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HomeMy WebLinkAbout22648-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-24034 Date NOVEMBER 20, 1995 THIS CERTIFIES that the building ADDITION Location of Property 55915 COUNTY ROAD #48 GREENPORT, N.Y. House No. Street Hamlet County Tax Map No. 1000 Section 44 Block 1 Lot 17 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MARCH 10, 1995 pursuant to which Building Permit No. 22648-Z dated MARCH 30, 1995 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 REPAIRS & PILING FOUNDATION UNDER EXISTING ONE FAMIY DWELLING AS APPLIED FOR. The certificate is issued to LAZAROS & MARY LASKOS (owners) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A UNDERWRITERS CERTIFICATE NO. N-357615 - JULY 11, 1995 PLUMBERS CERTIFICATION DATED NOV. 14, 1995- Robert Van Etten Plumbing (14 Building Inspector Rev. 1/81 FORM NOA 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) Date MARCH.. 30 r.. 19... 95... N°_ 22648 Z Permission Is hereby granted to: R & R HONE IMPROVEMENTS & BLDG INC - A/C LASKOS, L. P.O. BOX 676 . GREENPORT, NY 11944 CONSTRUCT A FOUNDATION UNDER EXISTING ONE„FAMILY DWELLING,TO,CQ,,,,,, to.... APPLIED FOR. NOTE: PERMITS REQUIRED FOR ANY ADDITIONAL WORK. DEC - RE 1-4738-01074/00001-0 at premises located at 55915 COUNTY ROAD 48 .......................GR&ENPORT „.,,,.„.,,,,NY County Tax Map No. 1000 Section .........44............ Block Lot No. 17 pursuant to application dated rARCH 10• 19...95........, and approved by the Building Inspector. Fee i..~• Building inspector Rev. 6/30/80 Form No. 6 ti re TOWN OF SOUTHOLD - BUILDING DEPARTMENT TOWN HALL', JUL 19 1995 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. 1. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic features. 2. A properly completed application and a consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dwelling $25.00, 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 - $20.00 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 i Date 19 1.9. 9, New Construction........... Old Or Pre-existing Building....... / Location of Property. 9 S.S y .4 c ..............®df°,.............. House No. Street Hamlet Onwer or Owners of Property... L!~.z~OS, S County Tax Map No 1000, Section.... Block Lot.... Q Subdivision ....................................Filed Map............ Lot...................... qq i Permit No. NO y 8. ...Date Of Permit.....Applicant Health Dept. Approval ..........................Underwriters Approval......................... Planning Board Approval Request for: Temporary Certificate........... Final Certicate........... Fee Submitted: at ('3X_50'yr) ..'.'j e JV Hof 10N APPLICANT Town Hall, 53095 Main Road Fax (516) 765-1823 U> Telephone (516) 765-1802 P. O. Box 1179 '5 Southold, New York 11971 r. 3 µ;r OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD C E R T I F I C A T I O N DATE: Building Permit No. Owner: L,4rry 1ASK6;s (please print) Plumber: R06e.r! 4w'Fae2>^/ ,s'oo 6' Zo (please print) - c, c}. I certify that the solder used in the water supply system - rdontains less than 2/10 of 1% lead. (Plumbers Signature) Sworn to before me this /4/' day of ~e~rtiC 19 g~ Notary Public Count HELENE D. (Votary Public, State of Ne iy York OU911f1d oin Suffolk County Commission Expires May 22, 1 ~ 63 S Ik ~I Uhl~1 1 I 3 N pp o N C p ~ e rl ~ LL Y ~ T C _ ~ W V ate, a ~ X i o ~ 'V W h 01 .C 1Y ~ [ w FNYWWI 7 T r 4 b = ~ 7~LL ~ ~ Ln y U Q x 5.0 W z C m w ~N= w g r 99 v W ~w d .y Z Y I V 0. 0 q t C w r E w W M .g m ~ z ~ v z Q w x 3 0 - y g Q 1C m r .y ~ x x 'G a ~ d„ z ~ a W }O ° V 6t:Uw~ gE g ?i 30 „ <L Z " LL. W o u x Y ® J o ti c a = a d w r ° 3 w o p ° 3 z H a Qz oWW ~o as N= ~w c o m z mN C e 4 N Z a x E ' tl O ^ q~ W f U m 00 Ole FCl) i s N Crw~J n o W a ti i n CJ Z 3 z m u ° tea n u 0.5 W O r d m ~ ~ w $f ~a o d ~ ~o v "Z a= q e < d s a; a o Y c k V W 2, QI [x w ul 3 a i~ r~ c~ ul [ v v t~ ~ °1 yyy W $ t L to 16 C W Ol Q V ~ ti b ~p W Y V ~ "t .-i U) h. rN~ •4 yy ~ ~ alit ~ w ~ o~OgOFFO(kCo o~ Gym y 2 Town Hall, 53095 Main Road p • Fax (516) 765-1823 y~Ip~ ~aO~ Telephone (516) 765-1802 P. 0. Box Southold, Now York 9 11971 soulh OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD November 3, 1995 R & R Home Improvement & Bldg. P.O. Box 676 Greenport, NY 11944 Re: Larry Laskos - SCTM#1000-44-1-17 Prem: 55915 CR #48, Greenport NY To Whom This May Concern: We are unable to complete your Certificate of Occupancy because of the following reasons: An application for Certificate of Occupancy is not on file. (Enclosed) xx No Underwriters Certificate on file. The check is (outdated/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 # 22648-Z Please contact our office on this matter. Thank you for cooperation. SOUTHOLD TOWN 'BUILDING DEPT. NEW-`/ORK STATE DEPARTMENT OF ENVIRONMENTAL COMSEPL'kTION DEC PERMIT NUMBER EFFECTIVE DATE FAC ) ILITY/PR44/OGRAM NUMBER(S) PE IT EXPIRATION DAT~ under the E)ar(rmmentaL February 29, 1996 Conservation Law TYPE OF PERMIT ¦ Now It Renewal 0 Modification 0 Permit to Construct 0 Permit to Operate 0 Article 15, Title 5: Protection 0 6MYCRR 608: Water Quality 0 Article 27, Title 7; 6NYCRR 360: of Waters Certification Solid Waste Management 0 Article 15, Title 15: Water 0 Article 17, Titles 7, 8: SPDES 0 Article 27, Title 9; 6NYCRR 373: Supply Hazardous Waste Management 0 Article 19: Air Pollution 0 Article 15, Title 15: Water Control 0 Article 34: Coastal Erosion Transport Management 0 Article 23, Title 27: Mined Lard 0 Article 15, Title 15: Long Reclamation 0 Article 36: Floodplain Island Wells Management 0 Article 24: Freshwater Wetlands 0 Article 15, Title 27: Wild, 0 Articles 1, 3, 17, 19, 27, 37; Scenic and Recreational Rivers ¦ Article 25: Tidal Wetlands 6NYCRR 380: Radiation Control 0 Other: PERMIT ISSUED TO TELEPHONE NUMBER Lazaros E. Laskos (201) 224-5446 ADDRESS OF PERMITTEE 1026 Inwood Terrace Fort Lee NJ 07024 CONTACT PERSON FOR PERMITTED WORK TELEPHONE NUMBER Same as Permittee NAME AND ADDRESS OF PROJECT/FACILITY Laskos Property 55915 Count Road 48, Southold NY LOCATION OF PROJECT/FACILITY SCTM 01000-44-1-17 COUNTY TOWN WATERCOURSE MYTH COORDINATES Suffolk Southold Long Island Sound Temporarily relocate existing single family dwelling to east to provide new pile substructure. Upon completion of piling work, relocate dwelling back to original Location. Construct 45 Linear foot bulkhead with approximate 81 angled armored return an west side. Construct approximate 451 return along west line of property. Place approximately 162 cubic yards of clean fill. Remaining concrete foundation to be broken up and placed under final house Location. Relocate septic system. All work shall be in accordance with plans stamped NYSDEC approved. By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, the General Conditions specified (see page 2) and wrl Special Conditions included as part of this permit. REGIONAL PERMIT ADMINISTRATOR: ADDRESS Robert A. Greene Bldg. 40, SONY, Room 219, Stain Brook, NY 11790-2356 AUTNORlZED SIGNATURE DATE February 10, 1995 TPage 1 of 5 Gl3JElV . OD\DITICM Inspections 1. The permitted site or facility, including relevant records, is subject to in- spection at reasonable hours and intervals by an authorized representative of the Department of Erwirormental Conservation (the Department) to determine vftther the permittee is carp iy1ng with this permit and the ECL. Such represen- tative Tray order the v%ork suspended pursuant to ECL 71-0301 and SARA 401(3). copy of this permit, including all referenced maps, draivings and special conditions, crust be available for inspection by the Department at all times at the project site. Failure to produce a copy of the permit upon request by a Departrmnt representative is a violation of this permit. Pe rrni t Changes and I l engine I s 2. The Department reserves the right to modify, suspend or revoke this permit when: a) the scope of the permitted activity is exceeded or a violation of any condition of the permit or provisions of the ECL and pertinent regula- tions is found; b) the permit wes obtained by misrepresentation or failure to disclose relevant facts; c) new material information is discovered; or d) environrental conditions, relevant technology, or applicable law or regulation have rreterially changed since the permit was issued. 3. The permittee must submit a separate written application to the Department for renenel, modification or transfer of this permit. Such application rrust include any fomrs, fees or supplarrantal information the Department requires. Any renem 1, rralification or transfer granted by the Department must be in writing. 4. The permittee mist submit a renenel application at least: a) 180 days before expiration of permits for State Pollutant Discharge Elimination System (SFDES), Hazardous V%bste Nbnagement Facilities (INWF), rrajor Air Pollution Control (APC) and Sol idytste Nbnagerent Facilities (W); and b) 30 days before expiration of all other permit types. 5. Unless expressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or determination perviously issued by the Department or any of the terns, conditions or requirements contained in such order or determination. Other Legal Cbligations of Permittee 6. The permittee has accepted expressly, by the execution of the application, the full legal responsibility for all damages, direct or indirect, of whatever nature and by Wwmver suffered, arising out of the project described in this permit and has agreed to indem ify and save harmless the State from suits, actions, damages and costs of every name and description resulting from this project. 7. This permit does not convey to the permittee any right to trespass upon the lards or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the permit. 8. The permittee is responsible for obtaining any other permits, approvals, lards, easements and rights-of-wey that may be required for this project. Page 20f5 .s 95-20.6a(7/92)-25c Tidal Wetland ) ADDITIONAL GENERAL CONDITIONS FOR ARTICLES 15 (Title 5), 24, 25, 34 and 6 NYCRR Part 608 ( 9. That if future operations by the State of New York require an al- other environmentally deleterious materials associated with the teration in the position of the structure or work herein authorized, or project. if, in the opinion of the Department of Environmental Conservation 13 Any material dredged in the prosecution of the work herein permitted it shall cause unreasonable obstruction to the free navigation of said shall be removed evenly, without leaving large refuse piles, ridges across waters or flood flows or endanger the health, safety or welfare of the bed of a waterway or floodplain or deep holes that may have a the people of the State, or cause loss or destruction of the natural tendency to cause damage to navigable channels or to the banks of resources of the State, the owner may be ordered by the Department to a waterway. remove or alter the structural work, obstructions, or hazards caused 14. There shall be no unreasonable interference with navigation by the work thereby without expense to the State, and if, upon the expiration or herein authorized. revocation of this permit, the structure, fill, excavation, or other modification of the watercourse hereby authorized shall not be com- 15 If upon the expiration or revocation of this permit, the project hereby pleted, the owners, shall, without expense to the State, and to such authorized has not been completed, the applicant shall, without expense extent and in such time and manner as the Department of Environmental to the State, and to such extent and in such time and manner as the Conservation may require, remove all or any portion of the uncompleted Department of Environmental Conservation may require, remove all or structure or fill and restore to its former condition the navigable any portion of the uncompleted structure or fill and restore the site and flood capacity of the watercourse. No claim shall be made against to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. the State of New York on account of any such removal or alteration. 10 That the State of New York shall in no case be liable for any damage 16 If granted under 6 NYCRR Part 608, the NYS Department of Environ- or injury to the structure or work herein authorized which may be caused mental Conservation hereby certifies that the subject project will not by or result from future operations undertaken by the State for the contravene effluent limitations or other limitations or standards under conservation or improvement of navigation, or for other purposes, and Sections 301, 302, 303, 306 and 307 of the Clean Water Act of 1977 no claim or right to compensation shall accrue from any such damage. (PL 95-217) provided that all of the conditions listed herein are met. 11. Granting of this permit does not relieve the applicant of the responsi- 17 All activities authorized by this permit must be in strict conformance bility of obtaining any other permission, consent or approval from with the approved plans submitted by the applicant or his agent as part the U S. Army Corps of Engineers, U.S. Coast Guard, New York State of the permit application. Stamped Office of General Services or local government which may be required. Such approved plans were prepared by 12 All necessary precautions shall be taken to preclude contamination NYSDEC Approved on 2/ 10/95 of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any refer to Special Condition #12 SPECIAL CONDITIONS 1. Any debris or excess material from construction of this project shall be completely removed from the adjacent area (upland) and removed to an approved upland area for disposal. No debris is permitted in tidal wetlands and or protected buffer areas. 2. The storage of construction equipment and materials shall be confined to within the project work site and or upland areas greater than 50 linear feet-from the tidal wetland boundary. 3. All fill shall consist of "clean" gravel and soil (not asphalt, slag, flyash, broken concrete or demolition debris). 4. No excavation of the beach is authorized for the purpose of obtaining fill or stone materials. 5. All peripheral berms, cofferdams, rock revetments, seawalls, gabions, bulkheads etc. Shall be completed prior to placement of any fill material behind such structures. 6. Equipment operation below apparent high water is strictly prohibited. DEC PERMIT NUMBER 1-4738-01074/00001-0 PROGRAMIFACILITYNUMBER Page 3 Of 5 ,rim, MN5.20-bfr(7107)-25c NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION SPECIAL CONDITIONS 25 Tidal Wetland For Article 7. Prior to any construction or removal of bulkheads and other shoreline stabilization structures all backfill shall be excavated landward of the bulkhead and retained so as not to enter the waterway, tidal wetland or protected buffer area. 8. There shall be no discharge. of runoff or other effluent over or through any bulkhead or shoreline stabilization structure or into any tidal wetland or adjacent area. 9. Broken concrete foundation to be temporarily stored in an upland location not exposed to tidal action. 10. Armor stone shall be a minimum of one ton. 11. Sanitary system (bottom of tank and leaching pools) shall be located a minimum of 2' above seasonal high groundwater. 12. A cross-section of the sanitary system, including test hole data, must be submitted to the Bureau of Marine Habitat Protection, attention Lou Chiarella, for approval prior to installation. Plan must meet Suffolk County Health Department standards. Supplementary Special Conditions (A) through (F) attached DEC PERMIT NUMBER 1-4738-01074/00001-0 FACILITY ID NUMBER PROGRAM NUMBER Page 4 of 5 M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] 1 ULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: ,a ( /ba~uadwarf - 4csN4-Ay /i6tSft~ 612d O~rJ n DATE INSPECTO FIELD INSPECTION REPORT _ IIDATE II =a..- -ssss= COMMENTS_ _ ~ II I ° FOUNDATION _(IST) II II I II II II II M FOUNDATION (2ND) =y=====--------------------------- - I II 4 z ROUGH FRAME & PLUMBING it ii u I - ii ii y 11 it INSULATION PER N. Y. STATE ENERGY II ii CODE II II e=essssaassxxaxaaaeaaas_aa=xaxaaa#% II ssa sxax=vsass ssx aaaxa 4-. II t+: V•~ II H I II I II II FINAL I II aasssx=_sssssssssassa=s=sse_sss$sses$sssxessaassss ADDITION COMMENTS: y~`rZ~C r -440 H i H ` 10 x rda ro H BLDG. DEP 1 g TO /N OF SOUTHOLD -1 'all 6. w 3 0 ~ Ali ~ a~ t9 s r ~ m ~Opy `G~~y 4 s'~ a n st~~M 7 r a 41, ~ z r me,,iH ~ r L 1 M,C3b,&51~? , ~ r l' New York State Department of Environmental Conse ( 0 Building 40-SONY, Stony Brook, New York 11790-2356 Telephone (516) 444-0365 1 419 IUI Facsimile (516) 444-0373 t angdon Marsh Commissioner February 10, 1995 Mr. Lazarous E. Laskos, 1026 Inwood Terrace 66 Igg) Fort Lee, NJ 07024 ~L G[` DEP1~ f N OF so~mt O r RE: 1-4738-01074/00001-0 Dear Permittee: In conformance with the requirements of the State Uniform Procedures Act (Article 70, ECL) and its implementing regulations (6NYCRR, Part 621) we are enclosing your permit. Please read all conditions carefully. If you are unable to comply with any conditions, please contact us at the above address. Also enclosed is a permit sign which is to be conspicuously posted at the project site and protected from the weather. Very truly yours, Marga t M. Rorke EnCon Program Aide MMR:cg enclosure C''J printed an recycled paper E _ PLEMENTARY SPECIAL CONDIT VS The following conditions apply to all Tidal Wetlands; Freshwater Wetlands; Coastal Erosion Management; and wild, scenic, and Recreational Rivers Permits: A. A copy of this permit, including all, conditions and approved plans, shall be available at the project site whenever authorized work is in progress. The permit sign enclosed with the permit shall be protected from the weather and posted in a conspicuous location at the work site until all authorized work has been completed. B. The permittee shall require that any contractor, project engineer, or other person responsible for the overall supervision of this project reads, understands, and complies with this permit and all its general, special, and supplementary special conditions. Any failure to comply precisely with all of the terms and conditions of this permit, unless authorized in writing, shall be treated as a violation of the Environmental Conservation Law. If any of the permit conditions are unclear, the permittee shall contact the Division of Regulatory Affairs at the address on page one or telephone (516) 444-0365. C. If project design modifications become necessary after permit issuance, the permittee shall submit the appropriate plan changes for approval by the Regional Permit Administrator prior to undertaking any such modifications. The permittee is advised that substantial modification may require submission of a new application for permit. D. At least 48 hours prior to commencement of the project, the permittee and contractor shall sign and return the top portion of the enclosed notification form certifying that they are fully aware of and understand all terms and conditions of this permit. Within 30 days of completion of the permitted work, the bottom portion of that form shall also be signed and returned, along with photographs of the completed work and, if required, a survey. E. For projects involving activities to be undertaken in phases over a period of more than one year, the permittee shall notify the Regional Permit Administrator in writing at least 48 hours prior to, recommencing work in subsequent years. F. The granting of this permit does not relieve the permittee of the responsibility of obtaining a grant, easement, or other necessary approval from the Division of Land Utilization, Office of General Services, Tower Building, Empire State Plaza, Albany, NY 12242 (516) 474-2195, which may be required for any encroachment upon State-owned lands underwater. DEC Permit No. 1-4738-01074/00001-0 Page 5 of 5 S• 1'65-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] 1 ULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY 4 REMARKS: r z /,//0. tl ..rryy ~ ~ueOwuP Q N/~l~a r /4nog 01040 rDLd , OF7 dv/PJ K C®1cQ 7 . DATE INSPECTO BOARD OF HEALTH MAR 1 01995 h .J FORM NO.1 3 SETS OF PLANS L TOWN OF S011THOLp SURVEY M,.. , iti Ctlr^. t: G . t3LCG. OUT NNO_FSOJTHOLD_ FIA L _ SEPTIC FORM SOUTHOLD, N.Y. 11971 TEL.: 765.1802 r:oTlFV; r~ CALL Examined 4?.~............. , 19% MAIL TO: - Approved ..~~.7 9......, 19 ~s ? Permit No..~a !..0 Disapproved. a/c N - (B iltf ding Spector) APPLICATION FOR BUILDING PERMIT Date ..R~'GY1...7.., 19`757 INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 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 stieet, 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 permi 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 Occupanc} 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 of 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 tc admit authorized inspectors on premises and in building for necessary inssp,Iections. (Signature of applicant, or name, if a corporatiio.o e.1.:.ea. ~ L72~e~v~aoYG~ at (Mailing address Wapplicant) 119Ny State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. /fJ,iIOEl2 Name of owner of premises I F-./r} ~.J..q. q S , , , , , , , , , , , , (as on the tax roll or latest deed) If applicant is ccorporaW n t re of duly authoriied officer. (Name d title of corporate 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 . . . ~ oU. J, . ~1~1..........C!rQeN P.©.r- House Number S eet Hamlet County Tax Map No. 1000 Section . . Block Lot Subdivision Filed Map No. Lot............... (Name) , 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy . . b. Intended use and occupancy ......Z . L?........ K!Ct . 3. Nature of work (check which applicable): New Building Addition Alteration Repair Removal . ' Demolition , .Other Work ,W'.ayr, 4. Estimated ( 1dj co (Description) Fee (to be paid on filing this application) , • • • , . • 5. If garage, dwelling, number ofdwelling units r..L , Number of dwelling units on each floor If number of cars 6. If business, commercial or mixed occupancy, specify nature and extent of.each type of use ^ . , . , , , , , , , 7. Dimensions of existing structur4s, if any: Front Rear. Depth . Height Number of Stories . Dimensions of same structure with alterations or additions: Front Rear . Depth . Height . . . . . . : . . Number of Stories . 8. Dimensions of entire new construction: Front . . Rear Depth . Height Number of Stories . 9. Size of lot: Front I Rear... Depth . 10. Date of Purchase . l l.', -,4 . Name of Former Qw.. * 11. Zone or use district in which premises are situated ......,es t t)~.hrj wi ' 12. Does proposed construction violate any zoning law, ordinance or regulation: 11Y0.. . . 13. Will lot be regraded ....Vi", .I, , , , , , , , , , , , , , , , , Will excess fill re oved f in premises: Y s o 14. Name of Owner of premises L4 Arat l ti 5 KP 5... Address N•r Phone No... Name of Architect$.ittrw.P. ft.r o,w, y,,t; , , , , Address a?Z K1 ¢~p`j,, Phone No..4.17 0 Name of Contractor ~'S .R. ! , . , AddressR. ~G7 ki. E/.4? , Phone No...y T7, ; l z5`S 15. Is this property within 300 feet of a tidal wetland? *yes..... No.. *If yes, Southold Town Trustees Permit maybe 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. I • I ' STATE OF NEW Y RK, COUNTY OF. • , being duly sworn, deposes and says that he is the applicant ..........rvidual signing (Name of nd' g contract) above named. je is the . (Contractor, agent, corporate officer, etc.) if said owner or owners, and is duly authorized 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 sit forth in the application filed therewith. ;worn to before me this ..day of JotaryPublic,~~ y~Y~ounty HELENE D. HORNE Notary Public, State of N~}wYork No. 4951354 (Signature of applicant) Qualified in Suffolk•County /5 Commission Expires PAav 27, 19.,Z_..~ I