HomeMy WebLinkAbout22962-z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-24420 Date JUNE 11, 1996
THIS CERTIFIES that the building FOUNDATION
Location of Property 145 MACDONALD ROAD LAUREL NY
House No. Street Hamlet
County Tax Map No. 1000 Section 128 Block 6 Lot 17
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 8, 1995 pursuant to which
Building Permit No. 22962-Z dated AUGUST 22, 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 A NEW FOUNDATION UNDER AN EXISTING ONE FAMILY DWELLING AS
APPLIED FOR.
The certificate is issued to MARILYN & ARTUDR L. SMITH JR.
(owner's)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N/A
PLUMBERS CERTIFICATION DATED N/A
zza-�� � Y
uil ing Inspector
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) Q('/
Date .............`�...`..`., .... s ............. 19.1..."...
NG 22962 Z
Permission Is hereby granted to:
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to.............. . ........... . .. ..... ..�-nQ�crc ,z6� G .. ... .....
..
.... . 6Q . .a.... ,.......... .. .... .... ......... .
.. ....... .. ... . .... . .. ..... ..........
....... .. ............-/-l................................
......... . ..., Alec—
..........................................
Q -
at premises located at.................. /.T.. ..... .GS Com..._.
..........................................I..................– ...... /..................................../......1.ry............
County Tax Map No. 1000 Section .....zek.PP.. Block
........4,44F-.....4.e.�.... Lot No. .....1....1...............
pursuant to applicatlon dated .................C�. .....ca ........... 19....9. and approved by the
Building Inspector.
Fee$....1.. .......
A o aG �
.................... 4 . . ? .,...
Building Inspector
Rev. 6/30/80
Form No. 6
i
TOWN OF SOUTHOI.D
BUILDING DEPARTMENT
TOWN HALL,
765-1.802
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 bui.l.ding 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 Pile Underwriters.
4. Sworn statement from plumber certifying that the solder used in system contains
less than 2/1.0 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.
0. Submit Planning Board Approval of completed site plan requirements.
B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and
"pre-existing" land uses:
1 . Accurate survey of property showing all property lines, streets, building and
unusual. natural or topographic Features.
2. A properly completed application and a consent to ,inspect: signed by the applicant.
If a Certificate of Occupancy is denied, the Building Inspector shall. state the
reasons therefor in writing to the applicant.
C. Fees
1 . Certificate of. Occupancy - New dwelling $25.00, 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 P,uildine - $100.00
3. Copy of Certificate of Occupancy - $20.00
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of. Occupancy - Residential $1.5.00, Commercial $.15.00
Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
New Constr.uction. . . . . . . . . . . Old Or Pre-existing Building./,�. . . . . . . . . . . . .
Location of Property. . kys /�c�cNrl�l�. . q ,4�'nGr'h,�.e�c1 , . . . . . .
. . . . . . . . . . . . . . . . . . . .
House No. Street Hamlet
Onwer or Owners of Property. . . . . . . . . . . . . . . . . . . .�''. . . . . . . . . . . .•. . . . . . . . . . . . . . . . . . . .
County Tax Map No 1.000, Section. . . . . . . .Block. . . . . . . . . . . .Lot. .pN 7
. . . . . . . . . . . . . . .
F�G�td z /f9rzk tiled Ma '7y1— •Zt3 /KCL
Subdivision. .-. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .p. . . . . . . . . . . .Let. . . . . . . . . . . . . . . . . . . . .
r7C L 2i SS I rync �/c2oc FC z
Permit No. . . . . . . . . . . . . . .Date Of Permit. . / . . . Applicant . . . . . !/. . . . . . !` . .� .'. ok�
HealthDept. Approval. . . . . . . . . . . . . . . . . . . . . . . . . .Underwr:iters Approval . . . . . . . . . . . . . . . . . . . . . . . . .
Planning Board Approval . . . . . . . . . . . . . . . . . . . . . . . .
Request for: Temporary Certificate. . . . . . . . . . . Final. Certi.cate. . . . . . . . . . .
Fee ,Submitted: $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . .
L ey t, t1 r1 APPLl • T
O.M.B. NO. 3067007,
ELEVATION CERTIFICATE Expires May 31, 199,
FEDERAL EMERGENCY MANAGEMENT AGENCY
NATIONAL FLOOD INSURANCE PROGRAM
ATTENTION: Use of this certificate does not provide a waiver of the flood insurance purchase requirement. This form is used only to
provide elevation information necessary to ensure compliance with applicable community floodplain management ordinances, to
determine the proper insurance premium rate, and/or to support a request for a Letter of Map Amendment or Revision (LOMA or LOMR)
Instructions for completing this form can be found on the following pages.
SECTION A PROPERTY INFORMATION FOR INSURANCE COMPANY USE
BLMMNC,OWNER'S NAME POLICY NUMBER
Arthur L. Smith, Jr.------ ---- -------------------
S1 FEET ADDRESS Ilnc uding Apt.,Unit,Suite and or Bldg.Number)OR P.O.ROUTE AND BOX NUMBER COMPANY MAIC NUMBER
Mc Donald Road
OTHER DESCRIPTION,Lol and Block Numbers,etc.)
S.C.T.M. No. : 1000-128-6-17
CITY STATE ZIP CODE
Laurel New York 1194.8
SECTION B FLOOD INSURANCE RATE MAP(FIRM) INFORMATION
Provide the following from the proper FIRM (See Instructions):
COMMUNITY NUMBER 2 PANEL NUMBER 3 SUFFIX 4.DATE OF FIRM INDEX 5 FIRM ZONE 6 BASE FLOOD ELEVATION
pn AO Zones use depth)
360813 D118 C June 15, 1983 A4 8
7 Indicate the elevation datum system used on the FIRM for Base Flood Elevations (BFE): NGVD'29 .Other(describe on back)
8 For Zones A or V, where no 8=E is provided on the FIRM, and the community has established a BFE for this building site, indicate
the community's BFE: I feel NGVD (or other FIRM datum-see Section B, Item 7),
SECTION C BUILDING ELEVATION INFORMATION
1. Using the Elevation Certificate Instructions, indicate the diagram number from the diagrams found on Pages 5 and 6 that best
describes the subject building's reference level-B_ .
2(a). FIRM Zones Al-A30. AE, AH, and A (with BFE). The top of the reference level floor from the selected diagram is at an elevation
of - 9 7 feet NGVD (or other FIRM datum-see Section B, Item 7).
(b). FIRM Zones V1-V30, VE, and V (with BFE). The bottom of the lowest horizontal structural member of the reference level from
the selected diagram, is at an elevation of 1 11-1_J.I-.J feet NGVD (or other FIRM datum-see Section B, Item 7).
c). FIRM Zone A (without BFEI. The floor used as the reference level from the selected diagram isI feet above I or
below (check one) the highest grade adjacent to the building.
(d). FIRM Zone AO. The floor used as the reference level from the selected diagram is l_ L J. feet above I I or below I (check
one) the highest grade adjacent to the building. If no flood depth number is available, is the building's lowest floor (reference
level) elevated in accordance with the community's floodplain management ordinance? i Yes No Unknown
3. Indicate the elevation datum system used in determining the above reference level elevations:K NGVD'29 -.. Other(describe
under Comments on Page 2). (NOTE: If the elevation datum used in measuring the elevations is different than that used on
the FIRM rsee Section B, Item 71, then convert the elevations to the datum system used on the FIRM and show the conversion
equation under Comments on Page 2.)
4. Elevation reference mark used appears on FIRM: Yes X_' No (See Instructions on Page 4)
5 The reference level elevation is based on: X-1 actual construction L construction drawings
(NOTE: Use of construction drawings is only valid if the building does not yet have the reference level floor in place, in which
case this certificate will only be valid for the building during the course of construction. A post-construction Elevation Certificate
will be required once construction is complete.)
6 The elevation of the lowest grade immediately adjacent to the building is:LA-1___L51.2_1 feet NGVD (or other FIRM datum-see
Section B, Item 7).
SECTION D COMMUNITY INFORMATION
1 If the community official responsible for 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 building's"lowest
floor"as defined by the ordinance Is: i I-L 1A.Li feet NGVD (or other FIRM datum-see Section B, Item 7).
2. Date of the start of construction or substantial improvement
FEMA Form 81-3),MAY 93 REPLACES Ail PREVIOUS EDITIONS SEE REVERSE SIDE FOR CONTINUATION
i
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 elevatio
information when the elevation information for Zones At—A30, AE, AH,A (with BFE),Vi—V30,VE, and V (with BFE) is required.
Community officials who are authorized by local law or ordinance to provide floodplain management information, may also sign th
certification. In the case of Zones AO and A (without a FEMA or community issued BFE), a building official, a property owner, or
owner's representative may also sign the certification.
Reference level diagrams 6, 7 and 8 - Distinguishing Features—If the certifier is unable to certify to breakaway,/non-breakaway wal
enclosure size, location of servicing equipment, area use,wall openings,or unfinished area Feature(s), then list the Feature(s) no
included in the certification under Comments below. The diagram number, Section C, Item 1, must still be entered.
I certify that the information in Sections B and C on this certificate represents my best efforts to interpret the data available.
understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001.
CER T IFIER'S NAME LICENSE NUMBER for Affix Seal)
Kenneth F. Abruzzo 49999
------ ------------ ------ ---- -----
T ITLE COMPANY NAME
Land Surveyor Young—& Young
ADDRESS CITY STATE
400 Ostrander Avenue Riverhead, New York 11901
SIGNATURE /� �p DATE PHONE
�>sutt. ztq 0Af991/gg (516) 727.-2303
Copies should be made of this Certificate for: 1)community official, 2) insurance agent/company, and 3) building owner.
COMMENTS:
ON WITH ON PILES,
SLAB BASEMENT PIERS,OR COLUMNS
A V A A V
ZONES ZONES ZONES ZONES ZONES
HEf ERENCE
DJ�CE
GEiLHENCF BASE LEVEL RECEFEN[F
I:VR ilk LP'Cl
EEETAiICW
BASE
BASE
clpVC AGRACEt REFERENCE i100
ELLv4 nON REFERENCE gDIpCENr GR0.DE LEVEL ELE'/At10N
E EVEL GRACE
GA
GRADEE
The diagrams above illustrate the points at which the elevations 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.
Elevations for all V Zones should be measured at the bottom of the lowest horizontal structural member.
Page 2
JUDITH T. TERRY Town Hall. 53095 Main Road
n = °;"' P.O. Box 1179
TOWN CLERK _ Southold, New York 11971
REGISTRAR OF VITAL SfATISTICs O� - Fax (516) 765-1823
MARRIAGE OFFICER �' yd Telephone (516) 765-1801
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION WAS ADOPTED BY THE
SOUTHOLD TOWN BOARD AT A REGULAR MEETING HELD ON AUGUST 24, 1993:
RESOLVED that the Town Board of the Town of Southold hereby adopts
two (2) new forms to be used under the Flood Damage Prevent regulations
of the Code of the Town of Southold: "Floodplain Development Permit
Application" [FDP(93) ] , and "Certificate of Compliance for Development in
Special Flood Hazard Area [C/C(93)] .
t_ _
IDs
TOWN OF SOUTHOLD
Audith T. Terry C/
Southold Town Clerk
August 25, 1993
APPLICATION #//
PAGE 1 of 4
TOWN OF SOUTHOLD
FLOODPLAIN DEVELOPMENT PERMIT APPLICATION
This form is to be filled out in duplicate.
SECTION 1: GENERAL PROVISIONS (APPLICANT to read and sim):
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
inspections required to verify compliance.
8. I,THE APPLICANT, CERTIFY THAT ALL STATEMENTS HEREIN AND IN ATTACHMENTS TO
THIS APPLICATION ARE,TO THE BEST OF MY KNOWLEDGE, TRUE AND ACCURA E.
(APPLICANTS SIGNATURE) DATE
SECTION 2: PROPOSED DEVELOPMENT (To be completed by APPLICANT)
NAME ADDRESS EPH E
APPLICANT
BUILDER
ENGINEER
PROJECT LOCATION:
To avoid delay in processing the application, please provide enough information to easily identify the project
location. Provide the street address, lot number or legal description (attach) and, outside urban areas, the
distance I"the nearest intersecting road or well-known landmark. A sketch attached to this application showing
the prId�ect location would be helpful.
FDP(93)
APPLICATION # 7
PAGE 2OF4
DESCRIPTION OF WORK (Check all applicable boxes):
A. STRUCTURAL DEVELOPMENT
ACTIVITY STRUCTURE TYPE
❑ New Structure ❑ Residential (1-4 Family)
❑ Addition ❑ Residential (More than 4 Family)
Alteration ❑ Non-residential (Floodproofing? ❑ Yes)
❑ Relocation ❑ Combined Use (Residential & Commercial)
❑ Demolition ❑ Manufactured (Mobile) Home (In Manu-
❑ Replacement factured Home Park? ❑ Yes)
ESTIMATED COST OF PROJECT $
B. OTHER DEVELOPMENT ACTIVITIES:
❑ Fill ❑ Mining ❑ Drilling ❑ 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)
❑ Individual Water or Sewer System
❑ 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. //C6 • Dated } —�
The Proposed Development:
❑ 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 Te site is: $� Ft. NGVD (MSL)
❑ Unavailable
❑ The proposed development is located in a floodway.
FBFM Panel No. Dated
❑ See Section 4 for addition • tructions.
SIGNED ✓ DATE
j 1
APPLICATION # �7�f
PAGE 3 OF 4
SECTION 4:ADDITIONAL INFORMATION REQUIRED (To be completed by LOCAL ADMINISTRATOR),
The applicant must submit the documents checked below before the application can be processed:
❑A site plan showing the location of all existing structures, water bodies, adjacent roads,lot
dimensions and proposed development.
*evelopment pians,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 utilities located below
the fust floor and details of enclosures below the fust floor.
Also,
❑Subdivision or other development plans (If the subdivision or other development exceeds 50
lots or 5 acres, whichever is the lesser,the applicant must provide 100-year flood elevations
if they are not otherwise available).
❑Plans showing the extent of watercourse relocation and/or landform alterations.
❑ Top of new fill elevation Ft. NGVD (MSL).
❑ 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
calculations supporting this finding must also be submitted.
❑ Other:
SECTION 5: PERMIT DETERMINATION (To be completed by LOCAL ADMINISTRATOR)
I have determined that the proposed activity: A><s
B. ❑ Is not
in conformance with provisions of Local Law # lig, 19 1�3 The permit is issued subject to the conditions
attached to and made part of this permit
SIGNED__y i DATE yz��
If BOX A is checked. the Local Administrator may issue a Development Permit upon payment of designated
fee.
If BOX B is BOX B is chocks ed, 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 #/7
PAGE 4 OF 4
APPEALS: Appealed to Board of Appeals? ❑ Yes ❑ No
Hearing date:
Appeals Board Decision --- Approved? ❑ Yes ❑ No
Conditions
SECTION 6: AS-BUILT ELEVATIONS (To be submitted by APPLICANT before Certificate of Compliance
is issued)
The following information must be provided for project structures. This section must be completed by a
registered professional engineer or a licensed land surveyor (or attach a certification to this application).
Complete 1 or 2 below.
1. Actual (As-Built) Elevation of the top of the lowest floor, including basement (in Coastal High Hazard
Areas, bottom of lowest structural member of the lowest floor, excluding piling and columns) is:
�i /SFT. NGVD (MSL).
2 Actual (As-Built) Elevation of floodproofmg protection is - FI'. 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 com len ted 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 S BY DEFICIENCIES? ❑ YES ❑r70 �L Crk�rF •t
DATE 7. i BY DEFICIENCIES? ❑ YES ❑ NO�
DATE/qi_ BY DEFICIENCIES? ❑ YES ❑ NO
SECTION 8: CERTIFICATF OF COMPLIANCE(To be com2letedLOCAL ADMIN) TRAT R
Certificate of Compliance issued: DATE: //AP,6 BY:
Attachment B
SAMPLE
CERTIFICATE OF COMPLIANCE
for Development in a Special Flood Hazard Area
• S
TOWN OF SOUTHOLD
CERTIFICATE OF COMPLIANCE
FOR DEVELOPMENT IN A SPECIAL FLOOD HAZARD AREA
(OWNER MUST RETAIN THIS CERTIFICATE)
PREMISES LOCATED AT: PERMIT NO. /7 F
PERMIT DATE ��-
OWNERS NAME AND ADDRESS: CHECK ONE:
11 NEW BUILDING
,'EXISTING BUILDING
Q VACANT LAND
THE LOCAL ADMINISTRATOR IS TO COMPLETE A. OR B. BELOW:
A. COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF
LOCAL LAW # ,6-, 195t.
SIGNED: , 62 DATED':`/
B. COMPLIANCE IS HEREBY CERTIFIED WITH/ THE REQUIREMENTS OF
LOCAL LAW # , 19_, AS MODIFIED BY VARIANCE #
DATED
SIGNED: DATED:
CIC(93)
� + T
FIELD INSPECTION REPORT DATEF COMMENTS
_________________________ -- ----- = -,, ----=____________________________________________= ro
it
FOUNDATION ( IST) I{-- -- ,
----- ---------- ----
{1---- ------ ---- -
------------------------
FOUNDATION (2ND) II
- ------ ------------
I 11
i
�I II
ROUGH FRAME 6
PLUMBING II ii
------it
I jj 1
�I------it
INSULATION PER N. Y. II----------i- -------- -------- y
STATE ENERGY
CODE I
N it
----------
n-- .---------------- ------------ --------------
�I
ii
u -------------
ii----- --„--/ - - --- --- -- - - --- ---
FINAL
_-_____________ ^^ = O
ADDITIONAL COMMENTS:
H
--------------------
O
x -
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13
FORM No.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
No. Date . . . . . . . . May . 2.g.. . . . . . . . . . . . . . . .. 1981 .
THIS CERTIFIES that the building . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Location of Property . . . 145 Edgemere Avenue ( Pvt... .Rd , . .Y
) La�re1.,. .New. ork
. . .
!louStreet No. � � � � � � ..treet Hamlet
County Tax Map No. 1000 Section . . . 1 28 . . . . .Block . . . . . . 04 . . . . . .Lot . . . . . . . 17. . . . . . .
Subdivision . . .Edgemere. .eark . . . . . . . . . . . .Filed Map No. 7.42. . . . .Lot No. . . .P./.0. 2. .& . 3Inc1 .
conforms substantially to the Application for Building Permit heretofore filed in this office dated
. . . . , . NP,vq b?? . 12. , 19 .aQ pursuant to which Building Permit No. . . . . . .109.7.1. .Z. . . . . . .
dated . . Noxemb.e.r . 17. , , , , , , , , , , , , 19 .8.0 , was issued, and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is . . . . . . . . .
Addition, to , Dwe,llinl; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The certificate is IssuedtD . . . . . Ar.thur. .L . . a.nd'4Mar.ilyn. .S . . Smith.,. .Jr.. . . . . . . . . . . .
(owner,/Q*g gCti4ptid
of the aforesaid building.
Suffolk County Department of Health Approval . . . . .NSR. .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
UNDERWRITERS CERTIFICATE NO. . . . .P15200,OQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. ;7 . . . . . . . .
Building Inspector
Rev V79
'YK t.s ;
/ ,/S- /1-1/9c i)0 rysa cn Ro
Z'P7
F
FORM NO.6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N.Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted in duplicate to the Building Inspec-
tor with the following; for new buildings 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 of Health Dept. of water supply and sewerage disposal—(S-9 form or equal).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa-
tions, a certificate of Code compliance from the Architect or Engineer responsible for the building.
5. Submit Planning Board approval of completed site plan requirements where applicable.
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing"
land uses:
1. Accurate survey of peoperty showing all property lines, streets, buildings and unusual natural or
topographic features.
2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings.
3. Date of any housing code or safety inspection of buildings or premises, or other pertinent Informa-
tion required to prepare a certificate.
C. Fees:
1. Certificate of occupancy $5.00
2. Certificate of occupancy on pre-existing dwelling or land use $5.00
3. Copy of certificate of occupancy $1.00
Date . . flay. 20, . 1981 . . . . . . . . .
New Building . . . . . . . . . . . . . Old or Pre-existing Building . as . . . . . . . . . Vacant Land . . • . . . . . . . . . .
Location of Property . 1,45.Edgemere .Avebue,•'.LAur-eI0 • Ner+•Yo.rk • • • • • • . • • • • • • • • • • • . .
House No. ,Street Hamlet
Owner or Owners of Property Arthur. L. - and •Mavilyn• 3. • Smithv- Jr►• • • • • • • • . • • • • • • •
County Tax Map No. 1000 Section . 12,13 . . . . . . . . . . Block 06. . . . . . . . . . . . Lot .old. . . . . :. . . . . .
Edgemere Park . . . . . . . . . . . . . .Filed Map No. ? . . . . . . .Lot No.Fafitr4f. .3 Q . 2
Subdivision . . . . . . . . . . .: all of lot 3
Permit No. .109.7.1 . . . Date of Permit . .11•.12_Mpilcant .George •Ah3:era• Ptfilderj • Inc
Health Dept. Approval . . . . . . . . . . . . . . . . . . . . . . . .Labor Dept. Approval . . . . . . . . . . . . . . . . . . . . . . . .
Underwriters Approval . .. . . . . , . ,Planning Board Approval
. . . . . . . . . . . . . . . . . . . . . .
Request for Temporary Certificate . . . . . . . . . . . . . . . . . . . . .Final Certificate . X . . . . . . . . . . . . . . . . . . . .
Fee Submitted $5'00. . . . . . . . . . . . . . . . . . . . . . . . . M1
. ISI
Construction on above described building and p rmit meets^all pap licable codes and regulations. }
Applicant . . G'C L(,. /.. . . . . . . . . . . . . . . . . . . . . .
BuilBer, Inc.
Ge 7Gtleres ) I'
Rev. 10.1046
George Ahura, Pres. P
��z y
/- �Zr�•�r r.
f7 _( c
�( %q
L C .[ Cer(7i9rJr� d/774?" 7�cvn( �F
5<"c
-7 Ile- He-! PC fj�' ,SC:. ` 1,7ql
771�=fZ /'lSr.` �7 cec-s7'
Vy s'
%,?/. pct` %�iz,�:r7C % �'.� %7�i- �l�F%� �ji7i�� Trc��✓
t, /
c
(ice /?c47`"
1111 -r ��
:9-,"114
Smith Jr
Marlyn &Larry Smith P.O. Box 494Caxavn,CT 068!0-oLU
Laurel, NY 11948
a'%� �2 i•4 . Si 50
t
762,
M-1802
{ BUILDING DEPT.
INSPECTION
[ ] FOUNDATION IST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] IN ATION
[ ] FRAMING [ FINAL
( ]
FIREPLACE & CHIMNEY
REMARKS:
DATE INSPECTOR
70-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION IST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ l FRAMING [ INAL
[ ] FIREPLACE & CHIMNEY
REMARKS-s >C' e'' �
3 It
DATE ( T INSPECTOR
I
M-1802
BUILDING DEPT.
1 PECTI®N
[ ] UNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION 2ND [ INSULATION
[ ] FRAMIING ( ] FINAL
REMARKS„
DATE INSPECTO
yr Ilf.r,r. rlt . . .
FMIM MO. 1 ) SETS OF I'L.\N5 . . . . . .
IOWN 0F 'lot IILIO(_l) SIIItvCY . . . . . . . . . . . . . . .
13UIL01NI; DEP/VI ImLNF Cilr.ci: . . . . . . . . . . . . . . . .
w� 'fOWNI1AL1_ SEPFIC FOIll i . . . . . . . . . .
SOU iIlol.h, N.Y. 11971
I EI_.: 766 11302 iio'F I fly ;
y� C A 1.I. "Dl FaE_ 1-1.E20LL+. .
1'.xamincd . ps�y9 � 11A I L Toe Z88—SO�(q
2� `�'
Appurved . . . . ., 9 , � 1 ennil No. . . . . . . . . . . .
Disnpprovednlc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c
(Ilnilding hfspcclor)
TLICAFION i OH BUILDING PERMIT
iNSFRUCiIONS
n. This npl llcalloll most Ire conlpleiely filled in by typewriter or in ink and subolilted to Ilse Iluiiding hrspeefol, '
sols of plans, accolalp plot plan (o scale. Fee accoldbtg to schedule.
h. Plot plan showing 1puntloo of lot and of buildings on preolises, teialipnship to ndjohdng premises or public r
or atcas, and giving n detailed description of htyoltl of property must be dfmvn on Ilse diagram which is part of this
calion.
c,. The work covered by (his npplicntion intly not be commenced before issuance of fhrfldBlg Permit.
It. upon approval of (his nppllenllon, lite Iluiiding htspeclor will issued a lluilding Permit to life npplicnut. Such I
Shall be kepl on the prernises nvnilable rot inspection fhfooghoIll life work.
e. No booilding shall be occupied of used in whole or in pari for any purpose whatever milli n Cerlificale, of Oceu
shall hnve been granted by life 11trthling hrspeclor.
APPLICATION iS iILRITY i\lADE to the Building Deflnrinlent for lhe .issuance, of a Ilnilding Pernrii pursonol
Iluiiding Zone Ordinance of the Town of SoulhOld, Suffolk Counly, New York, "fill olher nppllcnble Laws,Onlinan
keglilalions, rot the cons(nfclion of buildings, nddilious or allcrafi')Ils, or for removal ell denlolifion, as herein desc•.
1 hc, applicant agrees to comply wlih all flpplienlile, laws, ordinances, building code, housing code, and regulations, r
adnlil aoolhotized inspectors on premises flood ill boildlI16 for necessary 6rs11eC
(Sigoalinc of applicant, or name, if a cocpatation
pox.f5w('. . Ov. 1Vol
7
(blailiug address of npplicani)
Slnle whelher applicmtl is owner, lessee, agent, afchilccl, engineer, general contrnclor, eleclrichm, plumber or bt
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nnntc of owner of pternises . P.r27LHUf{.. .!-. .1?JIrp. Y!�ARti Y.N. S. . S!rnl7K. . .4R. . . . . . . . . . . . . . . . . . . . .
(as on the lax toll or inlest deed)
11 oppiil.mil I; " cotpolMion, signalule, of duly aulhollml oflicel.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(iJame, and title of corporaic ofliccr)
Itnildct's I.iccnse Flo.
I'lumtI 1,iccnse If . . . . . . . . . . . . . . . . . . . . . . .
4
Idectlician's License No. . . . . . . . . . . . . . . . . . . . . . .
o0wr1ladc's License No. . . . . . . . . . . . . . . . . . . . . .
i . Location or land on which proposal work will be dune. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
r.y5. . . . . . . . . . . . . . . . . . . . 1-7t? . . .NYe.Nv9 . . . . . . . . . . . t-amt . . . . . . ... . . . . . . . . .
Ilouse iJoolber Slice( Ilamlel
Counly Tax pimp No. 1000 Section . . . :L?-$. . . . . . . . . . Illock . . . .CAQ . . . . . . . . . . . Lol . 0 .17. . . . . :. .
Subdivision . .8t?.GE EtIFc. .PP K . . . . . . . . . . . . . . . Viled hiap No. . rg7lr. . . . . . . . Lot 410 7.4.3.it
(Name) '
I. Sl;uc existing Ilse and occupancy of premises flood intended use and omilmircy of proposed conslrrrchon:
a. Lxistittg lose Brill occupancy .$1AlG( ,-F.1�1!'hl4�y. .R�-.'SIOEaJCE 4 -t,E - .
r
b. intended Ilse and oc:c:up;mcy
. . . . . . . . . Allla{Illu❑ . . . . . . .
Ili J'Al . . . . . . . . . . . . .. . Itclnarlt . . . . . , t)cuulliliou . . . Oliva Wolk .t kms& KQQ-
P&?l(koxtvaxl-rEt_y 'a- wf-Yk uEw 3`I-L couusEs 7 E)ctSYIUG Foon)p A-iiow) (l)esnillllllll
d. ![stiluak,d'Cusl , t.R . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
tic) Ire ltnid l�lwRllug iLis ;lpltlicalinn)
S. Iftlhvelllnl;, rlttnlbar of dwelling mills . . . .CoA . . . . . . .. Hollillel of dwelling coils oil each Ilool . . . . . . . . . . . . .
III)er;lgl!' ounlbel of Gals . . . . . . . . . . . .N• VN.4 . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . .
G. 1f business, conuuetchl of mixed occupancy, specify uml+tle. ;tad exlenl of each type of use . N. .A. . . . . . . . . . . .
). 1)inlensions of exiraiug slnlclmes, it any: Hunt . . . .':/0. . . . . . . . Hear . . . 7a . . . . . . . . Depth . 3Y-4. . . . .
Ifeighl . , . .Z.l. . . . . . . . . Ilmubel o( Slolies . . . . . '7W.o• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . .
Dimensions of siuoc strttchtie wiUt mllcrnlinns or additions: i lent . . . . .':u . . . . . . . . . Rear . .7,0 . . . . . . . . . .
Drplh . . . . . ...3Y-S. . . . . . . . . . Ilvigh( . . . . . Z..q . . . . . . . . . . . : . : (lumber of Slories . . . . . . . . . . .
8. I)ime.116ons of eotim new c.omlim tine. holt( . . . . . . . . . . . . . . Hear . , . . . . . . . . . . . . . Ucplil . . . . . . . . . . . .
Ilcight . . . . . . . . . . . ... . . )lumber of Slolles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
M' lot: FIL)Il( . . . ,°7Q . . . . . . . . . . . . '. . . Itcru . . . . . .'11•.34 . . . . . . . . . . Ucp(h . . 1 4 . . . . . . . . . . . . .
101 Dale of 1'otch;lse .7449h. -ro •14•t5 t. . . . . . . . . . . . . . 1Jaote of homtel Ownel . . . , . . . . . . . . . . . . . . . . . . . . . .
1 1. Zone or use district in which plemises arc situated . . , . R.
d-10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11. Dors pnyalsod conslnlclion viulult: ally mating low, ntdinance ill regulation: . . . ..t.c . . . . . . . . . . I . . . . . . . . . . .
1 t. 15'111 htl he tcgtxdcil . . . . . . . .. . . Ah O. . . . . . . . . . . . . . . Will excess till be Ir.1110tIV l fturtlIre 1 es
cof _
1•I. 1 Lue Owllel of premises KPNQU y$.g!AC411-YQ SMIyHAddre.ss 4PX 21Y .N.Ew.CAup�'J, A o+ R. tG3' Q6g?'$1
1lantc nl All Ililixa-.Z?(Aj.)6. .R&IL . XP. . . . . . . . . . . . Ad1Ilcss60x.68'(. 4!kQi, 1147 hoar. tio. z8�-.SQ`{4. .
I l:ilm: of conttaclor ,.l:LVI'3 .l.QQS, Fxl6. OKI? . • Addtcss4? Bta04T�tw.A�@ . tut cl��u.5363'.4Z.Y.L
15 . In lllin plopetty within "Suri l'o.ct: nr a fldat tmllmnl7 fiYcs. . . .}�. . . tlo. . .. . .
hiI yes, Soutbill d 'I own '1t ual.ces Pel till l: may be requli erl.
1'l.01 DIAGRAM
Locale clearly mill disliuclly :111 buildings, v:frelher exisliol; of proposed, mnd. indicate all set bark dinleusions h
t'11tprlty liars. Civc street and block monbec of description mrcouling In deed, and show slice( lames toll indicate whel
iutrlim of touter lo(.
M'
t
ISI
SI/511 t)I 111:1V
1
l'Ullilll' C11' . . .U.�-tJ.�l� . . . .
. . . . . . . . . . . . . . . . . 1 tt% . . . . . .0!r4 t% . . . . . . hciug duly swonl, deposes and says Ilial he is lila al,;)h
(I Moue o1 indivithlal sil;niug conhacl)
Ibmv muucd.
. .
i; flu; . ... . . . . . . . . . . . . . . . . .� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ne. u; . . . . . . . . . . .
Wollh;ldLis, agent. corpollite, (If IIces, cic.)
u( said owliel of owtic.ls, Ind is duly aulhotized to pmfoun of have Imiloluled the said work and to snake and tilt
:Ipplit aliult; that oll statements conlained in this alydication ale true Io the best of his knowledge tool belief,sold that
v.ollc will be pcllolmed In lite 111,1111101 Set forth in the application filed (herewith.
Swoon to hclot,,e))lllc this 1
y . . . . f.�,itay o>f . . . U b (,).j. /, . . . . ...I 19 �
IIolaIY puhlic, . . . . T�S!�J1 . . . . . . . . . . . . . . . . Counly
. . . . . . . . . . ."� C, L'2 d1� . . . . . .
U (Signalwe oi' applic
0 0
�uung
planning
Engineering
6urueging
,
7
gP�
oil-
Po1
Call
11x99 s 9�
o F. tz8 s0.
.� o. E°RT�EWP69.29 0� �\ Ce COBE
6
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0° a , • ei J
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�'b O• °RIVE //// ., FP FF s mow- °,
�n o0' CNfTN`�w. \
7 �o �_WPtER MEtER 6g 29 OQ � �,
5 /
\101t. 5 /�
NOTE:
1. LOT NUMBERS REFER TO MAP OF `EDGEMERE PARK"
FILED IN THE OFFICE OF THE CLERK OF SUFFOLK COUNTY /
ON JULY 2, 1931 AS FILE NO. 742 /
2. TOTAL AREA = 8540 S.F. /
3. ■ MONUMENT FOUND /
4. SUBJECT PARCEL IS LOCATED IN FIRM ZONE A4 (BASE EL 8.0')
AS INDICATED ON FLOOD INSURANE RATE MAP 360813 0118C
DATED JUNE 15, 1983.
5. ELEVATIONS SHOWN HEREON ARE REFERENCED 70 N.G.V.O. (MSL 1929)
SURVEY FOR:
ARTHUR L. SMITH JR. &
MARILYN S. SMITH
At: LAUREL Town of: SOUTHOLD
Suffolk County, New York
Suff. Co. Tax Map : 1000 128 6 17
District Section Block Lot
Young & Young, Land Surveyors
400 Ostrander Avenue, Riverhead, Nein York 11901
516-727-2303 kyi-
Alden W. Young, P.E & L.S. (1908-1994)Howard W. Young, Land SurveyorDATE :JU
LY 20, 1995
Thomas C. Wolpert, Professional Engineer SCALE : 4
Kenneth F. Abruzzo, Land Surveyor JOB N0. : 42
O John Schnurr, Land Surveyor SHEET NO. : 1 O
IMAJOADRIZED ALIERADCN M COPIES OF THIS WRAY YAP NOT SENNNC DIS1ANUS SHOAN HEREON'a.
PROKIM LYRES CATIPCAMV INWCA1r0 HEREON WAX RUN ONLY TO THE PERSPV FCO MON THE WRAY THE LOCATION OF MILLS(Wf. YPIIC
ADD, 10 THIS WRYLY a A T1E WND WflVEYM'S INNEO SEAL OR TO EWSTNO STRUCTURES IAF FCq A SPEGFIC IS PREPARED AND ON fIR REHI.If 1°THE nR£CWPANY,DDYFRN4ENiA AGENCY AND IENDWG TANKS(Si)!CLSSPDMS(CP)$HOVM
NCIATON°!¢CiICN 110p 0(TiE ° EYDWSLD 3Eµ$HALL NOT aE CWSNCRED ° PYRPOSE ANO ARE NOT i°RE USED 1°ESiA$15N ° WSTTITCN tl3lfp HEREON.AND i0 THE ASLGNEES°Y Tif IFNpWO INSTIUTON. ° HLRCW ARE(ft0Y FIELD ONS[RVATOHS
NEN YMN STATE EWCAIIpN UW. TO DE A MIT TRUE CWY. PROPERTY LINES Gt FOR ERECTION OF FENCES. CERTIFICATIONS ARE NOT TRANSFETMSX TO ADDITIONAL NSTIUTOIS OR WSSEWENt O MER& AND ON DATA OSIMWO FROM DRIERS.
n."'.4I,Fry r.~,.,a.1,.,•:.-��ry-.'..°..,r.F.i1urv.r',..',{rrk.,{,",�.L„f„�r."Ks.^.'.I7R,rNG:.y�.S:"41;::n,.•,t_, .9.[a-�rit 4v;':„ry tn.�,�.0r r' • -<.'.<99Td.',,a reryi .i,:....d;am-i.5.,r.c1ay4',,k s .�-,,t .:a,:e„°at_".4P'�p't-Yf”„.x wav.,', .1 a.'. ..ry.,..h..;l ..h{1{..T,.lry.'Q,:a, ._.,...,{..:. .,r_..,-:: {,, 1' v .�-,:',i,•'N�-'.. 41 '' e.,'t'.;.;.A�,t;3v•i'P-'�”-=ry'f, ^'y ;,.-Ihc.n, ,ri.,•ry . r3;1-1, v + — ^ n- 'Tfl ,••qry+, - - _ _1rvi_ :
-
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7 Wn _ t -
76
--7'R'1,1,,•a,rx5
f�T
UNDERWRITERSCERTIFUTE i . - r, I -�` �I j
- K r '
REQUIRED
OCCUPANC� OR auc - a
D iMOTED
d ry BRN � USE IS UNLAWFUL oo ry ` PR, ;
B { FR IN LS EY - ", '_� ,l
DING o AT V�ITHOUT. CERTIFICATE of Fou AnoN.
7if•1e011 AM To M FOR THE HA N AVED.
FQL�bwINQINRPECTIDNS: OF OCCUPANCY - ° '
I{ MUNDATION
FpflMIAURRRaeUr�,"ATE - � '
II. 00tii* ru"Nk9*01 K RLUMHfNG 2.0 Cr 7 "
INStIdIMTu1NCawwnuc.PION MUST
'
( +fr er
F�f rve FGrs n
,
t R"II a PLUMBER CERTIF/CAT/ON
. "R f-
ON LEAD CONTENT
I�EFORE
CERTIFICATE OF OCCUPANCY --- 5
- -- —...
SOLDER USED.IN WATER —
z92
UPPLX SYSTEM CANNOT , � ,,,•
E
2110 of 1D/o'LEAD. Io.a'
-1b F,E..rwSFeUJ _F ; M f 1 Z 61?1
PLUMBING 4 'rip rltx% E. 10,z` Iti�"�s��I _X, liN�+ �!
h LATER LINES NEED -- - L_ ..� '"
� ALL PLUMBING WASTE
TESTING BEFORE COVERING
It copper tubing is used 4 `
for water distributing
y system; piping shall be } I V7
of 1 _ 1i) G lRr�Ei�
types K or L only A
_" IP�LAItJC� rt l�I Nt-.
I co x Et
Fczs. acc .ss- ui.TtL_. IIL` [
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0
OCCUACY OR '
UNDERWRITERS CERTIFICATE ' Al)� 8 , Y Y�+xIr�;A.ly
� p REQUIRED +
OV D�SNOTED 195 ES' 6JNLAWFU� FRA ' p # +{ r,�; r
Za I z' IFICATE
AFF '
Fr:i
VVI OUTCERT
NaIFY BUILDING DEPA NT AT. - .. "Dn Y ".TH
q NCY
785-1002 9 AM TO 4 FOR THE {'li w��°.�� 1i7 E �
1'h 0. as D F' .Ir HVEY
FALLOWING INSPECTIONS:
1. FOUNDATION - TWO REQUIRED - _ �Q'll (' {I(1 r' 9I'I,(7 I,hATIQ
FOR POURED CONCRETE
I ^?' t�'r t'` "
2. ROUGH FRAMING & PLUMBING T � ,J dl_Lit A '✓t� VED. ._ �zc), iJ, 7
3. INSULAT'IOPa .,� --.--•- --�T _ -._—� _ ��
' .4. FINAL .. r1,._� .,_^.,a rvlY r,�YcU. —'—•�-.-_.,y,,.,.-..�-...�.--,.,-_,. ;
CON„TRUCTTON MUST ,
I F 7 }I f 11
THE EREQUIREMENTS OF THE N.V. PLUMBER CERTIFICATION
ALL CONSTRUCTION SHALL MEET
STATE CONSTRUCTION & ENERGY ON LEAD CONTENT BEFORE �qM
CODES. NOT RESPONSIBLE FOR CERTZFOCATE Cr OCCUPANCY G - T ___,r.r_,_..- I! ',I y
DESIGN OR CONSTRUCTION ERRORS -
SOLDER USED IN VWITER
SUPPLYSYST� F�?' 61,el
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