed land surveyor, engineer, or architect authorized by law to certify elevation information, and you performed the actual survey for a building in Zones Al-A30, AE, AH, A (with BFE), V1-V30, V, AR, AR/A, AR/A1-A30, ARAE, AR/AH, or AR/AO, you must also complete Section D. Check Item G2 if information is entered in Section E by the community for a building in Zone A (withouta FEMA-issued or community-issued BFE)or Zone AO. Check Item G3 if the information in Items G4-G9 has been completed for community floodplain management purposes to document the as-built lowest floor elevation of the building. Section C of the Elevation Certificate records the elevation of various building components but does not determine the lowest floor of the building or whether the building, as constructed, complies with the community's floodplain management ordinance. This must be done by the community. Items G4-G9 provide a way to document these determinations. Item G4. Permit Number. Enter the permit number or other identifier to key the Elevation Certificate to the permit issued for the building. Item G5. Date Permit Issued. Enter the date the permit was issued for the building. Instructions—Page 4 Item G6. Date Certificate of Compliance Issued. Enter the date that the Certificate of Compliance or Occupancy or similar written official documentation of as-built lowest floor elevation was issued by the community as evidence that all work authorized by the floodplain development permit has been completed in accordance with the community's floodplain management laws or ordinances. Item G7. New Construction or Substantial Improvement. Check the applicable box. "Substantial Improvement"means any reconstruction, rehabilitation, addition, or other improvement of a building, the cost of which equals or exceeds 50 percent of the market value of the building before the start of construction of the improvement. The term includes buildings that have incurred substantial damage, regardless of the actual repair work performed. Item G8. As-built lowest floor elevation. Enter the elevation of the lowest floor(including basement)when the construction of the building is completed and a final inspection has been made to confirm that the building is built in accordance with the permit, the approved plans, and the community's floodplain management laws or ordinances. Indicate the elevation datum used. Item G9. BFE. Using the appropriate FIRM panel, FIS, or other data source, locate the property and enter the BFE (or base flood depth)of the building site. Indicate the elevation datum used. Enter your name, title, and telephone number, and the name of the community. Sign and enter the date in the appropriate blanks. Instructions—Page 5 BUILDING DIAGRAMS The following eight diagrams illustrate various types of buildings. Compare the features of the building being certified with the features shown in the diagrams and select the diagram most applicable. Enter the diagram number in Item C2 and the elevations in Items C3a-C3g. In A zones, the floor elevation is taken at the top finished surface of the floor indicated; in V zones, the floor elevation is taken at the bottom of the lowest horizontal structural member (see drawing in instructions for Section Q. DIAGRAM 1 DIAGRAM 2 All slab-on-grade single-and multiple-floor buildings All single-and multiple-floor buildings with basement (other than split-level)and high-rise buildings,either (other than split-level)and high-rise buildings with detached or row type(e.g.,townhouses);with or basement,either detached or row type(e.g., without attached garage. townhouses);with or without attached garage. Distinguishing Feature—The bottom floor is at or above ground level Distinguishing Feature—The bottom floor(basement or underground (grade)on at least one side.' garage)is below ground level(grade)on all sides. Buildings constructed above crawl spaces that are below grade on all sides should also use this diagram.' b a NEXT HIGHER a i FLOOR NEXT HIGHER b FLOOR GRADE BOTTOM FLOOR GRADE BOTTOM FLOOR (BASEMENT) f 9 (determined by existing grade) f g (determined by existing grade) DIAGRAM 3 DIAGRAM 4 All split-level buildings that are slab-on-grade,either All split-level buildings(other than slab-on-grade), detached or row type(e.g.,townhouses);with or either detached or row type(e.g.,townhouses);with or without attached garage. without attached garage. Distinguishing Feature—The bottom floor(excluding garage)is at or Distinguishing Feature—The bottom floor(basement or underground above ground level(grade)on at least one side.* garage)is below ground level(grade)on all sides. Buildings constructed above crawl spaces that are below grade on all sides should also use this diagram. a HIGHER b %BoTTOM FLOORS HIGHER NEXT HIGHER GRAFLOORSFLOOR NEXT HIGHER RADE BOTTOM FLOOR FLOOR LOOK BASEMENT ;.. ..:.,.,..,..•. ..... :., '•rir 'w f g (determined by existing grade) f 9 (determined by existing grade) * A floor that is below ground level(grade)on all sides is considered a basement even if the floor is used for living purposes,or as an office, garage,workshop,etc. Instructions—Page 6 C11,22- 5-(��- M-1802 BUILDING DEPT. INSPECTIO [ ] FOUNDATION IST [ RO H PLBG. [ ] FOUNDATION 2ND [ INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & ClIIMNEY REMARKS: �G�.c• X� ,DATE c ° / dD INSPECTOR X65.1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ✓] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: DATE INSPECTOR a40 4� �- M•isox suiLDiNa DEPT. /FOUNDATION NSPECTION [ IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND ( ] INSULATION [ ] FRAMING [ 1 FINAL [ ] FIREPLACE & CHIMNEY REMIARKe z� 47 7 lol � INSPECT ass-iso2 suiLciNa car. INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ L4"INL [ ] FIREPLACE & CHIMNEY REMARKS: y ,DATE INSPECTOR /� FIELD INSPECTION REPORT DATE COMMENTS ___-------- ______________� - u==== --- - FOUNDATION ( T) / --- IIII-------------- ----------- ------ II -----.---- II II FOUNDATION OND) II _-_ ROUGH FRAME & �T PLUMBING tt-- II II �� �— II II II l II H t INSULATION PER N. Y. STATE ENERGY II ii CODE n u u y3r aCIO II c H II jj �I FINAL n it ___________—__ — __=_------------ ---------------- ---- ADDITIONAL COUNTS: 1y ��✓ O!> tilsulr0 .SCO-� r - C=! z\ r� ro — H BOARD OF HEALTH . �/— . . . . . . . . . FORM NO. 1 3 SETS OF X(LANS . . . . . . . . . . . . . . . TOWN OF SOUTHOLD SURVEYA. . . . . . . . . . . . . . . . . . . . . . BUILDING DEPARTMENT CHECK . . . . . . . . . . . . . . . . . . . . . TOWN HALL SEPTIC FORM . . . . . . . . . . . . . . . . . . . SOUTHOLD, N.Y. 11971 TEL; 765-1802 N Pe CALL Examined...!�A-7........ t4.4Q MAIL. TO: . . . . . . . . . . . . . . . . . . . Approved..�/ ....... 9-4.00. Permit No. .....9.- ....... . ..... .. ................ . . . Disapproveda/c .................................. ............ .... ........... ..... . . ......................... -n ...................... Nt ... .. .... ............. � •ILA –J (Building Inspector) APPLICATION FOR BUILDING PERMIT DG.s ,nl_7 Date. . . . . . . . . . , 200 INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the fluildinb Inspector t 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of property must be drawn on the diagram wiiich is part of this application. 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 permit shall be.kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in Whole or in part for any purpose whatever until a Certificate of Occupancy shall have been granted by the Buildino Inspector. APPLICATICH IS HP3[iW MATE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Tom of Southold, Suffolk Canty, 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, ordi s, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildin for necessna� i pect VX (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 build Name of owner of premises ..�Rlrn.e S. ° .............................................. . ...... . . ..... . . ...... (as on the" tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. ......................................................... (Name and title of corporate officer) Builders License ND. .................:....... Plumbers License No. ......................... Electricians License No. ..................... Other Trade's License No. .................... I. Location of land on which proposed work will be done..................................... ..... .... .. . .. . . . . .. .... . ...................................041r Q re �leS �f/ �/� ........ ................. : ...... . . . .. . . . . . . .... . .... House Number Street y Hamlet Canty Tax Map No. 1000 Section ...7J.......... Block . ........... Lot e.J3..... Subdivision ... P.oJe�; s./ C...... ....... Filed Map No. ..... ..... Lot ...... ...... .. . (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ,;�i n�eG,�Q'••••/, EGD :::•(......................... . .... . . . ... ........ b. Intended use and occupancy .. /eS2Gr;L�t-/ ... ................................... 1. Nature of work (check wl►ic► applicable): New Building .......... Addition ..Z.. Alteration Repair ........ .... Ren7val ............. Demolition ............ Other Work .................................. .� .. .. ............................(Description) 4. Iistilliated Cost D 0 O L).......... fee .............. (to be paid on filing this application) 5. if (i elIing, rxni)er of dwelling units ... ...... Nurher of dwelling units on each floor ..I. ......... Ifgarage, txni)er of cars .....&A............................. 6. If lx►si►►ess, cxinnercial or mixed occupancy, specify nature and extent of each type of use...................... 7. Dimensions of existing stnictures, if any: Front..��..�.- Rear '72'........... Depth 5. ....... lkigl►t ......�'e............... Rmber of Stories ........... �2 Dimensions of saw stn►cture with alterations or additions: Front4�.. j..... Rear.......... Depth ......3.5.......... height ...+e............ Number of Stories 4f........... /!P r-�v � r• 8. Dim Dimensions of entire new construction: Front . Rear . . f)wptb ; Height ... ...... ............ NLuber of Stories Z.................. 9. Size of lot: Front ...'.o.............. Rear 46............... Depth ............ 10. 1�►te of Purchase ...I,A . ........... Name of Former Owner'^ .................................... II. Zone or use district in which premises are situated .............................................................. i2. Does proposed construction violate any zoning law, ordinance or regulation: .A0 ..'....... )3. Will lot be regraded .................. Will excess fill be renoved from premises: YES,. .' ND 14. Hanes of Owner of premises f rn<FACY KPI Zew...Y".......... Add res Pr/l f./✓�Ptare No. ........ ...... ...... . ... ... N.'me of Architect .................................... Address .................. ... .... pp flame of (cx►tractoran!cjp... .............. Address 8?P.S..Ia��iPa�aF U/te11.1..Phone 15. Is this property within 300 feet of a tidal wetland? * YES .......... NO .......... *I F YES, S(1UI1O D MM 'I1i3ISIEES PERMIT MAY BE W4HRED. PI.O'r DIAGRAM Incate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whetlwr interior or comer lot. Q,"LZ.c,LcQ� srAVn: OF N?W Wff,, SS CXAJNIY U. .... .. . . ..... .. . / .....being duly sworn, deposes and says that he is the applicant (Nave of individual signing contract) above rumed, Ile is the ..GOn ................ . ((',cx►tractor, agent, corporate officer, etc.) ..'•.'•••'•.. of said owner or cim)ers, 1TKI is ohily authorized to perform or have performed the said work and to make and file this applicatim; that all slatownts contained in this application are true to the best of his knowledge and belief; and that the work will. be performed in the manner set forth in the application filed therewith. Sworn to be I UI-e this s ......6....... ....day of. ...... `20.00.. Notary Public ✓..... ......... :............. G ,� �a � � HELENSD.HORNS .`...................Notary Public.State of NsNr York (Signature of Applicant) NO.4951364 Clualified In Suffolk County Commission Expires May 22, ,3�O 0 3 BUILDING PERT' -T__REVIEW CHECK LIST Applicant/ „, ff Date Owners Name: -3Cxr e5 K§/ 11 Reviewed: Architect/ Date Engineer: �CQ11 U TVA l) Submitted: 6--r, SCTM #: District: 1.000 Section- r) Block Lot: 3 Project h '1_ '/ _' Q Q Subdivision Location: ')bo VI,V�— Ave SQL � _ Name: Single&separate Required certification: (Yes/No) Req. Req. .� ^, Zoning Districc� [Lot size: Actual. A" � /6 l A""ZOO J [Lot covers e�g Proposed.= � J x�. Req r Req. i Req. / [Front Yard Proposed: [Side Yard /a Proposed:/� 32I [Rear Yard Proposed: ^,g J Project Description: X04).0770-" 70 )"I.S%'vAC a>.r� i¢�'"�y �LU� �,► $ice-�i7�c S7x�rr.r+s�F �Ys i�,�°1i�0 AGENCY PERMITS Q``”` permit EQUIRED FOR REVIEW N.A. NO YES Number Suffolk County Health Dept. New York State D. E. C. V7— Town Town Trustees Town Zoning Board approval. y Town Planning Board approval. Flood Plane Elevation??? Flood Zone: G12� CIA- ea Sv43 �0 `4l /S X0 U �— r t - ' SURVEY OF PROPERTY A T SO UTHOLD TOWN OF SO UTHOLD SUFFOLK COUNTY, NEW YORK eJi. 1000-77-01-03 SCALE: V=30' �rx FEB. 7. 2000 s Aeg. /0, 200 .({avncLu,f�on l fi 40 qf- a / . s4 y � \ 0 o LOT NUMBERS REFER TO 'MAP OF GOOSE_ q BAY ESTATES' FILED IN THE SUFFOLK COUNTY CLERK'S Qr v FICE ON NO13. 1934 AS MAP NO 1176 ARIFA FLOOD ZOf11ES FROM F"4 } � � tot NEW), 36103CO166 G Mr'I' 4, 19" A.Mir �p E�vctfia►s are r*fsrsac�d to NAV.D. � � ��ri �, . �,� � Y.S. LIC NE. 49618 ANY ALTERATION OR ADDITION TO THIS SURV€Y IS A VIDLATICNV CQ V Y S, P I OF SECTION 7299 O€' THE NEW Y STATE EDUCATION LAW. � 31)x' — SAX 0631) 7b5-1797 EXCEPT AS PER SECTION 7Z0 —Sjf"IWISjQ" a ALL CERTIFICATIONS q p �Q HEREON ARE VALID FOR TWS HAP AND C@PXS THEREOF ONLY IF $44D NAP OR COPIES BEAR THE IN RC$SED SEAQ. OF THE SURVEYOR � � STREET WHOSE SfGNA TURF APPEARS HLEWI . S 'y' 11971 99- 4'/ 1 f SURVEY OF PROPERTY ms`µ AT SOUTHOLD , 0 r� �a<� TOWN OF SOUTHOLD o� SUFFOLK COUNTY, NEW YORK 151 1000-77-01-03 SCALE: 1'=20' �I v FEB. 7. 2000 < o� 0 of f /; z Qo pati �a ,` ✓ i v,, p �' A � ^ °°'r Q c ✓V —OT NUMBERS REFER TO 'MAP OF GOOSE s o �4 BAY ESTATES' FILED IN 'HE SUFFOLk f 5 � COUNTY CLERK S O-FILE ON NO,/ 13 1934 AS MAP NO 1176. AREA = 11,200 sq.fl. \ j, r 4F MEW 36103COI66 G FLOOD ZONES FROM May 4,1998 �e \ \ \ �'�P���►� MFrjQy�9�' Elevations are referenced to N.G.V.D. /,S _I C �JO 49618 ANY ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION S15. CONZ14VE E PC OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW C�. > 5 SAX <631% 765-1797 EXCEPT AS PER SECTION 7209-SUBDIVISION 2. ALL CERTIFICATIONS o p HEREON ARE VALID FOR THIS MAP AND COPIES THEREOF 'ONLY IF 0�v9�@���fo�fti A/ t ' SAID MAP OR COPIES BEAR THE IMPRESSED SEAL OF THE SURVEYORSTREET ^ WHOSE SIGNATURE APPEARS HEREON SOU Y 11971 (� coF�PLrwrrN cNILrYEIt■48■ N copper tubing is used aOUYHOLD' TOWN CODE. far water distributing System.piping shall be of types K orL only APPROVED AS NOTED UNDERWRD M -06o a ell, REQUIRED ED 11 , 12 f'IT"t✓I'f' NOINY NIRIDIrNi DEPARTMENT A7 ^ , 7W1NaN & AM 70 4 FM FOR THE - ..- --- -- -- - - -- -- .--- ---- -- ------ FOtIOYYN10 NMiFECIlON6: PWMBING ALLPLUMBING WASTE _ t. FOINIDATWN • Tw0 REQUIRED &WATER LINES NEED FOII FOI CONp1E, TESTING BEFORE COVERING L NOUON - FNAKM & PLUMBING S. NBUL#gm C FINAL • CONSTRUCTION MUST F , I . COMKETE FOIL C.O. - -. ALL CONNTDU MEET CENTS OFTHE N.Y. j PLUMBER CERTIFICATION \ ,r W= CONNTiiUCnON & ENERGY NOF ,r. - ' . - _ ___ CODEL RESPONSIBLE FOR I ON LEAD CONTENT BEFORE - {T 0,-, mg XX Pi� i? r . —--------- - CEX(4111—m-) 16 -717 f VP I kr-�r- A, 2-,Aio rvlRpf% It Ws til— RA'-f %A 0, W-f Llaf to M ItJ.156 Co.I lj�'c 41 <Wi PAA-r l f �vi It eCRAWeF ftekef 17P- 16' s" C. w�za�- kA, ,oc 2 5,0 UL witippW --IG Tor, ma" HeW ---------D"OT`PROC6D-WITH k4- FRAMING UNTIL SURVEY ( In rA OF FOUNDATIO41 LOCATION HAS BEEN APPROVED. '0<00K- FtAt) J:�QQNVA-11%) - TLAO z 0322". A, PAP flof I /sb) b7s 1:7-� I . . - M r ., r.. . rr r .rr� , ., : _ s '>3 , {'^x. Fr.r „r•,:. ,a? tt ,' ,� r„ S?:` :,iiy, ^ 1.. !.M1' 4!.. ` x a2'p y _ r, ., hip i,�'t"rr4. +,. i+,1 . �a `-�r- , 7, ' i, , , r",s , w a x.. .i �, .a r -r•. VI .1 .. .a s �,1 xI' :.' .,d{ - .`f W "'— '-. ,n . 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