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23734-z
FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-24919 Date MARCH 5, 1997 THIS CERTIFIES that the building NEW DWELLING Location of Property 2530 GILLETTE DRIVE EAST MARION, N.Y. House No. Street Hamlet County Tax Map No. 1000 Section 38 Block 2 Lot 26 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated SEPTEMBER 17, 1996 pursuant to which Building Permit No. 23734-Z dated OCTOBER 9, 1996 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 ATTACHED TWO CAR GARAGE & COVERED FRONT PORCH AS APPLIED FOR. The certificate is issued to HEATHER J.C. & GENE O. WALKER, II (owners) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL- RIO-96-0036-FEB. 25, 1997 UNDERWRITERS CERTIFICATE NO. PENDING - FEBRUARY 26, 1997 PLUMBERS CERTIFICATION DATED MARCH 5, 1997-VANETTEN PLUMBING & HEATING Bu' ding Inspector Rev. 1/81 roRm NO. I 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) N° 23734 Z Date .......//��.................................... 19./...� Permission is hereby gronted to: �G!.�f:L...1r.:.d.'�„@!/..`��.U�9.1��1.�?�if'.�-�'u�- /✓/G {��r.. , .. z0................/......................... .........:�.t...... �.l.?! f...sl1.!� . .....�!� !.. ... �... �//..?f...... .....!y/o..... .... /..�..�/. .. at premises located at .........>7` v.!/. ....................................................... .../ ......................................................... ................................................................................................................................................................ County Tax Map No. 1000 Section .. 3 ............. Block .... ......... /LLot No. .. ......... ...../n .... pursuant to application dated ......... ......./ o�.�..........., 19,7..1?, and approved by the Building Inspector. Fee S fo-?� -41(o`I�• �" �>° e. 9, :... . ....................... uildl I for Rev. 6/30/80 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 17 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 showin4 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. Fees 1. Cer :ificai:a of Occupan.y -- New dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $25.00, Additions to accessory building $25.00. Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - .25c. 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 Date . .. . . . . 3`3l9 7. . . . . . . . . . . . . . . . . . . . . . . . . New Construction. . . . . VC. . . Old Or Pre-existing Building. . . . . . . . . . . . . . . . . Location of Property.a?J.3a. . �T.I � IBc . .1��1� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . House No. Street / Hamlet Onwer or Owners of Property 054J6 . . . YEATHGvz. W 14L1<&'9 T•�^F� y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .t . ... . . . . . . . . . . . . County Tax Map No 1000, Section. . $ . . . . . .Block. . . . . Z. . . . . . . .Lot. . . . '7_Y. • • - • • • • • • • • • Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed/ Map. . . . . . . . . . . .Lot. . . . . . . . . . . . . . . . . . . . . . Permit No. ? .Date Of rmit. . b Applicant. V&glrY ./e ,W"s r=l�L^• . . . 9 . . . . . A pp . . . . . . . . .'. q• • • • • • • Health Dept. Approval. . . . . . . . . . . . . . . . . . . . . . . . . .Underwriters Approval. . . . . . !. . . . . . . . . . . . . . . . . . alanning Board Approval. . . . . . . . . . . . . . . . . . . . . . . . aequest for: Temporary .Certificate. . . . . . . . . . . Final Certicate. . . . . . . . . . . Fee Submitted: $. . . . ✓!��. . . . . . . . . . . . . . .e .��.45aa �.�.���. . . . . . . . . . . . . . . APPLICANT r� 91q THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1 1000121BUREAU OF ELECTRICITY F 85 JOHN STREET, NEW YORK, NY 10038 Date MARC[X 10,1997 Application No.on file 1:3 1 902 97/97 N 41:3252 THIS CERTIFIES THAT only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of MR.& MRS.GEINti WALMIZ, 2530 GILLETTE DRIVE, EAST MARION, N.Y, in the following location; ® Basement ® Ise Fl. ❑ 2nd Fl. GAR/ATTI(VOUT Section Block Lot was examined on FEBRUARY 26,1997 and found to be in compliance Wilk,the National Electrical Code. FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISHWASHERS EXHAUST FANS OUTLETS @CFPTACLES SWITCHES INCANDESCENT FLUORESCENT OTHER I AMT. I K.W. I AMT. I K.W. AMTKW AMT. K,W. AMT. H.P. 24 33 1 F DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL RECIPTI TIME CLOCKS I SELL UNIT HEATERS MULTI.OUTLET DIMMERS Olt I H.P. GAS H.P. AMT NO, A.W.G. AMT, I AMP I AMT, AMP$ TRANS. AMT N.PSYSTEMS AMI. WAITS NO.OF FEET SERVICE DISCONNECT INO.OF S E R V 1 C E AMT. AMP, ME M@TER I A tW 1%SW 3%3W 3 A AW NO.OF CC GOND A.W G. NO OF HIdEG A.W G. NO.OF NEU1RAl5 A.W G. EQUIP. PER% OF CC. OND. OF HPLEG OF NEUTRAL 1 150 CB 1 X 1 1/0 1 1/0 OTHER APPARATUS: PADDLE FANS-3 WETS, PUMP-1 MGTUR5:3-F Fi.P. ,1-F u.P. G.F.C.It-8 SMOKE DETECTOR:-3 IQ%LC+K..sw�. L L PAUL R. BURNS LTC.0897 P P.O.BOX 105.1 GENNALMANAGER SOUTHOLD, NY, 11971-0932 �+ 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. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CgTIACATE.MUST NOT BE ALTERED IN ANY MANNER. PIh;LO ItI;PI:C I'IUN I2E1'OI2I' DAIH COMMENT; Y II II ._ .. ♦ , iC.V 1'(11I1JDA'I'TON ( I;'I') II I 4 - r•ourron'rtorr ( zrn)) -- --------------------------------- -- -------- -- I �- it unncN FRAMV R ,� it _ z PLUMBING _ .. II. 1 v _ I N.`i 111.A1'i()N I'Ii 12 N. Y . J A i'1'A 1'1'. RNh.RCY I COM". � n �1 7 - - M 4 -X- �, II 1TIMAI, II II _ .. . . . . . ... . . . . +` .... _. It .. .__ II II AUO fTIONAI. CUMMF.N'('; : O_y r� 9 ^` c•l� A Town Hail, 53095 Main Road { y Fax (516)765-1823 P. O. Box 1179 a Telephone (516) 765-1802 Southold, New York 11971 c, OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD C E R T I F I C A T I O N r� DATE: Building Permit No\ '., Owner: (;"eWAwe(21 (please print) Plumber: V/.}/1/ k- r-A) Robcci ?0v'q--P (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead . Len2z:::� (Plumbers Signature) Sworn to before me this day of // 19 �7 Notary Public, wl (J�2� County JOYCE M.WILKINS Notary Public,State of New York No,4952246,Suffolk Couryty Term Expires June 12, 19.7..'7 JUDITH T. TERRY w ' Town Hall. 53095 Main Road TOWN CLERK _` C P.O. Box 1 179 ,` trig' '� Southold, New York 11971 REGISTRAR OF VITALOFFICER .Y i` -��' O..r Fax (516) 765 118_3 MARL2IACE OFFICER - RECORDSMANAGEMENTOFFICER ''r�� j1� Telephon C516) 7-65-1801 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 993: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) ] . L ft+OGD Southold Town Clerk August 25, 1993 APPLICATION #_ PAGE I of 4 TOWN OF SOUTHOLD FLOODPLAIN DEVELOPMENT PERMIT APPLICATION This form is to be filled out in duplicate. SECTION 1• GENERAL PROVISIONS (APPLICANT to read and ig_g) 1. No work may start until a permit is issued. 2. The permit may be revoked if any false statements are made herein. 3. If revoked, all work must cease until permit is re-issued. 4. Development shall not be used or occupied until a Certificate of Compliance is issued. 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 inspectiocvq required to verify compliance. 8. 1, 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 10 l SECTION 2: PROPOSED DEVELOPMENT (To be completed by APPLICANT) NAME ADDRESS TELEPHONE APPLICANT Ge. e, IdA)i(ei fsoo MA's 2d 45+m4rtou-,1JJ/ Ilg3q �sIld ri oYa3 BUILDER I111cliAe.1 T, Uerel)� p,p,Oox 4-16 (x' ree.-,pe(J- NI / 119gV Ir(6)477-7Y17 ENGINE[,R Awbox 110.1 CTfe-0 pdf ytJy1114y _Vl1 q,7 1Gsa 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. vvi�nn —r10'} ` q jh (Y1Ario� l"nA�clF l=A'54 OAft'on, A Y w/S of 3& S'+4 fJ0 (lenues iso } /ZoA ERS+ MAr1otii N y — — FDP(93) APPLICATION # PAGE 2 OF 4 DESCRIPTION OF WORK (Check all applicable boxes): A. STRUCTURAL DEVELOPMENT ACTIVITY STRUCTURE TYPE 1jQ New Structure Residential (1-4 Family) ❑Addition ❑ Residential (More than 4 Family) ❑Alteration ❑ Non-residential (Floodproofmg? ❑ Yes) ❑ Relocation ❑ Combined Use (Residential & Commercial) ❑ Demolition ❑ Manufactured (Mobile) Home (In Manu- 0 Replacement factured Home Park? ❑ Yes) ESTIMATED COST OF PROJECTS 1090006 B. OTHER DEVELOPMENT ACTIVITIES: • Fill ❑ Mining ❑ Drilling Q Grading ❑ Excavation (Except for Structural Development Checked Above) ❑ Watercourse Alteration (Including Dredging and Channel Modifications) ❑ Drainage Improvements (Including Culvert Work) ❑ Road, Street or Bridge Construction ❑ Subdivision (New or Expansion) M Individual Water or Sewer System 13 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: I7 Is NOT located in a Special Flood Hazard Area (Notify the applicant that the application review is complete and 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) 0 Unavailable O The proposed development is located in a floodway. FBFM Panel No. Dated 11 See Section 4 for additional instructions. SIGNED DATE APPLICATION # PAGE 3 OF 4 SECTION 4:ADDITIONAL INFORMATION REQUIRED (To be com leted bkLOCAL ADMiNISTRATORj The applicant must submit the documents checked below before the application can be processed: 17 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 floodproofmg of utilities 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 must provide 100-year flood elevations if they are not otherwise available), 0 Plans showing the extent of watercourse relocation and/or landform alterations. ❑ Top of new fill elevation Ft. NGVD (MSL). ❑ Floodproofmg protection level (non-residential only) Ft. NGVD (MSL). For floodproofed structures, applicant must attach certification from registered engineer or architect. ❑ Certification from a registered engineer that the proposed activity in a regulatory floodway will not result in any increase in the height of the 100-year flood. A copy of all data and calctdations supporting this finding must also be submitted. Cl Other: SECTION 5: PERMIT DETERMINATION (To be completed by LOCAL ADMINISTRATOR) I have determined that the proposed activity: A. ❑ Is B. ❑ Is not in conformance with provisions of Local Law # , 14 , 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? 0 Yes ❑ No Hearing date: Appeals Board Decision --- Approved? ❑ Yes ❑ No Conditions SECTION 6• AS-BUILT ELEVATIONS (To be ubmitted by APPLICANT before Certificate of Comnhance 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 I or 2 below. I. Actual (As-Built) Elevation of the top of the lowest floor, including basement (in Coastal High Hazard Areas, bottom of lowest structural member of the lowest floor, excluding piling and columns) is: Fr. NGVD (MSL). 2. Actual (As-Built) Elevation of floodproofing protection is Fr. 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. INSPECTIONS: DATE BY DEFICIENCIES? OYES LINO DATE BY DEFICIENCIES? OYES ONO DATE BX DEFICIENCIES? ❑ YES ❑ NO SECTION 8: CERTIFICATE OF COMPLIANCE(To be comoleled by LOCAL ADMINISTRATOR) Certificate of Compliance issued: DATE: BY: Attachment B SAMPLE CERTIFICATE OF COMPLIANCE for Development in a Special Flood Hazard Area r . 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: O 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 # , 19 AS MODIFIED BY VARIANCE # DATED > SIGNED- DATED: C/C(93) ENERGY CVUli CALCULA'T'IONS (Por Non-Electric Cleat) besigu Criteria 6 , 000 begree' Ilays / f ��j O.A. 10°L•' I -A- 7VF /' FOR: f�ea�'1<� Wei)e gla e,. J� PER• Ajp �s grJOYI DATED: 1 Pg bES1GN 1'kIl!.i2MEL REMARKS SUBSYSTEM ARTA "U" RATING f;xterj.or Walls (Opaque) �, p77 q- // 2 � arses � _/�"=6ryjebo Glazing j 2. 98 37 o S`3 6Y Po f a! boors Ivo - 2.3 Cciliug/Roof (Opaque) p � , 05 q Skylights Floor Foundation Walls Slab Insu.l.atial TOTAL + ,36 Notes'. I3ulldj.11y C;nvelope SysLentS to meet requj.rements of: 7015 . 2 IIVAC Equj.pement to meet- requirements of 7615. 11 IiVAC Systems to meet• requirements of 7015 . 'r2 buct Sysl:ems to meet requirements of 7915. 13 Veutil,lL•ions Systems to Meet requiremettLs of '7015 . 14 1usu.laLlou of Pipiny Systems to meeL- requir.emernLs of 7015 . 15 Service Water HeaUllU Systems & LquipmenL' to meet requirements of: 7015 . 7.1 Electrical & LighUllcj Systems & Equipment to meet requirements of 701.5 . 31 ,ro tite best of illy knowledge, O3.3M/,q belief:, & professional ��'j judyemenL, thege plans are 3.:1 compliance with Lhe code. w � LI 765-1802 BUILDING DEPT. INSPECTION [ J FOUNDATION IST ( ] ROUGH PLBG. [ ] FOUNDATION 2ND [ INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE A CHIMNEY REMARKS: - DATE INSPECTOR 3 73r M-1802 BUILDING DEPT. INSPECTION [ ] FO NDATION IST [ ] ROUGH PLBG. [ FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACES CHIMNEY REMARKS: DATE INSPECTOR /�C O`3 M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [✓]/FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: p b DATE INSPECTOR ~"" M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] RO PI [ ] FOUNDATION 2ND [ INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: DATE INSPECTOR J�, �t'. .�5 � �S� d4� 1 BOARD OF HEALTH . . . . . FORM NO. 1 3 SETS 9,;P�PLAPIS lh� TOWN OFSOUTHOLD SURVEY I' SEP "�' � � BUILDING DEPARTMENT CHECK .� �_ • • . , , , . • • . 6 u i TOWN HALL SEPTIC PORP] . . . . . . . . . . . . . . �D P7. SOUTHOLD, N.Y. 11971 4.� ()l3;i"oul-- ,yy,e�aa TEL.: 765-1802 NOTIFY ; Examined . . �� 19/. CALL �7✓'- J7 . / Nnzr To : Approved . . . .�t�.�. . . ., 19/7PPermit No. .dJ.l '� Disapproved a/c . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .-.'/ (B ilng spector) APPLICATION FOR BUILDING PERMIT Date :'�' /`'`. . 1 ./. . ., 19 /W INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector,with 3 sets of plans,accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public stieets or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- cation. 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 issued 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 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 . . . o:� � �� . . . . . . . . . . (Signature of applicant, or name, if a corporation) . . .`f..h. . . . . . . . . . . . . . .� . dY (Mailing address of applicant) State whether applicant is owner, lessee, 'agent, architect, engineer, general contractor, electrician, plumber or builder. !oe"5 . . . . . . . . . . . . . . . . . . Name of owner of premises . . . . `4 . � .`. . .?4 . . .r!�lFr J. .I: . . . . . . . . . . . . . . (as on the tax roll or latest deed) If applicant is a corporation, sig ture of duly authorized officer. (Name and title of corporat8 officer) Builder's License No. �. . . . . . . . . . . . . . . . . Plumber's License No. Electrician's License No. . . . . . . . . . . . . . . . . . . . . . . Other Trade's License No. . . . . . . . . . . . . . . . . . . . . . 1. Location of land on which proposed work will be done. . . . . . . . '�! �✓. . . . . . . . . . . .ti . . . . . . . . . . . . . . . . . . . . . . . . . . .:. . . . . . . . . . . . . . .. House Number Street Hamlet County Tax Map No. 1000 Section . . . : > . . . . . . . Block . . . . . . .'�-77 . . . . : . . . Lot . . . . ..Z Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... Filed Map No. . . . . . . . . . . . . . . Lot . . . . . . . . . . . . . . . (Name) '-: State existing use and occupancy of premises and intended use andoccupancyof proposed construction: a. Existing use and occupancy . . . :. . l ! . . l b. Intended use and occupancy . . . . . 'O" ' . . . . . . . .c�'.a`.".`'.�. . . . . . . . .: . . . __sek'iabiur.#faAiam't..so-•`' . _,� z...,z�'•'..*n+n��u:u-. •. . . �_...... _ K _ ....._ s „�.;r.:rwa�.w4.a.�sli�rei,�ra'"ba§a�zA�i„1� 3. Nature of work check which applicable),( . . . . . . Re oval able); New Building . . ,/ . . . Addition . . . . . . . . . . Alteration . . . . . . . . . . Repair . . . . . . . . . . . Demolition Other Work . . . . . . . . . . . . . . . • • • •A?L9 Gov �6 (Description) 4. Estimated Cost . � . . . . . . . . . . . . . . . . . . Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (to be paid on filing this application) S. If arae number of cars . . . S , I ,s. • ' ' ' ' ' , • • Number of dwelling units on each floor . . . . . . . . . . . . . . • , If dwelling,number of dwelling ulitsp • . . . • • • • • „ . • • • • . . • • • , • • . • , • „ • . • • • • • • • . • • • • • . . • • • , • • • • • • • • • . garage, 6. If business commercial or mixed occu ancy, specify nature and extent of each type of use . . . . . . . . . . . . . . . . . . 7. Dimensions of existing structures, �f any: Front . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . • . Height . . . . . . . . . . . . . . . Number of Stories . . . Depth . , , , , , , , , , , • • • • Dimensions of same structure with; alterations or additions; Front ' ' ' ' ' ' Depth . . . .. . . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . . . . Height . . . . . . . �. . . . . : . . Number of�Sto�es . . . . . . . . . . . . .'. � . .f� . . . $ Height o etltyre new c Number(tion: Front . . , , �rz ,0 Rear , . , (p, a?, �, , , , , De th . ..3� , , , , , , , • y r of Stories . . . , /, p p 9 • 1 . . . . . . . , . . . . . /p4R . . . . . . . . . . . . '. ... . . Rear . , . . . . ©��. , . . . . . . . Dept . . . . ,/. . 10. Date of Purchase r2• • f • • •,• • •tu t d . . . . N e of Forme Owner 9. 11. Zone or use district in which rem` ' Size of lot: Front . . . /CJ,S, , ; . . . . . . . . . . . . . uses are situated . . . . 12, Does proposed construction vilt 'zoning law, ordinance or regulation: . 13, Will lot be regraded violate any " "� �" Will excess fill be removed from premises: Yes o 14, Name of Owner of premiseslei * ° �,' l/ 1�� ddress `pp o Name of Architect r�4,'6 ..y; • • • • Phone No. . ; ' j I;� Address , Phone No. . Name of Contractor .�Y ? . . . . . . . . Address * �D:Box f7G. es y, . Phone No. P Yes . . 15. ' Is this property within 30 f a tidal wetland? et of � . . . . . . . . No. . . .•. • '`If es Southold Town Trustees Permit may be required. PLOT DIAGRAM Locate 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 whether interior or corner lot, j j STATE OF NER / COUNTY O ( S y . . . being duly sworn, deposes and says that he is the applicant ( ame of individual signing contract) above named. fieis the . . . . . . . . . . . . . . . . . . . . .I• . "� (Contractor agent, corporate officer, etc.) if said owner or owners, and is duly aut ed-•to"perform or have performed the said work and to make and file this application; that all statements contained in 'this application are true to the best of his knowledge and belief;and that the vork will be performed in the manner so n the appl ation filed therewith. iwom to before me th s /n. . . .�. .day of. 197.x' , Jotary Public, unty / Notary Public,State of Now York No.4979505 Commission Ex in Suffolk County /Y/n (Si ature of applicant) Commission Expires DecQm�tar 8,t 8 Y'�$&?i°�wwHp14 ... �.. ,4e.!.='.e Y�.a�M, ....-.,„e e.� ,. .. .. � �.- �_ i .... ..,,gym«.w.'xsan.�.f4d�nfi._fia.r:W:K.Y3.FditiV`uF:W1• i� r-,�. 1 y LINE ri � Pf VE j to ISUIFOLK COMMEPARTNffWOP r y HEALTH SERVICSS \^ � POG2i5 i r { = 'APF OVAL OF C`0,4S'@'[ uC'@'S,.--ib oR FOR € t Ks A 5.NOLE FA eA�M ;.: t Da F' B 5 7H.5.Rer.No. o ' 0034 TOWN )OF �. T S�t?e to :.i. ti VE �f Y._ Th#I diVomi aad waatr i k �. ! ti fi Xj, ;46AFF Y w1itia at al lomps n have been t�.:� .� d t— — — Mtj ry POR fieri this D elses�egs.or B er znafes and t to & 7/ 82 11pa A.C t Office of IVa sr and E Chief p { 7 w 4 J,04& F s it ? E , .. A r�¢autwo w� rscz � WAttC;$ t h2A`I 1°34ED -fit t 5S2Tf{ k4 o .rtf` C M C 0G $+ 3 �>{. S4 $ B(o39kr. j j 2 vp, tg 90�x Ai^� APQ25, icea ss m i 4. WATT-R SW PLY AND SEWAGE DISPOSAL SYSTEMS MUST P,PIZ fiEw 4AP OF JPEM coNFoRmwnia STANDARW DATED NOVEMBER 13,199& k0ftaftw" Surd o With - f Review 1H P 2 C13t"NE , in m 2 9 I A i TSUMX COMM DWARUMT Op MLnj SMVICFSTI C� AT P=khff FOR APPROVAL OF CONMUMON FOR A (j WiGLIFAMMYMMINMONLY EO*T MAPQNff 1996 9110 TOWN QF 'S0QT14CLD N Y, - OF,DMOOMS 4FM 1 �jE)11"2S T*UMYEARS FROM JDATS OPAPPROVAL. , 4,— )F J 14 S;UVfMY-CM tAX k `f tt %CT, ft-OCA� -OCL. - �o 4 0 w 4 i low _J tu C,4 -till- CDR 7-6 -A. "MT To CW4§10 PAGE 9,UWk O'� BOY, t013 i M-1 I I i C- 5T MAP-ION! , N.Y 119,39 W A i � 1 11 i I I 1 /?// 1 J�l 5"6 a P; "ALW9 n � - Z so this mmyls avbwmd Siscuon 72DO ofthe NeWyamaw Ul Educsdaa Less, Copies of this WrAymap MbWAV thotandsurmyoesk"clsealw i FL. eAl 5T. GQ- t .�bossod seal SW M be considoW ()-�O! , GIL.I t; to be avaiitivue orals 102 76 GuaranteesinclicaledhemeMS1181oln - 6 t-,lc,-arPz,,qo�e.rowvw agerxyxd 1.2, 6.9 46.4 T6.. rnWeLl- RVEM 5. CIO#eM� <k�w vo cleou" tr.c-a •:ces are ml Ya9rufemLte D WA MWT KV 'OF M NOfZ PLEP WVON MA Ijff, CO'CILEEWS OFfite-A6 MAP Wn213. 3$ X VM IEF- - APC.23, 11;09G Z MEAN SEA LEVSL,' 0 j S 2S LAND 5 JP 77 - - qq I - � g , d I� 1y /fit tit tetY 6 _ s4W .. ' rr\ _ ��.Jy�y,C���,te9�"(!�i,1;? +�yK�+4.t�-gTy7 -, I � \ S 11� I � a'( tj i.T - { [uc. ,tYzlks ptVK2d& I'2 n T `i -' ',2xtc .d" - -- --4,. -r 4" er vt t':�xrz� r1� �1��n - ;ESM�JGr a T*c.'17`-, t,L:t` f0 m 4"co N.C;,rL k'!-W&+r mimic r_- pp ,. , ¢ RATED SEPARATION TO PART.717.3 M(1)0F Moappertubl A and N.Y.STATE BUILDING CODE :' ' k. for to eRbwftMnp ovalm PIDIna MWI be - I: ofMaKorLonhr CERIaICI1TE ` UNDERWREWIRED 2 S7 1: PLUMBING astE A TE4TING EEPORE COVERING h LNTER 41S NEED COMEMBEfORE CERTIFI ONLEACATION PLUMBER L) — — - CERTIFICATE OF OCCUPANCY "` _--- - - -- ti SOLDER USED IN WATER SUPPLY SYSTEM CANNOT EXCEED 2/10 of I%LEAD. J APPROVED AS NOTED M Z / T DATE: a ..,� G:P.Njjjj wv c J9�� FEE: 6Y: L�LIG). - _ - _ V% \ �4 C4 h r° r rn�h Gc N9TIFY BUILD NG DE PARTIVlENT Ar _ '''r` E ln- ' 'A' C S-> 766.1802 8 AM TO 4 PM FOR THE L-N ref q FOLLOWING INSPECTIONS: /�L-f/ yY C-F '\ GU 1. FOUNDATION - TWO REQUIRED - ,// FOR POURED CONCRETE PROVIDE OPENINGS FOR r O 2 M l h 4 ,�3 - f h r / �- 2, ROUGH FRAMING & PLUMBING EMERGENCY ESCAPE AS tit /-5 p r / 3, INSULATION REQUIRED BT PART.714 OF ���'�;�CE fu Sq 4 V Vr e1 O� Ch 119 4S �' P9 4. FINAL - CONSTRUCTION MUST' - �'��f+✓/�° 4��1' `-*/�"— � �� J BE co;HPLETE FOR c.Q. N.Y.STATE BUILDING COOL ' �! r AL4 CONSTRUCTION SHALL MEET ' �- , .� mG`';,r`" j:. �L✓� ( �J LL��Ly) , " t, J/rP 7l e >7 {. TI.F.. REOUIREMENTS OF THE N.Y. �-lil h 2 STATE CONSTRUCTION & ENERGY CODES. NOT RESPONSIBLE MR DESIGN OR CONSTRUCTION ERRORS OE ESSIDNT a DO NOT PROCEED WITHld � FRAMING UNTIL SURVEY OF FowwATaN IOCATION OCCUPANCY OR tIASBEaiAPPROVED. USE IS UNLAWFUL WITHOUT CERTIFICATE. 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