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HomeMy WebLinkAbout26014-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-27312 Date: 09/22/00 THIS CERTIFIES that the building ACCESSORY Location of Property: 2465 FAIRWAY DR CUTCHOGUE (HOUSE NO. ) (STREET) (HAMLET) county Taz Map No. 473889 Section 109 Block 5 Lot 14.22 Subdivision Filed Map No. Lot Mo. conforms substantially to the Application for Building Permit heretofore filed in this office dated JULY 19, 1999 pursuant to which Building Permit No. 26014-Z dated OCTOBER 5, 1999 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 AS APPLIED FOR. The certificate is issued to DONALD J & NATALIE J WILCENSKI (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE No. PENDING 09/22/00 PLUMBERS CERTIFICATION DATED N/A A,)Othoriied Signature Rev. 1/81 FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-27311 Date: 09/22/00 THIS CERTIFIES that the building NEW DWELLING Location of Property: 2465 FAIRWAY DR CUTCHOGUE (HOUSE NO. ) (STREET) (HAMLET) County Tax Map No. 473889 Section 109 Block 5 Lot 14.22 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JULY 19, 1999 pursuant to which Building Permit No. 26014-Z dated OCTOBER 5, 1999 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ONE FAMILY DWELLING WITH SCREENED IN PORCH, COVERED FRONT ENTRY, SECOND FLOOR DECK AND ATTACHED TWO CAR GARAGE AS APPLIED FOR. The certificate is issued to DONALD J & NATALIE J WILCENSKI (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL R10-99-0106 09/18/00 RLACT ICAL CERTIFICATE NO. N 529255 07/07/00 PLUMBERS CERTIFICATION DATED 04/18/00 TALBOT PLUMBING & HEATING tho ized S gnature 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. 26014 Z Date OCTOBER 5, 1999 Permission is hereby granted. to: PAGANO (WILCENSKI) 3465 FIARWAY DRIVE CUTCHOUGE,NY 11935 for CONSTRUCTION OF A NEW SINGLE FAMILY DWELLING WITH ATTACHED TWO CAR GARAGE, SCREENED IN PORCH, COVERED FRONT ENTRY & 2ND FLOOR DECK AS APPLIED FOR at premises located at 2465 FAIRWAY DR CUTCHOGUE County Tax Map No. 473889 Section 109 Block 0005 Lot No. 014 . 022 pursuant to application dated JULY 19 1999 and approved by the Building Inspector. Fee $ 1,107. 00 r Authoriz d SignapRftb ORIGINAL Rev. 2/19/98 ��,� TOWN OF SOUTHOLD �/ /.__-- 4ti C "- ,.�,,, BUILDING DEPARTMENT /37 63 SEP 18 2000 11'1 si 765-180 L 'ByL 7. PLICATION FOR CERTIFICATE OF OCCUPANCY Y04bi,yr SOIiTHOLLl A. This application must e filled in by typewriter OR ink and submitted to the bt: inspector with the following: for new building or new use: I. Final survey of .property with accurate location of all buildings, property streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage-disposal(S-9 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system cont less than 2/10 of 12 lead. 5. Commercial building, industrial building, multiple residences and similar b and installations, a certificate of Code Compliance from architect or engin responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. 1� B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildi "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building a unusual natural or topographic features. 2. A properly completed application and a consent to inspect signed by the app If a Certificate of Occupancy is denied, the Building Inspector shall state reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.0( Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $2' Additions to accessory building $25.00. Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Buildine - $100.00 3. Copy of Certificate of Occupancy - _ .250. 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate Of Occupancy - Residential $15.00, Commercial $15.00 Date j+.. 2 S, 24500 New Construction. .. ..... Old Or Pre-existing Building. . . . . . . Z+(b5 Location of Property. . . . . ?:^��. .�w� . . . . . . .C+ l��oci4� . . . . . . . . . House No. Street Hamlet Onwer or Owners of Property.. �?.... ,..+ }1Q i�< W 1,I c { �n 5 � . . . . . . . . . . . . . . . . County Tax Map No 1000, Section. . . .'.9. . .. ..Block. . . . . . . . . . . . . .Lot. . y.Z7- . . . . . Subdivision. .. . . ./!� �`! h� �o , .. ' !'���. . . . . .. .Filed Map. . (PA'. . .Lot. . zZ . . . . . . Permit No. .(9 Date Of Permit. l 15/V . . . . . .Applicant. ow. CkAI`LJn. Health Dept. Approval. .j.� yl --., , , , , , , , , , , , , ,Underwriters Approval. . . . . . . . . . . . . . . . . Planning Board Approval. . . .. . .. . ... . . ... .. . . . . . Request for: Temporary Certificate. . . . . . . . . . . Final Certicate. . . . . . . . . . . Fee Submitted: JJ J . aA PLICANT TOWN OF LD DEPART BUILDING DEPARTMENT - TOWN HALL 765-1802 ~ .� f /` ' APPLICATION FOR CERTIFICATE OF OCCAN,CY A. This application must be filled in by typewriter OR in and�suubmit to'the bo inspector with the following: for new building or new u U� 1. Final survey ofpropertywith accurate location of all dings, pX6perty streets, and unusual natural or topographic features. 2. Final Approval from Health Dept. of water supply and sewerage=<`s' o-41(S-9 3. Approval of electrical installation from Board of Fire Underwr�.t.�. J 4. Sworn statement from plumber certifying that the solder used in sy cont less than 2/10 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar b and installations, a certificate of Code Compliance from architect or engin responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. *ti B. For existing buildings (prior to April 9, 19571) non-conforming uses, or buildi. '-`pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building a, unusual natural or topographic features. 2. A properly completed application and a consent to inspect signed by the app If a Certificate of Occupancy is denied, the Building Inspector shall state -- reasons therefor in writing to the applicant. C. Fees 1 . Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.0( Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $2' Additions to accessory building $25.00. Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Buildine - $100.00 3. Copy of Certificate of Occupancy - _ .25C. 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.0/0, Commercial $15.00 Date . . . . �Ll./4J.t'n-o. . . . . . . . . . . . . . . . . New Construction. .. . . . . .. . . Old Ore-existing Building. ./. . . ./. . . . . . . . . . . Location of Property...... ~ . • House No. Street Hamlet Onwer or Owners of Property.. ... . .°". ... .... ... ... . ..... . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . County Tax Map No 1000, Section. . .. .. . . .. . . ..Block. . . . . . . . . . .. . .. .Lot. . . . . . . . . . . . . . Subdivision. . ;.. . . . . . . .. .Filed Map. . . . . . . . . . . .Lot. . . . . . . . . . . . . . Permit No. . 4;('op L .Date Of Permit. . .��r '�`1 . . .Applicant. . . . . . . . . . . . . Health Dept. Approval. . . . . . . . . . . .. . . . . . . . . . . . . .Underwriters Approval. . . . . . . . . . . . . . . . . Planning Board Approval. . . . . . . . . . ... . ... . . . . . . . Request for: Temporary Certificate. . . . . . . . . . . Final Certicate. . . . . . . . . . . Fegg Submitted $. . .:�. . . . . . . . . . �l� a�131Ga . If JC L I� I APPL . . . . . . . . . . . . . . CANT . . Town Hall,53095 Main Road y = Fax(516)765.1823 P.O. Box 1179 • Telephone(516)765-1802 Southold, New York 11971 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD C E R T I F I C A T I O N//rr DATE• Building Permit No. Owner: I- na1�1+ tilal e Wr (tet ,sk (please print) Plumber: I a LbrR �1 wLwg �twhti.� (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. l� l� of I-Wlumbers Signature) Swojr(,n. to before me this IIS day of h Notary Public, County n MELANIE V.BROWN N*v fO k swY of Now York atidw 9�ulbtk co m"W"'BON Oct.19�Z 00 I .IJ', l-RG r TION REPORT DATE 1 c _OMMENTS- ___ - � -__---- -- - ------- --- 5 - - - - A� - ----- // � i --- r --- -- INDATIOx- -- (-IST)- --- " _. ;; -- -------- -- -- - JNDATION (2ND) it II - J 47 it JGH FRAME S ir-__---11 - --- — PLUMBING, r --- ell — ------------------ It if (�nJl(aai/a / y SULATION PER N. Y. u-- i' ------- �c STATE 6ERGY ii 11 H c. ILL------11 CODE II ii --------------- 1 II � FINAL 11 N _ ADDITIONAL COMMENTS: -______-----_-------- wego, iIf q lx-a _ Z/7 �7 C_ od e H H p x r ro - H M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ROUGH PLBG. [ ] F(jUNDATION 2ND [ ] INSULATION [ FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY o REMARKS: DATE ✓ oa INSPECTOR ��� 765-1802 BUILDING DEPT. INSPECTION ZFOUJATION 1ST [ I ROUGH PLBG. [ FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ I FINAL REM RKS: 4e DATE J / !c� INSPECTOR M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: I DATE INSPECTOR M� 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ FINAL [ ] FIREPLACE &))CHIMNEY REMARKS: /S�I/o SS DATE� INSPECTO 4 M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST { ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] 1 LATION [ ] FRAMING [ FINAL [ ] FIREPL CE & CHIMNEY REMARKS: a DATE 7/6/&0 INSPECTOR THE NEW YORK BOARD OF FIRE UNDERWRITERS l lar�c'7 BUREAU OF ELECTRICITY F 40 FULTON STREET, NEW YORK, NY 10038 Date TEPTEPMER 29,2000APPJieation No. on file N 538070 THIS CERTIFIES THAT r on the electrical equipment as described below and introduced b the applicant named on the above application number is in the remises o r onlyY aPP PP P f L r L CIONP.LD WILCEduKI. 2455 FAIRWAY DRIVE, CUTCHOGUE, NY c in the following location; ❑ Basement ❑ 10 Fl. ❑ 2nd Fl. OUT Section Block Lot was examined on SEPMOER 22,2000 and found to be in compliance with the National Electrical Code. y r FIXTURE RECEPTACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS N OUTLETS INCANDESCEN FLUORESCENT I OTHER AMT. K.W. AMT. K.W. AMT. K.W. AMT. K.W. AMT. H.P C DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'Pi. TIME CLOCKS BELL UNIT HEATERS MULTI-OUTIET DIMMERS SYSTEMS AMT. K.W, OIL H.P. 6A5 H.P. RMF. NO, A,W.6. AMi. AMP. RMF, AMPS. TRANS. AMT. H.P. NO.OF FEET AMT. WATTS C i 2tJ _ .iti; SERVICE DISCONNECT NO.OF S E R V I C E - METER NO.OF CC COND. A.W.G. A.W.G. A.W.6. AMT. AMP. TYPE EQUIP. 1 RP/ 1 SW 3 d SW 3 0 6W PER 0 OF CC.GOND. NO.OF HIAEG OF Rj-UG NO.Of NEUHGIS OF NW"L OTHER APPARATUS: SfiI3'IlSING sC}��L•-1 � _.P.C. 1:-_ "(SWURUIh P,-+3L: This certificate covers compliance at the date of inspection on1v. Because of unusual environments it is advisable to Nave frequent test/and or repairs made t'/ qualified person. LL <:a¢. Continued on Page 2 >>> GENERAL MANAGER Per This certificate must not be altered In any manner;return to the office of the Board It incorrect.Inspectors may be identified by their credentials. COPY FOR BUILDING DEPARTMENT THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. r. THE NEW YORK BOARD OF FIRE UNDERWRITERS PrT_E 2 1'�c-'147 BUREAU OF ELECTRICITY E F 40 FULTON STREET, NEW YORK, NY 10038 E "EPTIT 1BER 29.2W90 :R /rd n? Td 51 070 Date Application No. on file THIS CERTIFIES THAT E only the electrical equipment as described below and introduced by the applicant named on the above application number is in the premises of 6 I DONALD WILCENSKI. 2465 FAIRWAY DRIVE. CUTCHCCUE, NY in the following location; ❑ Basement ❑ Ist F1. ❑ 2nd Fl. IIUT Section Block Lot was examined ort }'.FTEIMER )2""IO and found to be in compliance with the National Electrical Code.. C F FIXTURERECEPTACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS OUTLETS RECEPTACLES INCANDESCENJ FLUORESCENT I OTHER AMI. K,W. AMT. K.W. AMT. K.W. AMT, K.W. AMT. H.P. A DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS ISPECIAL RECPT.I TIME CLOCKS BELLUNIT HEATERS MULTI-OUTLET SDIMMERS AMT. KX OIL H.P. GAS N.P. AMT. NO. A.W.G. AMT. AMP. AMT. AMPS. TRANS. AMT. H.P. NOYSTEMS.OF FEET AMT. WAITS p pGp SERVICE DISCONNECTNO.OF S E R V I C E G AM. AMP. TYPE EOEUIP. I 0 RW 1 R JW J R JW J 0 dW NO.OPE OCOND. OF A. COND. NO.OF HI-LEG OF W. NO.OF NEUTRALS OF.W.. P E M1 OTHER APPARATUS: Q� ¢E pV pG pG G M1 G SEAT ELECTRIC LI%.#4204E Td Lr, _ LL I 517 FAT LANG 11 TTITUCK, NY, 15552 GENERAL MANAGER E „1 I Per This certificate must not be altered In any manner;return to the office of the Board if incorrect. Inspectors may be identified by their credentials. I COPY FOR BUILDING 05PARTMENT, THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. THE NEW YORK BOARD OF FIRE UNDERWRITERS PACE 2 1198197 BUREAU OF ELECTRICITY F 40 FULTON STREET, NEW YORK, NY 10038 Date JULY 07,20M Application No. on file 19822500/4e N 529255 , THIS CERTIFIES THAT only the electrical equipment as described below and introduced by the applicant named on the above application number is in the premises of DONALD WILCMU, FAIPTIAY ORM, CUTCHOGUE, NY In the following location,, ® Basement ® Ist Fl. ® 2ad FL GAR/ATTIC/OUT Section Block Lot was examined on 'Uri' 29,2000 and found to be in compliance with the National Electrical Code. FIXTURERECEPTACIE3 SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS i OUTLETS CANfnSCE fUIORESCFNT OTHER AMT. K.W. AMI, K.W. AMT. K.W. AMI. M.W. AMT. L H.P. L r L r DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS I SPECIAL REC'Pr.j TIME CLOCKS SELL UNIT HEATERS MULTI-OUTLET DIMMERS E SYSTEMS r AMT, K.W. OIL X.P. GAS N.P. AMT. NO. A.W.6. AMT. AMP. AMT. AMPS. TRANS. AMt. H.P. NO.OF FEET AMT. WATTS f C G V SERVICE DISCONNECTNO.OF S E R V I C E _!' METER NO.OF CC COND. A.W.G. A.W.G. A.W.C. D AMT. AMP. TYPE EQUIP. r e ZW r e JW S 0 3W S e dW PER a OF CC.COND. NO.OF NI-LF6 OF 014EF NO.OF NEUFRALE OF N11=AL F. L N V M1 OTHER APPARATUS: E SHOKE DETECTOR1 -5 B B B B B B - Sper SABAT ELECTRIC LIC,#4204- t�_... L50 PAT LANEMATTITUCK, NY, 11952 GENERAL MANAGER11— B This certificate must not be altered in any manner; return to the office of the Board If Incorrect. Inspectors may be Identified by their credentials. B COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1 1195197 BUREAU OF ELECTRICITY 40 FULTON STREET, NEW YORK, NY 10038 n- Date JULY 072000 Application No. on file 1-822600%00 N 529255 r. THIS CERTIFIES THAT onlythe electricals equipment as described below and introduced b the A qutp y applicant named on the above application number Lr in the premiss of F n v DONALD WILCENSKI, FAIRWAY DRIVE, CUTCHOGUE, NY in the following location; ® Basement ® Isl FL © 2ad Fl. GAR/ATTIC/OUT Section Block Lot 4 was examined on .TUNE 29,2000 and found to be in compliance with the National Electrical Code., v r. FIXTUREFIXTURES I RANGES I COOKING DECKS I OVENS I DISH WASHERS EXHAUST FANS OUTLETS I RECEPTACLES SWITCHES INCANDESCE FLUORESCENT I OTHER AMT. K.W. AMT. K.W. AMT. K.W. AMT. K.W. AMT. N.P. n u 78 65 69 78 1 1.2 4 F n DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT. TIME CLOCKS BELL UNIT HEATERS MULTI.OUTLET DIMMERS E SYSTEMS AMT. N.W. OIL H.P. OAS H.P. AME. No. A.W.G. AMT. AMP. AMT. AMPS. TRANS. AMT. H.P. NO.OF FEET AMT. WAM E R 5 F 2 - 12 600IT SERVICE DISCONNECT IAEiERF 3 E R V I C E AMT. AMP. ME ECUIP. 1 R]W I ]W J e JW ]e IW NO.OF OC COND• A.W.O. NO.OF XIAEG A W O. NO.OF NFUIIIALJ PEP OF OC.GOND. OF NIlFO OF NEULRAL r L c" 150 CE 1 X lid 2 1/0 e e OTHER APPARATUS: F WELL PUMP F-1 c WIRLPOOL BATH-1 u 30A GEN-TRAM TRANSFER SWITCH-'1 G AIR CONDITIONERS-2 2 TON-1 3 TON-1 MOTORS.1-2 H.P. ,1-3 H.P. ,2-F H.P. e PANELBOARDS:2-1 CIR. 60 \ G.F.C.I:-16 l\ 1L r dddtititiLLE ... ___ L L c<c Continued on Page 2 >>> c GENERAL MANAGER Er L Per L L This certificate must not be altered In any manner; return to the office of the Board if Incorrect. Inspectors may be Identified by their credentials. r I.- - FICAT"E--MUST NOT BE ALTs -EE) IN ANY MANNER. BOARD OF HEALTH . . . . . . . . . . . . . . . FORM NO. 1 3 SETS OF PLANS . . . . . . . . . . . . . . . •-�,.n --.�---� TOWN OF SOUTHOLD SURVEY . . . . . . . . . . . . . . . . . . . . . . . . •0•:'.�rCrSOUOUTHOLO BUILDING DEPARTMENT CHECK . . . . . . . . . . . . . . . . . . . . . . . . . TOWN HALL SEPTIC FORM . . . . . . . . . . . . . . . . . . . SOUTHOLD, N.Y. 11971 TEL: 765-1802 NOTIFY: CALL 17&f-/v 15-b. . . . . . . Examined..... .. 19..✓. MAIL TO:/;),. Approved... ....: ...., 19 Permit No. ................ ...,ypwS Rr—jc 2� Disapproved a/c ..... c-r��C.. ............................. ......... ...................................................... (Iiuilding tor) APPLICATION FOR BUILDING PERMIT Date. . .��//. . . . . . . . . , 19.$g. INSTRUCTIONS a. This application most be completely filled in by typewriter or in ink and submitted to the Building Inspector wi 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 which 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 permittshall 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 Building Inspector. 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, Ordinancesor 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 inspection .... . ................................... (Signature of a icant, or name, if a corporation) ................................................... (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builde ................��e,�......................,,..``...1`...................... ................................. Name of owner of premises .... '� NaTG � l e. t 1 �.Q^° ..............................................................._................ (as on the tax roll or latest deed) .a If applicant is a corporation, signature of duly authorized officer. ......................................................... (Name and title of corporate officer) Builders License No. ............. �� L Plumbers License No. ......................... Electricians License No. ..................... Other Trade's License No. .................... 1. Location of land on which proposed work will be done.............................................................. 2` (,0-C ................ .. :rte,Ia D"te u t-.................... c ..aq U-e-................... F .............. House N.mber Street q /Hamlet County Tax Map No. 1000 Section ...1..Q.9....... Block ... '� ......... Lot Subdivision ...71i;"RA( !aJ....r�,,�,2N".3....... Filed Map No. ..0Ob� .... int ...Z�:...... (Name) 2. State existing use and occupancy of oem s and intended use and occupancy of proposed construction: a. Existing use and occupancy .......� .. ....................................................... b. Intended use and occupancy ............................................................................. ature of wdr (check which applicable): New Building .......... Addition ....... Alteration ..... ... .. / Repair ............ Removal ............. Demolition ............ Other Work .....7/Lj)/.71str�-�...nO.,l•1 v (Description) 1. Estimated Cost ......1".V oao ....... fee .............................................. (to be paid on filing this application) If nkaelling, number of dwelling runts ............ Huber of nkelling units on each floor .... ... ......... Ifgarage, number of cars ...................................... If business, commercial or mixed occupancy, specify nature and extent of each type of use...................... Dimensions of existing structures, if any: Front....Z:�........ Rear ... ........ Depth ...... ........... height ......................... Number of Stories ...................... Dimensions of sane structure with alterations or additions: Front ............... Rear ............... Depth .................... Height .................... Number of Stories ............... Dimensions of entire new construction: Front ................ Rear ............... Depth .............. Ileiijht ......................... Nuber of Stories ..................... Size of lot: Frust .................... Rear .................... Depth .................... 0. Date of Purchase ..................... Nape of Former Owner ........................................ ro I. 7.one or use district in which premises are situated ......X ................................................ �2. Does proposed construction violate any zoning law, ordinance or regulation: .... /v0.............. 13. Will lot be regraded ......9Q......... Will excess fill be removed from premises: YES 14. Names of Owner of premises ....Sa...r'.`.'.............. Address .............................. Phone No. ............. Name of Architect .................................... Address .............................. Phone No. ............. Nae of Contractor ................................... Address ...............................Phone No. ............. 15. Is this property within 300 feet of a tidal wtland? * YRS .......... NO .. ..... , _ *IF YES, SOLMIZZ MN 'IRDSIEES PMM MAY BE REQUIRED. � PLOT DIAGRAM I.ocate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block saber or description according to deed, and show street nares and indicate whether interior or corner lot. � �(f wiviE or hili Y(MK, 9"11 OrT...50.......k L .........`1`?:^.G: `.r".d. . �.1 c'P� .(...............being duly sworn, deposes and says that he is Lite applicant (Name of individual signing contract) above named, Iceis lite .......�i•.!!!`!N................................................................................. (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed tine said wrk and to make arxd file Lhis application; that all statements contained in this application are true to the best of his knowledge and belief; and Lhhat the work will be perfonred in the manner set forth in the application filed therewith. Sworn Lo/before me [his �/ / ....i!.............(lay of/Y.J.✓�lh:ll> f4-.. 19..q.S . Notary Public ..' . .... .. ................... (S' tyre of A cant) SHARON L. BAJEA 1:otary 1 abiiq Scute of New Yuri, No. 4x6.3767 Qualified ip Suffolk Gamby anavr;nriun, h'pavw Oct. i0 w I o0o BOARD OF HEALTH . . . . . . . . . . . . . . . FORM NO. 1 3 SETS OF PLANS . . . . . . . . . . . . . . . TOWN OF SOUTHOLD SURVEY . . . . . . . . . . . . . . . . . . . . . . . . BUILDING DEPARTMENT CHECK . . . . . . . . . . . . . . . . . . . . . . . . . TOWN HALL SEPTIC FORM . . . . . . . . . . . . . . . . . . . SOUTHOLD, N.Y. 11971 TEL: 765-1802 NOTIFY: CALL 5 . ,,yam/ 4q . . . . . . . . . Examined....�:��1 .+--s 5 191�1/q MAIL T'O' O W:`r'�'�S�' Approved..�FrC..`5:.., 19 f. / Permit No. .�? Ol ! .... 38"1 5 Qa 1K Lf Disapproved a/c .................................. .....`2?5rr..'..'5:..+.�y.S ... ...................................................... Q 7 r 1 clluildi r) D K11 1 j1 :_APPLICATION FOR BUILDING PERMIT - Date . . . . . . 19[[777.t0o . . BLDG. DEPT. INSTRUCTIONS CCS TO`_r, OF-3ntIT.l-'t In a. This application oust be completely filled in by typewriter or in ink and submitted to the Building Inspector 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan slowing location of lot and of buildings on premises, relationshipjoining premises or public streets or areas, and giving a detailed description of layout of property mist be dr%Bu diagram which is part of this application. c. the work covered by this application ray not be commenced before issuance od 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 Building Inspector. APPLICATION IS UEREBY 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, lousing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. r, -............. (Signature o licant, or nam, if a corporation) UaQ.5.... ...Cec cpm IU,--d... (Mailing address of applicant) 1kCj- 775 State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or build .................4 !,?NtZ...`................................................................................... Nacre of owner of premises �4���t.�:.W:�cRvuY .:,:..A;ju �Oi�t?-:..T W: �C..tin�k:f....................... (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 No. ........ ..... . ........ Plumbers License No. ........ .. .. ...... Electricians License No. ........... .. Other Trade's License No. .................... 1 r 1. Location of land on which proposed work will be done... 7..aPa�{�? �. /'.cR-!''f:�7....D�!`^�:...... ........?:`((a 1� clLWa .,d"p.2iMrt....,�!"kc.�.o th-c. Nil .....LI�.J.��........................... House Number Street Hamlet County Tax Map No. 1000 Section ....ID- ... I...... Block ....5.......... Lot �Y• 2,Z // .... ..... . Slubdivision ..... �w`� ........ Filed Map No.'1 ..cP-Q�o,(ca..... Lot ..... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy .......vach;;�.....�.�.i................................................. -S1�n It Fam..1 t7w+AA.• b. Intended use and occupancy ...........s.............7............ .....................-............... BOARD OF HEALTH . . . . . . . . . . . . . . . FORM NO. 1 3 SETS OF PLANS . . . . . . . . . . . . . . . TOWN OF SOUTHOLD SURVEY . . . . . . . . . . . . . . . . . . . . . . . . BUILDING DEPARTMENT CHECK . . . . . . . . . . . . . . . . . . . . . . . . . TOWN HALL SEPTIC FORM • . . . . . . . . . . . . . . . . . . SOUTHOLD, N.Y. 11971 TEL: 765-1802 NOTIFY: J�`'�], CALL • tjltn:.Z S: (,'1 SO Examined.P�.-S S 19./9q.I. lo TO: .�`.g: ^� Approved..ClflC...'S:.., 19� Permit No. .T. O'�. � ......7,.21. .. Qa,)K 1_1 ........ Disapproved a/c .................................. ...... . .......... . ...................................................... R Q (Ikrildi�l� r) D 11 i1 APPLICATION FOR BUILDING PERMIT 1 a �+p Date,�W'�.. . . . . . . . . . , 197.[. . BLOG. DEPL INSTRUCTIONS TOt^drcrnl1Ti s I n a. 'Ilurs application m,ct be completely filled in by typewriter or in ink and submitted Co the Building Inspector 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, relationshipjoining premises or public streets or areas, and giving a detailed description of layout of property must be draiMt a diagram which is part of this application. c. The work covered by this application may not be canrenced before issuance of Bu d 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 Building Inspector. APPLICAPION 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. ...C.N.: 4 ! ............. (Signature o licant, or name, if a corporation) (Mailing address of applicant) i1�1 5'g State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or built ................. !.?N R—...`.•................L..............................................................._ Name of owner of premises .,,aA!�t.�:.W:iePy�Sk:.:4:..�u lq�w,.:..T W: �C.2H.Sk:l...................... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. ......................................................... (Name and title of corporate officer) Builders License No. ....... Plumbers License No. ....... y Electricians License No. ... . • .. Other Trade's License No. .................. 1. Location of land on whichproposed work will be done... r.� .........P..... .....�„r1.1..2. y. .......... .............. .. `....?-Ww�..;;.^°2v>1j'� Cu�'c-��G J•-t ...N. ,......11�T.d.•�........................... House Number............. Street /. ��Hamlet County Tac Map No. 1000 Section .•.•101...... Block ....5........•. Lot Z7- Subdivision ....1.j .. �_"� ....... Filed Map No.'i .�e.4lP{a..... Iv[ ..... �y'!Rw.7......••••• I ZZ....... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ........ .... .,:................................................ � � �m. mow. b. Intended use and occupancy ..........r 5.............7............. .....................•...........•.. 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Z uear d da.t r6"eP•• Qayod "'Gq°`rq .wa>a,,.d.e�.......,,tP•„ z•+rn<wnd ..x .rn. '20,xt 4r®' 4 •.d sr.••rdq q+ddr ad♦an.d r•W•d ,ML,.•rw rf ��•'� alcfq.riY.s♦p•r•rr�wi. aewm... NaL,w' .3 Wn tw 'I�E� ,�'•d'•w'L•, �•"yravE3tv,.PF'a.a•e uN�o MAY.. . N.oab . ::�,L. usisllmG ••° •.rov .Fbn e •♦w. ! RKUNGU r RAW H•!M♦Yr r•M.Mf tYNM F. SU1z\/EY OF LOT # ,22 - - �� - -- - ---- -- -- MAP OF "FARWAY FARM5" FILED JAN 15, N-14 A5 FILE #6066 51TUATE: GUTGHOGUE TOWN OF 50UTi4OLD 5UFFOLK COUNTY NY ------ 5URVEYED 04-28-qq `;UFFraLK ,-'GUINT'rvr,*'c�:; �','ti,•,�'+w;;..., tr.., AMENDED 05-20-gq Aa ,,�z,� AMENDED 06-15-qq r - AMENDED 09-2q-qq FOUNDATION LOG. 10-28-qq FINAL 6-22-00 SUFFOLK COUNTY TAX # 1000 - IOq - 5 - 14.22 , -} ` ,1 rl - iCU'7d l'J SUFFOLK COUNTY DEPT. OF HEALTH 5ERVIGES; "�- -l r -a i.. RIO-qq-0106 a. j�' CERTIFIED TO: + f DONALD WILGENSKI NATALIE WILGENSKI 15LAND EAST 5ERVIGIN6 CORP. NORWE5T MORTGAGE INC. FIR5T AMERICAN TITLE IN5URANGE COMPANY Lot #12 Lot x21 Dwelling Dwelling Lot x24 i Dwe I I ing S89012'10"E 200.00' E CD ,„ of Ip W I Lot #13 - Voc.ant -!O_Ol - n o / } 4 I O r fin m o !� 1 x N / Q 1 g ryLL m nAwRrniHrrce PATIO C Il5 TI I � GE V V a GARAGE o W 160' I O I O OV I (J Lot 423 g S Vacant aIT z V1 I s*ov=_ wAu •��A - p'yyl!}B CPSE"IEnG FOP Lot 1114 N89012'10"W 175.00' Dwelling Green Way l Lot #n Lot #Ib Dwelling Dwelling o� rJF� NOTE5: coy i IN MONUMENT FOUND SPIKE FOUND \4'p 5020 0;I:' � s,.,.'?u9` 1�8�,oY'o°o7.:°o C.Laa:�CC' HEDGE CFhp SUPT „°: o kf: .... I,.,. 11 Id 111111 _ AREA = 43 5F 1.01OI ACRES JOHN C. EHLERS LAND SURVEYO ALL CESSPOOLOOL S HAVEVE TRAFFIC BEARING GONERS. GRAPHIC SCALE: i"= 50' 6EAST MAIN STREET N.Y.S.LIC.NO.50', � _ — RIVERHEAD,N.Y. 11901 r 369-8288 Fax 369-8287 REF.D;UOBS%99-1c SUR\/EY OF LOT # 22 SEPTIC DETAIL Test Hole not to 5r-ole obtoined MAP OF "FAIRNAY FARMS" 4,_2s_gq FILED JAN 15, ICI-14 A5 FILE #6066 OL high tide 51TUATE: GUTGHOGUE , ,n, I TOWN OF SOUTHOLDinv. `n SUFFOLK GOUNTY, NY ,�� � � ° e.o „ mai ,..I1 SURVEYED 04-28-4G " 3.a AMENDED 05-20-qci AMENDED Ob-I5-G9 SUFFOLK GOUNTY TAX # 1000 - I0cl - 5 - 14.22 c"Of 5a �a SUFFOLK COUNTY DEPT. RIO-4q-0106 SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT FOR APPROVAL OF CONSTRISCTION FOR A N CERTIFIED TO: SINGLE FAMILY RESIDENCE ONLY Ground DONALD WILGEN5KI DATE !�r _U�� 1/i/- E water e. HS W.NO. R to -3 r APPROVED S FOR MAXIMUM OF, B R )OMS EXPIRES THREE YEARS FROM DATE OF APPROVAL, Lot #12 l 'I i. Lot #21 Dwelling - Dwelling ;0.o Lot a2h .� Dwelling �5.. in j S89012'10"E 200.00' �i vw�ea p � S O cl Lot 413 Vn6ont °� 2G, lo' 0.Q o ot #23 i I p � Var.nnt \Jl estL hope x a epsemenC 'or Lot ning TS�� NV 9-12'16"W 175.00' Green Way Lot dl-7 Lot #15 Dw_Ilin 9 DwePincj 1 ' t� O C. EECOD /y hP O't'N HGF `p " NOTES: r l I °olet yey�Br° eeel°n i r N � n'Stet!EJ. ■ MONUMENT FOUND • SPIKE FOUND SFp 2 SAND S\—' 1.Id IfYfi AREA = 43,Sbb 5F OR I.OI ACRES JOHN C. EHLERS LAND SURVEY( GRAPHIC, 564LE: I"= 50' 6 EAST MAIN STREET N.Y.S.LIC.NO.5( DRICDLTC At\ T.TV 111Tf11 SURVEY OF LOT # 22 � MAP OF "FAIRNAY FARMS" FILED JAN 15, la-74 AS FILE #6066 OCCUPANCY O SITUATE: GUTGHOGUE TOWN OF SOUTHOLD USE IS UNLAWFUL SUFFOLK COUNTY, NY SURVEYED 04-28-qq VdTHOIJT CERTIFICATE AMENDED 05-20-qqg^� N AMENDED O6-I5-qq AMENDED Oq-2q-qq OF OC"CLIPANCY ,, , FOUNDATION LOG. 10-28-qq SUFFOLK COUNTY TAX # N/ � E 1000 - IOq - 5 - 14.22 S SUFFOLK GOUNTY DEPT. OF HEALTH 5ERVIGES RIO-qq-0106 GERTIFIED TO: DONALD WI1-CEN51<1 "IMMEDIATELY" NATALIE NILGENSKI ENCLOSE POOL TO CODE ISLAND EAST 5ERVI6IN6 GORP. UPON COMPLETION NORNEST MORTGAGE ING. BEFORE "WATER" FIRST AMERICAN TITLE INSURANGE COMPANY UNDERWRITERS CERTIFICATE REQUIRED Lot 412 Lot #21 DweWno Dwelling , Lot #24 Dwellino S89012'10"E 200.00' I Lot kl3 �, p ', jn_JLI[ 1hJ.0' a r�� O ° 4 O LL Ct ° f� 10.0' 1 l • .w n Lot #23 VC1 cnL Z F z f ��� li �' wlae easement Fa7r "y\� �f _ drolnage swaie Lot #14 �9 N89°12'10"W_ 175.00' Dwelling I ,� Green Way i Lot #1 7 Loi alb Dwelling Lol ling i �Q�oac.eH�`o . NOTES: � - .. - °[, r _ Y slaeoe. eeel stlell [on[ei°e[e°to Ee`' ■ MONUMENT FOUND r ` su,.eY'un epee etl e[[on¢19n1i1 t ¢ • SPIKE FOUNDDFti 56��2 JJD HE06E SFO LAND AREA = 43,866 5F OR 1.01 AGRE5 JOHN C. EHLERS LAND SURVEYOR GRAPHIC SCALE: "= 50' 6 EAST MAIN STREET N.Y.S.LIC.NO.5020% RIVERHEAD,N.Y. 11901 369-8288 Fax 369-8287 REF.D:UOBSV9-166( SURVEl r OF LOT # 22 f� � MAP OF "FA.I RW,4Y FARMS" � 2=9 FILED JAN 15, 1x74 AS FILE #6066 SITUATE: GUTGHOGUE `OG,DEP7 TOWN OF SOUTHOLD 2^,~r BOUTt1OLD SUFFOLK COUNTY, NY SURVEYED 04-28-qq AMENDED 05-20-qq N AMENDED 06-I5-qq AMENDED Oq-2q-qq FOUNDATION LOG. 10-28-qq E SUFFOLK COUNTY TAX # N/ r ` 1000 - IOq - 5 - 14.22 S SUFFOLK GOUN7r DEPT. OF HEALTH 5ERVIGE5 RIO-qq-0106 GERTIFIED TO: DONALD INILCENSKI NATALIE A1LCEN5KI 15LAND EAST 5ERVIGIN6 GORP, NORAEST MORTGAGE ING. FIRST AMERICAN TITLE INSURANCE GOMPANY Lot #12 Lo! >t21 Dwelling Dnelling Lot 424 Dwelling S89012'10"E 200.00' � 1 i 1 lig S : x111 Vacant a 0 0 LLo ^ -90 0 bo-,d o o � o Lot 423 � S �lG III � 1 e easement fog 9\\ 2s drglnage s.vale Lor xla N89°12'10"W 175.00' Dwelling i -- - - Green Way 1 Lot YID Lot WE) Dwel I Ino Dwelling 13� NE co I NOTES: s .9.,a...�.r ...� e� ?� `aV • MONUMENT FOUND —,X • SPIKE FOUND 1+ °'"` " �Fti e s "v.: : o�'P..res:..°m SFO LAND HEDGE AREA = 43,866 5F OR 1.01 AGRE5 JOHN C. EHLERS LAND SURVEYOR "= 50' 6 EAST MAIN STREET N.Y.S.LIC.NO.50202 GRAPHIC SCALE: RIVERHEAD,N.Y. 11901 369-8288 Fax 369-8287 REF.D:UOBS\99-166C SURVEY OF LOT # 22 5EPTIG DETAIL Test Hole MAP OF "FAIRNAY FARMS" of to scale " obtained 4-Z8-qG FILED JAN 15, Icf-14 A5 FILE #6066 of high tide 51TUATE: GUTGHOGUE -� I o TOWN OF SOUTHOLD '^ a.a 66 om SUFFOLK GOUNTY, NY a�.- 6.z ° 5 G.a I , . mam SURVEYED 04-28—qq AMENDED 05-20—qq AMENDED 06-15—qq SUFFOLK COUNTY TAX # 1000 — IOq — 5 — 14.22 SUFFOLK COUNTY DEPT. Rlo-qq-olob SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT FOR APPROVAL OF CONSTRUCTION FOR A N GERTIFIED TO: SINGLES FAAMILY REST7ENCE ONLY Ground DONALDWILGENSKI DATE — 1� 1 `HS NO, R�Oy �V�t{ 0j W /1 E ✓doter 8 APPROVED S FOR MAX�IUM OF B K mMS EXPIRES THREE YL FROM DAT. 0 OF APPROVAL d Lot #12 I I;, Lot #21 Dwelling Dwelling 1 , I Lot #24 +.I Dwelling �5` in S89012'10"E 200.00' I p � • :. i;a;;r a 1..('f; tr t r:LJ.:l..3,7 s O � Loc #13 IN Vacant � > ,�yeaea.ap[I= 20' kin I w o p Lot 423 OO vacanytun � j � kest X o T N� aN O pE I \� p i I-i I 1 1, I_� � dfQInPPE 5wPE Loting llin Dwe9 '00, _ N99°12'16"W 175.00' . .I r Green Way Loelling t #I-1 Lot #Ib DwDwelling � 11. I �O. � OF NE(y ,rl. II C. E/�'��`o�` ea.r mo'e°i�=e.aee NOTES: 1 t >Luan x u, e rm°° Iie-,1 ema a 1 ork`5[a[eeE°U[e[ton Le � :nsuao s...oe...o to o.:aliov`oa ■ MONUMENT FOUND Q ° 2 NO p2 yo aat t 1, f o—II 1 ;...°. ;;; ■ SPIKE FOUND SFp 25vP,� °.s[.1. : °;a Paero;r oLaalo:° HEDGE L.I. �y1.111.10141` '27 p:rea e„a o ms mu �a:�:a�"a:'e 5�9nee¢°o e1len°In9 1 !1=� aGe=tl�l=a- [.ona ere not tre�sie�na,e ea seeltlonel =ne[,tut,ona AREA = 45,866 SF OR 1.01 AGRE5 JOHN C. EHLERS LAND SURVEYOR GRAPHIC SCALE: I"= 50' 6 EAST MAIN STREET N.Y.S.LIC.NO.50202 RIVERHEAD,N.Y. 11901 369-8288 Fax 369-8287 REF.D:VOBSU9-16613 \ r4� - ' 1.✓��/ ,O .. r� ,, � r'--'�� � , �i� n � �I,.I H- _�Gfv� {4w tY.F_ 1 �ilf3/ � 4 �nG•--____ _ -. __ F �hl;m<y�l�,^ I �r-nt;7 n.r� r C —_ _ __ ' I rill r 1 —__?�✓!�^-Fad:% � rr�__.__ 'I e 3 � r o I �? r IIS Ajri r I — I Ioj ko vi 8 ' Pn guy VD ° O �Y � 2x ✓ 44r ' 6f P N � '.- � i I •` II _ it 1 �, i Sj,04Y _ , � �-�..�F IV) t 0 rl T_2'Y 666 e - �Al t • o �oPE%r 1�0 C"➢ Ft,mo1 a lii '� �Q G kri [ lIIN�� 'C1J".99 "_ °.g° 0IeaY I:fe " "2g4Z' p k "Ebu PY,c+"c �5wp ° e At , 6 I� — . _ -�--•-ice--- - , _ � - -- ,�����+� - � — - , K11ocr -tW \A/f L C. &JA 'Dom¢ s AINO wirroau s' A'S r AF➢lE - ' . -- ?'i�lb uy�. �e,..IGad t+•TS To AGL l'fe4•'t, 6wlA4 F-"J tt? COAej�ie:Ar,/A ,v,tl (6wlal7, CODEb . 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Subdivision Location: (� Name: `/ • — Single&separate Required certification: ve— Req D OiDD at Req Zoning District— (Lot size: Actual: 9/ (Lot coverage Proposed: 6170 Req. �') Req. ISf Req. (Front Yard Proposed: (Side Yard — Proposed: 1 (Rear Yard .�d Proposed: Project Description: /�l AGENCY PERMITS Permit REQUIRED FOR REVIEW N.A. NO Y'ES/ umber Suffolk County Health Dept. New York State D. E. C. Town Trustees Town Zoning PP Board approval: / q Town Planning Board approval: V �/ 71 Flood Plai q Elevation ??? Flood Zone: Notes: - _TIA/ z ��