HomeMy WebLinkAbout24779-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEP~%RTMENT
office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-25785
Date: 06/19/98
THIS CERTIFIES that the building ADDITION
Location of Property: 300 CEDAR BIRCH RD' ORIENT
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 15 Block 8 Lot 25
Subdivision Filed Map No. __ Lot No. --
conforms substantially to the Application for Building Permit heretofore
filed in this office dated MARCH t0, 1998 pursuant to which
Building Permit No. 24779-Z dated MARCH 18, 1998
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 BATHROOM ADDITION TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR.
The certificate is issued to CHRISTINE RENDEL
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. PENDING 06/18/98
PLUMBERS CERTIFICATION DATED 05/29/98
K & K PLUMBING
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. 24779 Z Date MARCH 18, 1998
Permission is hereby granted to:
ANNE CHRISTINE RENDEL
300 CEDAR BIRCH RD
ORIENT~NY 11957
for :
CONSTRUCT AN ADDITION TO AN EXISTING SINGLE FAMILY DWELLING AS
APPLIED FOR.
at premises located at
County Tax Map No. 473889 Section 015 Block
pursuant to application dated MARCH 10 1998
Building Inspector.
300 CEDAR BIRCH RD
ORIENT
0008 Lot No. 025
and approved by the
Fee $ 175.00
~ ' ~/ld!ng I~spector
ORIGINAL
Rev. 2/19/98
{~%" / { 7d5-1802
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:
i. 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.
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.
3. Fees
1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00,
Alterations to dwelling $25.00, Swim, ming pool $25.00, Accessory building $25.00,
Additions to accessory building $25.00. Businesses $50.00.
2. Certificate of Occupancy on Pre-existing Buildim~ - $100.00
3. Copy of Certificate of Occupancy -
4. ~ Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residemtial $15.00, Commercial $15.00
~e~/onstruction ........... Old Or Pre-existing Building .................
Location of Property .........................................................................
House No. Street Hamlet
9~wer or Owners of Property ......
County Tax Map No 1000, Section ..... I.~.. ..... Block ...... u.. ........ Lot ......................
Subdivision Filed Map Lot ·.
O'
,ermit No.~.~.~.Pa.'.~.Date Of Permit ................ Applicant..'~...~f ...... ~. · ---~.-
Realth Dept. Approval ................... ... .... Underwriters Approval .........................
~lanning Board Approval - ·
Request for: Temporary Certificate .......... .. Final Certicate ...........
Fee~oSubmitted:~ ~Q$ ............................. ~ C. /'~ ~ ~ ~ ~ .~
TOT/Iq, OF $OUTHOLD '
OFFIC~ OF I~UILDIHG {NSPECTo~
P.O. DOX 728 ·
TOWN IIALL
'~OUTIIOI. D, N.Y. 11971
-C g R T' I F ~ C A T i 0 N
i~ULtd-tn9 l~m~m.tb No. "*':,"t~ '
~ IpAmaee prAnb} -- " '
. ~ eo~l[~ Eha~ ehe ~o.td~ u~,l [,3 ~13~ wa%e~ supply
" ~ * ~' ~
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, NewYork 11971
Fax (516) 765-1823
Telephone (516) 765-1802
May 28, 1998
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
Anne Rendel
300 Cedar Birch Lane
Orient, New York 11957
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
XX An application for Certificate of Occupancy is
not on file. (Enclosed)
XX No Underwriters Certificate on file.
XX The check is (not on file.)$25.00
No Health Department Approval on file.
No final inspection has been made.
XX No Plumber Solder Certificate on file.
(All permits involving plumbing being
issued after April 1, 1984).
BUILDING PERMIT # 24779-Z
Please contact our office on this matter.
cooperation.
Thank you for
$OUTHOLD TOWN BUILDING DEPT.
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New York 11971
May 28, 1998
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
Anne Rendel
300 Cedar Birch Lane
Orient, New York 11957
Fax (516) 765-1823
Telephone (516) 765-1802
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
XX An application for Certificate of Occupancy is
not on file. (Enclosed)
XX No Underwriters Certificate on file.
XX The check is (not on file.)$25.00
No Health Department Approval.on file.
No final inspection has been made.
XX No Plumber Solder Certificate on file.
(All permits involving plumbing being
issued after April 1, 1984).
BUILDING PERMIT # 24779-Z
Please contact our office on this matter.
cooperation.
Thank you for
$OUTHOLD TOWN BUILDING DEPT.
FOU~DAT!ON (1st}
FOUNDATION ( 2nd )
ROUGH FRAME &
.PLUMBING
INSULATION PER N.
STATE ENERGY
CODE
FINAL
ADDITIONAL COMMENTS:
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION I ST
[ ] FOUNDATION 2ND
[ ] FRAMING
[ ] FIREPLACE & CHIMNEY
REMARKS:
[ ] ROUGH PLBG.
[ ] IN,,,.~ULATION
['~FINAL
765.1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST
[ ] FOUNDATION 2ND
[ ] ROUGH PLBG.
[ ~INSU~TION
[ ] FRAMING
[ ] FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS: ,
DATE ~ INSPECTOR
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST
[ ] FOUNDATION 2ND [~___--]'~SULATION
[ ] FRAMING [ ]FINAL
[ ] FIREPLACE & CHIMNEY
DATE INSPECTOR
JUDITH T. TERRY
TOWN CLI~RI~
OFFICE OF THE TOWN CLERK
TOWN OF SOU'I'I-1OLD
'[own flail, 53095 Main l~ead
P.O. Il{tx 1179
Soulhold, New Ymk 11971
Fax (516) 765-1823
Telephone {516} 765~ 1801
Tills IS TO CERTIFY THAT THE FOLLOWING RESOLUTION WAS ADOPTED BY THE
SOUTHOLD TOWN BOARD AT A REGULAR MEETING HELD ON AUGUST 24, 1993:
of the Code of the Town of Southold: "Floodplain
Application" [FDP(93)],' and "Certificate of Compliance
Special Flood Hazard Area [C/C(93)].
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
Development Permit
for Development in
// Judith T. Terry
Southold Town Clerk
August 25, 1993
APPLICATION
PAGE 1 ef 4
TOWN OF $OUTNOLD
FLOODPLAIN DEVELOPMENT PEI~CIIT APPLICATION
This form is to be filled out in duplicate,
SECTION 1: GENERAL PROVISIONS (APPLICAI__',IT to rgad and _fipya'}:
1. No work may start until a permit is issued.
2, The permit may be revoked ii any false statements are made here~n.
3. If revoked, all work must cease until permit is re-issued.
4. Development shah not be used or occupied until a Certificate of Compliance is issued.
5. The permit will expire if no work is commenced whlfin six months of issuance.
6. Applicant is he/eby informed that other permits may be required to fulfdl local, state and federal regulatory
requirements.
7. Applicant hereby gives consent to the Local Administrator or his/her representative to make /easonable
inspections required to verify compliance.
8. I, THE APPLICANT, CERTIFY THAT ALL STATEMENTS HEREIN AND IN ATTACHMENTS 3['0
~ THIS APPLICATION ARE, TO THE BEST OF MY KNOWLEDGE, TRUE AND ACCURATE.
SECTION 2: PROPOSED DEVELOPMENT £To be comnleted by APPLIGAN'D
NAME ADDRESS
APPLICANT
. TELEPHONE
BUILDER
EplGINEER
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 weli-kunwn landmark. A sketch attaclied to tiffs application showing
the project location would be helpful.
APPLICATION
PAGE 2 OF 4
DESCRIPTION OF WORK (Check all applicable boxes):
A. STRUCTURAL DEVELOPMENT
ACTIVITy
STRUCTURE TYPE
[] New Structure
[] Addition
121 Alteration
[21 Relocation
~ Demolition
[] Replacement
[] Residential (1-4 Family)
[] Residential (More than 4 Family)
[] Non-residential (Hooflproogmg? [] Yes)
[] Combined Use (Residential & Commercial
Fl Manufactured (Mobile) Home (In Manu-
factured Home Park'/ [] Yes)
ESTIMATED COST OF PROJECT $
B. OTHER DEVELOPMEIx~ ACTIVITIES:
[] Fill [] Mining D Drilling El Grading
[] Excavation (Except for Structural Development Checked Above)
' [] Watercourse Alteration (Including Dredging and Channel Modifications)
[] Drainage Improvements (Including Cnlvert Work)
[] Road, Street or Bridge Construction
[] Subdivision (New or Expansion) . .
[] Individual Water or Sewer System
[] Other (Please Specify)
After completing SECTION 2, APPLICANT should submit form to Local Administrator Ior review.
SEq;TI0.N 3;. FI,,OQDPLAIN DETERMINATION (To be comoleted b'/__LQCAIo ADMINISTRATOR)
The p"roposed develnpment is located on FIRM Panel No, , Dated
The Proposed Development:
[] Is NQT located in a Special Flood Hazard Area (Notify the applicant that the application
review is complete ~md NO FLOODPLAIN DEVELOPMENT PERMIT IS REQUIRED).
[] Is located in a Special Flood Hazard Area.
FIRM Zone designation is
100-Year flood elevation at the site is: Ft. NGVD (MSL)
[] Unavailable
[] The proposed development is located in a floodway.
F13FM Panel No. Dated
[] See Section 4 for additional instructions.
SIGNED
DAT~
APPLICATION
PAGE 3 OF 4
SECTION 4: ADD1TIQNAL INFOIUVIATION RI~_Q_~IRED~(To be comvl_eted bY LOCAL ADMIN1ST_.~_~T.~_~).
The applicant must submit the documents checked below before the appllcatlon 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 first floor, details of floodprooFmg of utifitles located below
the first 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 ~ provide 100-year flood elevations
if they are not otherwise available).
El 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. NOVD (MSL). For
floodproofed structures, applicant must attach certification from registered engineer or
architect.
[] Certillcation from a registered engineer that the proposed activity in.a regulatory floodway
will not result in a_~ increase in the height of the 100-year flood. A copy of all data and
calculations supporting this f'mding must also be submitted.
[] Other:
SECTION 5:, PERMIT DETERMINATION (To be cqmpl~ed bY LOCAL ADMINISTRATOR)
I have determined that the proposed activity: A, [] ls
B. El Is not
in conformance with provisions of Local Law # ,19
attached to and made part of this permit.
· The permit is issued sub3ect to the conditions
SIGNED , DATE
If BOX A is ehecke~, the Local Administrator may issue a Development Permit upon payment of designated
If BOX B ischec_~.4, the Local Admtmstrator' ' ',~ll' pro'nde' a written summary of del~clencies. Applicant tnay
revise and resubmit an application to the Local Administrator or may reqnest a hearing from the Board of
Appeals.
APPEALS: Appealed to Board o[ Appeals? [] Yes [] No
Hearing date:
Appeals Board Deeislon --- Approved7 [] Yes
Conditions
[3 No
APPLICATION
PAGE 4 OF 4
8ECT1ON 6: AS-BUILT ELEVATIONS {'To be submitted bv APPLICANT ~eforv ~ertificate of Compliance
is issued)
The following information mu_4t be provided for project structures. This section must be completed 12y a
registered professional engineer or a licensed land surveyor (or attach a certlfleation to this application).
Complete 1 or 2 below.
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. Nox, rD (MSL).
2. Actual (As-Built) Elevation of floodprooting protection is FT. NOVD (MSL).
NOTE: Any work performed prior to submittal of the above information is at the risk of the Applicant.
SIgCTION 7: COMPLIANCE .ACTION (To be comoleted by LO.CAI~., ADMIN!~TRATOR'I
The LOCAL ADMINISTRATOR will complete this section as applicable based on inspection of [he project to
ensure compliance with the community's local law for flood damage prevention.
INSPECTIONS: DATE BY DEFICIENCIES? [] YES [] NO
; DATE BY DEFICIENCIES? [] YES [] NO
~ DATE BY DEFICIENCIES? El YES [] NO
.SECTION 8: CERTIFICATE OF COMJ?LIANCE(To be completed by LOCAL ADMINIS. TRATOR)
Certificate of Compliance issued: DATE: BY:
Attachment B
BAMPLE
CERTIFICATE OF COHPLI~%NCE
for Development in a Special Flood Hazard Area
TOWN OF SOUTHOLD
CERTIFICATE OF COMPLIANCE
FOR DEVELOPMENT 1N A SPECIAL FLOOD HAZARD AREA
(OWNER MUST RETAIN THIS CERTIFICATE)
PREMISES LOCATED 'AT:
PERMIT NO,_
PERMIT DA, TE ....
OWNERS NAME AND ADDRESS:
CHECK ONE:
E] NEW BUILDING
E] EXISTING BUILDING,
ID VACANT LAND
THE LOCAL ADMINISTRATOR IS TO COMPLETE A. OR B. BELOW:
COMPLIANCE IS tIEREBY CERTIFIED WITIt THE REQUIREMENTS OF
LOCAL LAW #_ , 19
SI GNED: DATED:
COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS
LOCAL LAW #. _, 19_, AS MODIFIED BY VARIANCE #.,
DATED,
SIGNED: DATED:
OF
C/C[93)
'" NS
ENERGY CODE CALCULAiIO _
(For Non-Electric lleat)
Design Criteria 6,000 Degree'.Days
O.A. IOeF £.A. 7OeF
A- ¢. "''' /
SUBSYSTEM
Exterior Walls (Opaque)
Glazil,g I 9 %
ce,il~g/R3of (Opaque)
skylights 7, Z %
Floor
l;oundat£on Walls
Slab Insulation
AREA
¥0
77
TOTAL
REMARKS
[.lo [es:
l]uildlnq Envelope Systems to meet requirements of 7B15.2
IIVAC Equlpement to meet requirements of 7B15.11
[IVAC Systems to meet requirements of 7815.1'2
Duct Systems to mee~ require,ltents o~ 7g15.13
' s
Ventilations Systems to meet r~qu~rement of '1B15.14
Insulation of Piping Systems to meet requirements of 7~15.15
Service Water lleating Syste,us & Equipment to meet requirement of '~15.21
Electrical & Lighting Systems & Equipment to meet requirement of 7~15 31
To the best of my knowledge,
belie2, & professional
judgement, the:~e plans are -~. t
compliance with Ehe code.
ii
TITE'E
ih,lAPi':O
OF'
SECTION E CERTIFICATION
This certification is to be signed by a land surveyor, engineer, or architect who is authorized by state or local law to certify elevation
information when the elevation information for Zones Al-A30, AE, AH, A (with BFE),VI-V30,VE, and V (with EIFE) is required.
Community officials who are authorized by local law or ordinance to provide floodplain management information, may also sign the
certification. In the case of Zones AO and A (without a FEMA or COmmunity issued BFE), a building official, a property owner, or an
owner's representative may also sig. n the certification.
Reference levai diagrams 6, 7 and 8 - DistfnguJshing Features-If the certifier is unable to certify to breakaway/non-breal~wa.y wall,
enclosure size, location of servicing equipment, area use, wall openings, or unfinished area Feature(s), then list the Feature(s) not
included in the certification under Comments balow. The diagram number, Section C, Item 1, must still be entered.
I cer~'f7 that the informs#on in Sect/~ns B and C on this certificate represenZs my best efforts to [r~tsrpret the data available.
I under~tand that any fa/se statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.
CERTIFIER'S NAME LICENSE NUMBER (or Afffx Seal)
'nTLE COMPANY NAME
Copies should be ma"de of this Certificate for: 1) community official, 2) insurance-agent/company, and 3) building owner.
~ ON PILES,
BASEMENT P/ERS, OR COLUMNS
A A V
· ZONE~ ZONES ZONES '
The diagrams above illustrate the points at which the elevations should be measured in A Zones and V Zones.
E[evatiens for all A Zones should be measured at the top of the reference level floor.
Elevations for all V Zones should be measured at th~ bottom of the lowest horizontal structural member.
Page 2
FEI` ERAL EMERGENCY MANAGEMENT AGENCY
IATIONAL FLOOD INSURANCE PROGRAM
' AS'TENTiON: Use of this ce~[ficate does nc'~ provide a waiver of the flood insurance purch~e r~uirement. ~is form is used only to
provide elevation info~aflon necessa~ to ~ nsure comp~ian~ with ~pJicab~e communi~ ~oodpl~n management ordinances, to
dateline the proper insurance premium m e, an~or to suppoA a request for a Leffer of Map Amendment or Revision (LOMA or LOMR).
Instructions ftr completing this fo~ can be found on the following pages.
SE~ON A PROPER~INFORMA~ON FOR INSU~NCE COMPANY USE
S~R~ AODRES~ (tn~u~g A~t., Unff. ~uite ~or ~dg. Number) OR P.O, ROUTE AND BOX NUMBER COMPANY ~lC NUMBER
Provide the following from the proper FIR~ (See Instructions):
7. '~dicste the elevation datum system used an the FIRM for Base Flo~d Elevations {BFE):~NGVD '29 ~ Other (describe on b~ck)
8. For Zones A or V, where no BFE is pro~ided on the FIRM, and the communi~ has established ~ ~FE for this building site, indicste
~e community's BFE:I I I I ~.j.~ feet NGVD (er other FIRM datum-see Se~on B, ~tem 7),
SECTION C BUILDING ELEVATION INFORMATION
1, Using the Elevation Ce~ificate lnstmctibns, indicate the diagram number from the diagrams found on Pages 5 and 6 that best
descnbes the sublect building s refereoce level
2(a). FIRM Zones Al-A30, AE, AH, and ~(with BFE). The top of the reference ~eve~ ~oor from the seJected d~agram is st an elevetlon
of[ ~ [ ~ ~.~ fee{ NGVD {or ot~er F RM datum-see So.ion B, Item 7).
(b). FIRM Zones V1-V30, VE, and V (wit~ BFE). The bo~om of the lowest horizontal structursl member of the reference {evet ~om
the selected diagram, is at sn elevation of ( ~ ~ ~ ~ ~,~ feet NGVD (or other F~RM datum~ee Section B, item 7).
(c), FiRM Z~ne A (without ~FE). The fl~or used as the reference level from the sele~ed disgram is ! ~ I.~ feet above ~ or
below ~ (cheek one) the h ghost g~ade adjacent to the building.
(d). FIRM Zone AO. The floor used as t~e reference levei from the selected diagram is ~ ~ ~.~ feet ~ove ~ or be~ow ~ (check
one) the highest grade ~djscent ~o t~e building. ~f no flood depth number is available, is the building's lowest floor (reference
level) elevated in accbrdance with t~e communi~'s floodplain management ordinance? ~ Yes ~ N~ ~ Unknown
3. Indicate the elevation dstum system u~ed in determi~in'g the above reference ~evet e~evat~ons:~ NGVD 29 ~ Other (describe
under Comments on Page 2). (NQTE~ If the elevation datum used in measuring the elevations is different than that used on,
the FIRM [see Section B, Item ~, the;n conve~ the elevations to the datum system used on ~e FIRM and show the conve~on
equation under Comment$ on/=age 2.~ ·
4. Elevation reference mark used appea~s on F~RM: ~ Yes ~ No (See instructions on Page 4)
5. The reference level elevat on s based: eh: ~ actual construction ~ construction drawings
(N~=· //~ ~f ~n~c~r.ct/on drawings s only va/id if the building does not yet have the reference level floor in p/ace, in which
case this ceCificate wi I only be va/id ~r the building dur ng the course of construct/on. A poshcon~t~ctlon E~evat~on Ca.if/cate
will be required once con$tru~Jon is c~mplete.)
6. The elevation of the lowest grade ~m~ed~ately sdjace t to the buiiding [s:~ I I ~1.~ feet NGVD (or other FIRM datum-see
Section B, Item 7).
SEC~ON D COMMUNI~ INFORMA~QN
1. f the commum~ off ca[ respons hie for vet ~ ng building elevations specifies that the re~erence level indicated in Se~lon C, Item 1
is not ~he "~owest floor" as defined in ~he communi~'s floodplain management ordinance, the elevation of the bu~ld~n~'s "lowest
floor" as defined by the ordinance is;~ ~ ~ ~ ~ ~.~ feet NGVD (or other FiRM dstum-see Section B, ~[em 7).
2. Date of the sta~ of construction or su?tan~Ja~ improvement
FEMA Form 81 -Sl~ MAY 90 ~EPL~CES ALL PREVIOUS EDITIONS SEE REVERSE SIDE FOR CONTINUATION
°0 $
,/
3. P;~lure of ~0ork (check ~hidl applicable): Neu lluilding .......... /VJdltia~ ..~..... Mteration ..........
I~ir ............ ~al ............. l~liti~ ............ Other
- · (to ~ ~id ~ filing this al~licati~)
5. 1[ &~lli~, a~t~r of &~lli~ units ~ tlsder of ¢[~lling traits
If garage, t~Imr of cars
6. If Ixmir~sa, ~ercial or mi~ ~]I~, s~ci~ ~tore a~ ~tent of each ty~ of u~..~. ...............
7. I)in~nsi~is of ~iating atrtetures, if any: Print ................ ~ar ............... ~pth .................
I~i~,t ......................... ~r of Stories ~ ...............
llln~nai~m of ~m stnmt~re ~ith alteratiam or ~itions: Front ............... ~ar
lgpth .................... lhi~t .................... a~t~r of Stories .~ .......
8. Ill,ensia,s of entire ~ ~st~tia~: }kmt ..~ ........ l~ar ...[~ ........ ~pth ~ ...........
I~i~]t ...... ~ .................. ~tmr of Stories .....................
9. Si~e of lot: [~mr .............. ~ar .............. ~pth ................
m.. ~,t, o~ ~i~d,,~ Z/.~.[ ............. ~ o~ ~,,,,~ ~ .gl.U~.~Y.~ ...............
II. ~ or n~ district in ~dd~ pr~fi~8 am si~t~ .~'. . . .
12. ~s ~ro~l ~mt~tim violate say m~i~ ]~ o~i~[re or regulati~: .~.0 ..................
13. ~ill lot I~ egr~B ..~ ............. ~ill eess rill I~ r~mg
~e or ~rd~itect .......... ~.~ ................ ~lress .... / ........................ ~m ~ ...............
~,~ o~ ~.~o~ .......... 3~ ................ ~.~ .... x ......................... ~ ~ ...............
15. Is this pm~rty ~ithJn ~ ret ~[ a ti{hr ~etl~xl~ ~ ~3 ........... ~ ..........
FI.OT I)IfiGRAH
l~ate clearly/~ dlsrimtly all ~ildi~s, ~mtlmr ~isti~ or pro~, a~ i~xlicate ail ~t-l~ fllmnsions
~m~ prq~rry.lims.) ]~i~ st~r aM bl~k t~ler or ~scr~prim according to ~, a~ g~ strut ms a~l imitate
xgmrtmr inter,or or tenor lot. '
(11111[3[ (W .......................
....... ....................
(~ of i~ivi(l~t signh~ c~tract)
........ o. .....................................
(C~tractor~ agenC~-aor~ra~e officer, etc.)
or said ¢~r or ~rs, ar~l is duly athorJg to ~r[on, or h~a l~rl:o~d Ihe aid ~rk alii to n~ke a~ file this
aloft ication; that ail statemnts cmtai~ in 'this ai~)llcatil~l are trle 'tO ~le lest of his kll~l~ge am~ lmlief~ a~gl
that the ~)rk will le ~rfon~l ia II~ m~llll~r ~C forth ill the appllcation filal tl~r~iflt.
~r~a to beEore ne this
............. (lay or
~ta~ lS~lic . .~ ..........
No~ ~ ~ ol New Yo~
No. 01BE~4751
~i~ ~p~ ~u~ al, I~~
FORN NO. I
TOI/N OF SOUTIIOLD
)ISOUTIIOLD, N.Y. 1197 I
TEL: 765-1802
I)iaapprtr~ed a/c ................... ~ ...............
APPLI CA¢~tON' FOR/BU I LBINC PEEIIlT
I~STRUCTIO~S
',--/3 SETS OF PLANS ......... ......
t,,'""SURVEY ........................
C.C,.i~ .........................
~ .
NAil. TO: ....................
3.o.A .,c. ~..c!~.r..~:.c..~.~..,.~..,¢.
........... ,.~ .......... ~....9 ....
a. '/his applicatJrm mist be mnpletely filled in by L~T~ewriter or in ink at~l ~lmitt~ to
3 ~ts o~ pla~, acetate plot lfl~ tb ~ale. V~ acco~i~ to ~le.
b. Plot pl~ i~i~ lmtim ~f lot ~ of ~ildi~s ~ ~i~s, mlationd~ip to Mjoini~
s~r~rs or ar~s, ~ givi~ a ~tat~ ~ripti~ of laya~t of pro~rty ~st ~ dr~
this a~flicati~. ~i
c. '~e ~ c~r~ ~ fl~is a~Jlicati~ ~y ~ be cm~ed before issue o[ ~ildi~ Pe~it.
d. UIm a~r~al o[ flus a~l~{at~, tim ~l}d~ Inslmctor mil ~s~ a ~lldn~ Pemit ~o the applicant. ~ch
I~mit dsall ~ ~pt ~ ~ ~i~slavail~le for lns~ti~ rh~t the ~rk.
e. ~ Imildi~ Mmll ~ ~pi~l or u~ in.~le or in ~rt for any ~ ~mt~ar
(kcmf~my Jmlt h~e l~n grant~ byj tim ltdhli~ lns~tor.
~HA~rI~ IS I~Y ~ to t~ l~ildi~ ~r~ent got the ia~o o[ a ~ildi~sg Pemdt ~ws~nc co ~he
I~il~ing ~ Ordlm~e of ~ T~ ~[ ~tl~ld, ~ffolk ~ ~ York, a~ othor a~icable ~, ~di[~os or
~lati~s, for tim c~mtnm~l~ o[~ ~nIdi~s, ~iti~a or alterations, or for r~al or d~llti~ as herein
¢~scril~. ~ applier a~8 to ~a~ply with ail a~lieahle l~s, ordi~mes, beildlng c~e, h~si~ c~, a~l
(/
~!Cp~~.':: ........ ::...: ......
(8ig~mture of a~licant, or ~, iff a co.ration)
State ~mflmr a~tleant is ~r, l~s~, ~ent, arddt~t, engi~r, ~t~ral contractor, elecrrlclan, pl~r or Imlhler.
....... ~.~t.~.K ............. ~, ........................................................................... . .........
C~t~%rt ~ ~ ~U65~ .........
~ of ~r o~ pr~t~s ......... ~ ........................................................................
(a) a~ the tax mll or latest d~)
If a~licant is a c~ratim, si~e of duly mttmrlz~ officer.
.................................. ..............
(~ aid title of ~rate
hall&rs l.icen~ ~ ......... ~ ................
Plata l.icen~ ~. ' ..........
El~trici~8 Liee~ ~. ...~ ................
I. l~atim of lam m ~id~ pr~ ~rk will ~ ¢~ .....................................
SECTION E CE~ilPiCATION
This ce~ificetion is to be signed by a land surveyor, engineer, or architect who is a~odzed by state or local law to certify alev;
information when the sievaiton information for Zones Al-A30, AE, AH, A (with BFE),V1-V30,VE, and V (with BFE) is required.
Community officios who are authorized by local law or ordinance to provide floodplain management information, may ~so sign
certification, In the case of Zones AB and A (without a FEMA or communify issued BFE), a building official, a property owner,
owner's representative may also sig. n the ceraficetion.
Reference level diagrams 6, 7 and 8 - Distinguishing Features-if the cerffiier is unable to certify to bmakaway/non-breakaway
enclosure size, location of servicMg equipment, area use, wall openings, or unfinished area. Feature(s), then list the Feature(s)
included in the certification under Comments be/ow. The diagram number, Section C, Item 1, must still be entered.
I certify that the information in Sections B and C on this cartiEcata represents my best efforts to interpret the data available.
I understand that any false statement may be punishable by #ne or impdsonmant under 18 U.S. Code, Sect/on 1001.
LICENSE NUMBER (or Affix
COMPANy NAME
AB6RES$ - CITY
DATE PHONE
C.ople$ should be m~de of this ~lflcete for: 1) communi~ official, 2) Insurance agen~company, and 3) building owner
The diagrams above illustrate the points at which the elevat/ons should be measured in A Zones and V Zones.
Elevations for all A Zones should be measured at the top of the reference level floor.
Elevaltons for all V Zones should be measured at th~ bottom of the lowest horizontal structural member.
Page 2
i ELEVATION CERTIFICATE
FEDERAL EMERGENCY MANAGEMENT AGENCY
,NATIONAL FLOOD IN .SURANCE PROGRAM
· ATTENTION: Use of this cer~ficete does not provide a waiver of the flood insurance purchase requirement Th s form s used only to
provide elevation information necessary tolensure compliance with applicable community floodplain management ordinances, to
determine the proper insurance premium rate, and/or to support a request for a Letter of Mab Amendment or Revision (LOMA or LOMR).
Ins, trucflons !or completing this form can be found on the following pages.
SECTION/~ PROPERTY INFORMATION "J FOR INSURANCe COMCANY usa
B(JI(.O[NG OWNER'S. NAME ~ I P~L~Cy NuMeER
Provide the following from the proper FIR~ (See Instructions):
7. indicate the elevation datum system Usl'ed on the FIRM for Base Flood Elevations (BFE):.,~NGVD 29 .' ~Other (descdpe on back}
8. For Zones A or V. where no BFE is pro,vided on the FIRM, and the community has establlshed a SFE for this building site. indicate
the community's
I.~.~ feet NGVD (or other FiRM datum-see Section B, Item 7).
ISECT]ON C BUILDING ELEVATION INFORMATION
I. Using the Elevation Certificate Instructions, indicate the diagram number from the diagrams found on Pages 5 and 6 that best
describes the subject buiJding'e refere, nce level 2~. .
2(a}. FIRM Zones Al-A30, Ad, AH, and ,~, (with BFE), The top of the reference level floor from the selected diagram is at an elevation
of! ! I t I~1.~_.~ feet NGVD (or c,~ther FiRM datum-see Section S. Item 7}.
(b). FIRM Zones V1-V30, Vd, and V (w~th BFE). The bottom of the lowest horizontal structural member of the reference level from
the selected diagram. [s at an eleva!ion oil I t I !, I.L_~ feet NGVD (or other FIRM datum-see Section B, Item 7).
(c), FiRM Zone A {without EFE). The fl~or used as the reference level from the selected diagram is I I I,L_J feet above [] or
below [] (check one) the highest irade adjacent to the building.
(d). FIRM Zone AG. The floor used as ithe reference level from the selected d agram ~s I I I.L_J feet above [] or below [] (check
one) the highest grade adjacent to lhe building. If no flood depth number is available, is the building's lowest floor (reference
level) elevated in accbrdance with t~he community's floodplain management ordinance? [] Yes [] No [] Unknown
3. Indicate the elevation datum system ctsed in determihi~g the above reference level elevations:,~ NGVD '29 [~ Other (describe
under Comments on Page 2). (NO?,~: If the elevation datum used in measuring the e/ovations is different than that used on
the FIRM [see Section 8, Item 7], then convert the elevations to the datum system used on the FIRM and show the conversion
equation under Comments on Page ~.)
4. Elevation reference mark used appears on FIRM:
5, The reference level elevation is bass t on: ,~ antual construction [] construction drawings
(NOTE: Use of construction clrawin~ ~ is only va/id if the building does not yet have the reference level floor in place, in which
case this certificate will only be va/id i =r the building during the course of construction. A post-construction Elevation Certificate
will be required once construction is 3replete.)
6. The elevaflon of the lowest grade iml 3ediately adjacent to the building s;' I I I./~l~ I.~,','~ feet NGVD (or other FIRM datum-see
Section B, Item 7).
SECTION D COMMUNITY INFQRMATIQN
1. If the community official responsible ior verifying building elevations specifies that the reference level indicated in Section C, item 1
is not the "lowest floor" as defined in the community's floodplain management ordinance, the elevation of the buildlng's "lowest
floor" as defined by the ordinance iai [ ! ( I I I.~ feet NGVD (or other FIRM datum, see Section B, ~tem 7).
2. Date cf the start of construction or s~bstantial improvement
O.M.B. NO 3067,0077
OCCUPANCY oR I
USE IS UNLAWFUt
UNDERIAfl~ITER$ CERTIFICATE
REQUIRED
:
J.J-JlJ
4. FINAL - CONSTRUCTION MUST
BE COMPLETE r43R c.o.
ALL CON~ITIUCTION SHALL MEET
THE REQUIREMENTS OF THE N.Y.
STATE CONSTRUCTION & ENERGY
CODES, NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
PROWDE ANll-SCAtD
THERMAL SHOCK PREVENTING
DE~ICES ASTO PARt 902.G(K) ·
N.L STATE BUILDING CODFJ
If copper tubing is used
for water distributing
system; piping shall be
of types K or L only
PLUMBING
AU. PLUMBING WASTE
& WATER UNES NEED
TESTING BEFORE COVERING
PLUfv?BER CERTIFICATION
ON LEAD CON~ENT BEFORE
CERTIFICATE OF OCCUPANOY~'
SOLDER USED IN WATER
SUPPLY SYSTEM CANNOT
EXCEED 2/10 OF f% lEAD.
-I, OCCUPANCY OR j
~ USE IS UNLAWFUL~
.... .~-//,.-# 7---$/DF :F/-[~'iTH 0 UT CERTIFICATE
......... ...... W" OF OCCUPANCY ~ :~:~2~-~
?~-llXl t AM 10 4/Il I~il N: '
I FOUND~ -
· FOR POURE~ CONIIIIE~
2. ROUGH - FRAMIN~ I ~
3 INSU~ON
~,~AL - CONSTRUCTION MUST
~ COMPLETE FOR C,O.
ONSTRUCTION SHALL MEET
~c,?"gEMENTS OF THE N,Y.
'~'RTRL~CT~ON & ENERGY
PROVIDE ANTI-SCALD AND/OR
THERMAL SHOCK PREVENTING
DEVICES AS TO PART. 902.6(K)
N.Y. STATE BUILDING CODE.
If copper tubing is used
for water distributing
system; piping shall be
of types K or Lonly
PLUMBING
AU. PLUMBING WASTE
& WATER UNE$ NEED
TESTING BEFORE COVERING
PLUMBER CERTIFICATION
ON LEAD CONTENT BEFORE
CERTIFICATE OF OCCUPANCY
SOLDER USED IN V~,~T. ER
SUPPLY SYSTEM CANNOT
EXCEED 2/10 01~ 1% LEAD.