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HomeMy WebLinkAbout21280-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-22253 Date APRIL 9, 1993 THIS CERTIFIES that the building ACCESSORY Location of Property 1040 HOLBROOK AVENUE MATTITUCK N.Y. House No. Street Hamlet County Tax Map No. 1000 Section 113 Block 6 Lot 13 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated OCTOBER 19, 1992 pursuant to which Building Permit No. 21280-Z dated MARCH 23, 1993 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ACCESSORY SHED WITH DECK & BOARDWALK ADDITION AS APPLIED FOR The certificate is issued to CAROL BLASUCCI (owner) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A UNDERWRITERS CERTIFICATE NO. PENDING - APRIL $ 1983 PLUMBERS CERTIFICATION DATED N/A 9z B ilding Inspector Rev. 1/81 F; rosat NO. $ 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°N° 21260 Z Date . ......................................... I9 .'r, Permission is hereb ran ed to: .�� fQQ� .......... .... . ....... ...4 41 4 to . ,,?......... L Xr. ....... . . (�I • :!"� �....A�6G G���� .....R .....% . .. . 4n....�..-�.. ..DOW.......!- //�3 at premises located at ... Q.. Q..... .... . ......lrtl` e................................................... ... ......... ................!r .......... . ....... 4 County Tax Map No. 1000 Section .......l�.l�f...... Block .........ia......... Lot No. .........Z' ...... pursuant to application dated ......�dJ/1 ...................................... 19..�r. .., and approved by the ' Building Inspector. ��e '�/� ✓'� t // d Fee S.............:.�,-rv�J s .:...n ... .. . toll...................... � g nspec i Rev. 6130180 i , F V 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 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. 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 Building - $100.00 3. Copy of Certificate of Occupancy - $5.00 over 5 years - $10.00 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certi£icat�e of Occupancy - Residential $$155..00, Commercial $15.00 r// Date . .!../. .a. 7�� . . . . . . . . . . . . . . . . . . . . . . . . . New Construction. . . . . . . . . . . Old Or Pre-existing Buildin/ . . . . . . . . . . : : : : : : : . �G Location of Property. . . .16 .nd. . . . . . . . . . �. .House No. Street Ha let Onwer or Owners of Property. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . County Tax Map No 1000, Section. . . . .1� . . .Block. . . . . . . . .).ro. . . . .Lot. . . . . . . . l 3 . . . . . . . . Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map. . . . . . . . . . . .Lot. . . . . . . . . . . . . . . . . . . . . . Permit No.a'f;?.q!�f��. . . .Da't/e Of Permit.���T-'�,�c� . .AppIicant � eZ /. . . . . . Health Dept. Approval. . . . .!((!✓. . . . . . . . . . . . . . . . .Underwriters Approval. . . . . . . . . . . . . . . . . . . . . . . Planning Board Approval. . . .e$ . . . . . . . . . . . . . . Request for: Temporary Certificate. . . . . . . . . . . Final Certicate. . . . . . . . . . . Fee Submitted: $.1� �` �. . . . . . . . . . . . . . . . `� r�� APPLICANT 1= D 1NS:'E . iJ:i ��D i(i1LNT YJ m H OUt7DATI0N _ ( 1st ) OUNDATION ( 2nd ) m OUCH FRAME & I o� -PLUMBING ti H n H aISULATIO;t PER N . Y. STATE ENERGY II CODE i x FINAL ADDITIONAL COMMENTS : x • I m� • x H A \ ' H F) N O V m • m ; H 1`�. /, 4�:._rf:�.. �, d '��+1'TS�°iv'9.t" "!vt7.r 'ex•P'"�i "� '_.[ � +" '^y. r'�i'»' ':sL,^^,r^:T�^S+iy y Imam MAIMM NAM Board Of Southold Town Trustees �i SOUTHOLD, NEW YORK M 1 PERMIT NO. . 4103 DATE: .. .. ISSUED TO Peter.. & Carol Blasucci I Pursuant to the provisions of Chapter 615 of the Laws of G i p p / the State of New York, I893; and Chapter 404 of the Laws of the A� State of New York 1952; and the Southold Town Ordinance en- ;F titled "REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM � s $i LANDS UNDER TOWN WATERS;" and in accordance with the ikx j Resolution of The Board adopted at a meeting held on 12/17 << `•'E 19 92, and in consideration of the sum of $ 150,00 paid by ° F• ; Peter Biasucca of Port Washington N. Y, and subject to the r �? Terms and Conditions lisfed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: ` A Grandfather Permit for 40'X5' dock, 12'X3' walk & 40'X5' ! float in Howards Branch of Mattituck Creek. \ all in accordance with the detailed specifications as presented in f" the originating application. ° R IN WITNESS WHEREOF, The said Board of Trustees here- �E " by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this date, VFD(���, ,,� '�` ... ... .. s eea ... �4 / ,.4.Lei fs.,'.a:: s s .,, y, y —,:.dL.Se..ie..'.:�. 0 eG,:.L'�..✓�' .fr.a..rh.C„va!•d.'." y�QV111 IN PERRY_ ij ON A`ILA � A � A .� New York State Department of Environmental Conservation Building 40—SUNY, Stony Brook, New York 11790-2356 ve NW Thomas C. Jorling Commissioner March 11, 1993 Stanley J. Isaksen, Jr, P .O. Box 294 New Suffolk, NY 11956 Re: Order on Consent - Peter Blasucci Dear Mr. Isaksen: We have received the photographs for the above referenced Order on Consent that you submitted, They are acceptable as proof of compliance with Schedule A page four. The case is now closed , Thank you for your cooperation. Very truly yours, Jennifer B. Piazza Encon Program Aide cc ; Peter Blasucci P .O. Box 1259 Port Washington, NY 11050 _ — _ TIP i ------< - - --- -- --- - - - - ' Dee pc%C.C� r�Airii.✓G � T�Pc:�rc--� Lw�i�JG'-c-i�'�-.---- - --..-----= -------.—_—_---- ------- `r2 .-r'-6• T.Pc-��c-.7,,,� n.y Oc•-ct.C' --- _-----� 'St.�,� -- -- ------- _ 4.�l �60 --- -- L s e;,yu a --- STATE OF NEW YORK DEPARTMENT OF ENVIRONMENTAL CONSERVATION X In the Matter of the violation as of indirated Articles 15 , and/,or 25 and 71 , below, of the New York State Environmental Conservation Law, by ORDER ON CONSENT - - - FILE -NO.--i- - - - Respondent( s) : ( �'��1bi1L. . .county). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y WHEREAS, Article 15 , Title 5r, of the section New York S )aprohibits te Environmental Conservation Law conducting any regulated activities in any of the navigable watersrotected streams of withhthetate wi requisiteuPermitt the Leandsite WHEREAS, Article 25 , Title 4 , of the New York State Environmental Conservation Law, (Tidal Wetlands Act) prcent to any ohibits conducting any regulated activities on orindnoncompliance with ja wetland without the requisite permit, or the requisite permit; and p P artment of Environmental Conservation (DEC) WHEREAS , the Del in that --- --has documente a-viiSSa Lori-of-sai n�aGPrctionGpP� ' -Sew that Section __— Respondent( s) r..aused and/or permitted to be caused, _ �. mat- G4 e �'x 32' �..,.a�c.t,.,• ti: 1cE sce f1 taa + *�nI:2 to kJ ( e la rr 11 t p`p `1 n rl.' .ZVt...�r.Y�41 �y[W14.Yc.�IK..:N V•�i.+� ScTm tc-�-u3� oo' �•'� and WHEREAS, Respondent( s) haublicphaffirmativelyin waived in the his/her/its/their right to a manner provided Of this order w agree ( s) nt consented a and obebound by the terms1andand issconditions contained herein. NOW, having considered this matter and being duly advised, it is • t ay. Dept. Resp. Page 1 of 5 ORDERED , that. with respect. to the aforesaid violation( s) , there is hereby'\ imposed upon Respondent( s) , a penalty in the stem of ,,re �:1»Pu6� Dollars , of which Dcllars shall be maile payable to the Department 11p011 execution of __ ..._. _.__xlni _crdFr,_and --the. remaining -C« -- Dollars to be suspended provided Respondent.. ( s ) strirtly ar.here ( s ) - to the terms and conditions outlined in this order, i_ncli.i:'.ing sched�-Ile A, the compliance schedule attached hereto and made a part hereof; and it is further ORDERED, that nothing contained herein shall he construed as preventing the Department from collecting regulatory fees c•;hF, e applicable; and it is further ORDERED, that this order shall not become effective until it is executed by the Regional Director on behalf of the Commissioner, and the date of execution by the Regional Director shall be the date of execution of this Order; and it is further OPDER.ED : that in those instances in which the Respondent( s ) desire ( s ) that any of the proVi �Fions terms or conditions of this )_-der be changed ,. ( s ) he/lt'they shall make written .=,ppli.carion,- serting forth the grounds for the relief sought, to t.the Commissioner, c/o Lori J. Riley, Regional Attorne_•, New York State Pr'_ar-rn•ant of Environmental sons: rvation . 3,iildii,g State University Campus, Stony Brook, New York 11790-2156 : and it is further OPMERFD, that Pespc,ndent ( s ) shall strictly adhere to the 'c•rms and -nondi-,Ao s il.ir 1 ined in this Order and -In :-arias - TT . TII Q' S f,Gdl'le L 711e rn. mpli ^.g $[h dl._P at.'.a }1 ^, ?lerctQ -ind nadi, a part hereof; and it is fi,rr.h�r ORDERED, that any c.'lange in this order shall not be made or become effective , except as specifically set forth by written order of the Commissioner, such written-order being made either upon written application of the Respondent( s ) or upon the Commissioner' s own findings; and it is further ORDERED,, that this Order shall be deemed binding on the P.e.cpondentfsl , it/his/her/their successors and assigns and all persons , firms and Corporations acting ,,nder or for it/himher/them; including, but not limited to those who ma carry on any or all of the operations -now being conducted by R.e,Gpor,dent.( 5 ) , whether at the present location or at any other in this state , Dated: r.lbaany, iQ,_w ynrl: 10 Commissioner of Environmental Conservation gv RAY E . C_.OWEN, P .E . Regional Director To : ' kcc� Initial q P•c , g� ,c izs7 �C (z{ WPSIt. 51a i A k� Dept . Resp. i 110SV Page 2A. of 5 - i CONSENT BY RESPONDENT- (Individual) Respondent acknowledges the authority and jurisdiction of the Commissioner of Environmental Conservation of the State of New York to isglle, the foregoing order, waives public hearing or other proce-.edings ,ZCCPpt,.s the terms --and C•C'•nd-1 lO-llo.._�Pt ..f.'�=1Y:h lll_ .t=sP .. in this ma,.t.er r . . order 'and consents tp the iggtlariCe thereof . STATE OF NEW YOR.K) COUNTY OF ) On the day of �� �vG+✓ 1993 before me personally came. to me k�n3wn wh being duly swn dPLOSPd and said that 11P r'5 Ctd ' at i ed sp�Y �POQ xeclte� th foregoing that he is the individual- e7 .ribed in fnd wh(� instrument and acknowledged to me t.ha.t he executed same . MARY CATATE OF N EE NOTARY PUBLIC, STATE OF NEW YORK No. 30-4725371 N rpPY P inT.1C: Qualified in NasI;" Mu"ah 3 1gQ LA Symmission Sxpirac �'y.�;vsJ�•t2 .O^NSENT RY RESPONDENT F�orpornti.Onr Respondent acknowledges the authority and jurisdiction of the �- mnisgionel of Environmental Conservation of the state of New Ycrk to ' ,�.slle the for?going Or:I,ar, waives public. hearing other,- prooeed ingG ' tinpE ,et. forth in the _n this matter; accepts the terms and r..ona_ Order and consents to the issuance thereof . NAME OF CORPORATION a� NAME AND TITLE STATE OF NEW YOR.K) e . g . : On the daY. of 19 before me personally came to me known, who being duly sworn, deposed and said that he resides at of Respondent Corporation and that he that he is the ' and on behalf of said Corporation with full signed his name for authority so to do . NOTARY PUBLIC Page 3 of 5 SCHEDULE A Compliance Schedule for Article 15 and/or 25 -I: --GENERAL--REQUIREMENTS: -- immediately, Respondent(s) shall cease and desist from any and all future violations of the New York State Environmental Conservation Law and the rules and regulations enacted pursuant thereto. Respondent(s) shall submit photographs of the completed work, if any, required under this schedule, to the Department within five (5) days of its completion. All submittals to the Department required under this Order shall be made by Respcndent(s) as follows: 1) One cony to the Legal Affairs Office, Region One, New York State Depar'mient of Environmental Conservation, Building 40, S .U. N.Y. , stony Brook, New York li7 0-_3 6; aad - 2) Cne copy tO Regulatory SeCticn, Bureau Ofi i'Iar-.rt6 F itat Protection, Region One, New YOLK State Department of Environmental. Conservation, Building 4o, S.U.N.Y. , Story Brock, New York 117y0-2356. II. REMOVAL REQUiRE•M.ENTS: Within thirty (30) days Respondent(s) shall have removed afrom the date of the the st_actures and/or fill which execution of this Order, are the subject of this Order. Removal S,,peer(=_cations A No Removal Required Ini fps , Dept. 1--lesp. page 4 Of 5 DI. RESTORATION REQUIREMENTS: � • Within thirty (30) days Respondent(s) shall submit to the from the date of the Department, an approvable restora- execution of this Order, tion plan and time schedule for implementation of said plan. Approvable in the context of this Order shall mean-approvable--by--the----- DEC with- minimal revision. Minimal revision shall mean that Respondent(s) incorporate(s) the revisions required by the DEC and resubmits the plan for approval within fifteen (15) business days of receipt of the DEC's comments. This plan shall include: ❑ Regrading. ❑ Plantings in disturbed area. ❑ Specifications ❑ Other Upon approval by the Department, Respondent(s) shall implement the— approved restoration plan in accordance with the approved time schedule. Respondent(s) shall maintain all _ restoration required under this Order for a minimum of five (5) years from the date of the completion of the restoration. said maintenance shall ensure a success ratio of at least 85%• X No Restoration Required. " Initials DepL_.t J R p Page 5 of 5 � ^<'n•"av-.rr_war-;-rr-fT'"," ,+C:Mv`n...x.1'v:Il a.:z,�g_pad"•'r.-,<•--t7F:-7 '•-'-_?..—.er_..-• -.r_-�!�• �n... v+.�.�-v_..�w� & L v Ob S 800 00'0.0"E Q ?0, 30.00' OOK, LA.) Fd CM Fd CM 2 W RSv A rrT o � B3 FRAME „, tV GABADE � 3 2Z3 .3, MAP OF It DESCRIBED PROPERTY BLOCK rq SITUATE WALL MATT/TUCK, TOWN OF SOUTHOLD —273 5.3, SUFFOLK COUNTY, N.Y. 112 NIF STORY I NIF GRGAS WOOD ARGENTIERI FRAME SURVEYED FOR: CAROL BLASUCC/ Ir RES. _ J GUARANTEED TO: wooD CAROL BLASUCC/ DECK TOWN OF SOUTHOLD y EMIGRANT BANK for SAVINGS AMERICAN TITLE INS. CO. PLANTE 0 TM#I000-113-06-13 O h SURVEYED 17 OCTOBER, 1992 I•. B2' W FR. E 0.7 t s so SCALES I = 40' !{ 4/6 Ya Nit/6 Zi i5 Guarantees indicated here on shall rut only to the person for whom the survey is prepared, and on his behalf to the C LP FOUND ON LINE title company, Govermental Agency, 0 Eo.a lending institution, if listed hereon, and to the assignees of the lending institution. , Guarantees are not transferable to 4 additional institutions or subsequent owners e SURVEYED BY uiAGKWA'( 3 Z,7'oA.✓a4k, STANLEY ✓. ISAKSEN,✓R P.O. BOX 294 HIGH WATER LLN ] °rE NEW SUFFOLK,N.Y,11956 !7 OCT 1992 /) °e 9�oA,r,e�P�/Js // (516) 734-5B35 TIE LIN 9 E• N8 °OB'21'W - ✓ "�l'�a d Wi, Copies of this survey map not bearing 52.80, 5' the Land Surveyors embossed seal shall o not be considered to be a valid true WE9/11 15,01VC/1 op a /V//dTT/TG/CK CC�EE/� copy. .Unauthofzed alteration or addition to this f survey,is,l`vjolation of Section 7209 of 'the' 'tw "okk S ate ucation Law. PiL "Va5 • z� FLOAT/NC DOCK S' LICENSE -L ND SURVEYD 2-24-99 Boordwo%F reduced Jo 4'm width Isom shed to do* 92R49/ 3. Nature of work (check which applicable): New Building . . . . . . . . . . Addition . . . . . . . . . . Alteration . . . . . . . . . . Repair . . . . . . . . . . . . . . Removal . . . . . . . . . . . . . . Demolition . . . . . . . . . . . . . . Other Work . . . . 6.... . . . . . . Ut(11Ty s H t 0 Aab b, 1(. (Description) 4. Estimated Cost . . . . . . . . . ��. �.C�":'. . . . . . . . . . . . . . . Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (to be paid on filing this application) S. If dwelling,number of dwelling units . . . . . . . . . . . . . . . Number of dwelling units on each floor . . . . . . . . . . . . . . . . . If garage, number of cars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use . . . . . . . . . . . . . . . . . . . . . 7. Dimensions of existing structures,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 Stones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Size of lot: Front . . . . . . . . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . . . . . . . . Depth ­ ­ ­ ­ * epth . . . . . . . . . . . . . . . . . . . . . 10. Date of Purchase . . . . . . . . . . . . . . . . . . . . . . . . . Name of Former Owner . . . . . . . . . . . . . . . . 11. Zone or use district in which premises are situated . . , . , . _ . . . , . . . . . . . . . . . . . 12. Does proposed construction violate any zoning law, ordinance or regulation: . . . . . . . . . . . . . . . . . . . . . . . . . . 13. Will lot be regraded . . . . . . . . . . . . . . . . . . . . . . . . . . . . Will excess fill be removed from premises: Y.es. . .N. . o 14. Name of Owner of premises . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Rhone No. . . . . . . . ..: . . . . . . Name of Architect . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . , . . . . . . . . . . . . . Phone No. . . . . . . . . . . .°. : . . Name of Contractor . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . . . 5. Is this property within 300 feet of a tidal wetland? *yes. . ., . . . No. . . . . . . . . *If yes, 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. l d r0117 A AS NOTED DATB.P#FEE:' ByNOTIDEPARTM Ar 765-1802 9 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED FOR POUNED CONCRETE 2. ROUGH - FRAMING €a PLUMBING 1 INSULATION 4. RNAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N.Y. STATE CONSTRUCTION & ENERGY CODES. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS STATE OF NEW YyOK��v S.S COUNTY OF . . . . . . . . . . . . . . . . . J�E7 � I3G�SUGC/. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , , . , , being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. Heis the . . .4.�IV47_ ?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Contractor, agent, corporate officer, etc.) of 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 work will be performed in the manner set forth in the application filed therewith. Sworn to before me this . . . . . . . . . 9T/F. . . . . . . . .dayof. . . . . . . . . ., 199;2 Notary Public, ?? '� "' /1!� f County STEPHEN F. THOMAS' . . . . . . . . . . . . . . . . . . . . . . . Jignaiture . . . . . . . . . . . . . . . Notary Public, State of New York No.30-4634377 of applicant)Qualified in Nassau County Commission Expires August 31, 1994 T,.��✓ 7G1��sBOARD OF HEALTH . . . . . . . . . FORM NO. 1 1�'3 SETS OF PLANS OWN OF SOUTHOLD SURVEY BUILDING DEPARTMENT CHECK . . . . . . . . . . . . . . . . . . . . TOWN HALL SEPTIC FORM . . . . . . . . . . . . . . SOUTHOLD, N.Y. 11971 TEL.: 765.1802 t:OTIFY : CALL 19 . .I / Examined .3�.y�, MAIL T O Approved : . . . .Y/,�'� . . . ., 190. Permit No. /�14.01�: �/G�t s� /L . . . . . . . . . . . . . . . . . . . Disapproved a/c . . . . . . . . . . . . . . . . ',. . . . . . . . . . . . . . . . . . . . . / (Bui d�specter) APPLICATION FOR BUILDING PERIMHT Date . lol rt 9Z. . . . . . .. 19 . . . 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 sea�e. Fee according to schedule. b. Plot plan showing location of 1lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this 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 availablel,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'lall applicable laws, ordinances, building code, hoVor nd regulations, and to admit authorized_inspectors on premises-and in building for necessary inspections. . . . . . . . . . . . . . . .pp . . . . . . . . . . . . . . . . . . —" (Signature of applicant, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Q� . . . . . . . . . . . . . . . . . . 1 . . . .nn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of owner of premises rku.t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (as on the tax roll or latest deed) If applicant is a corporation, signaturelof duly authorized officer. . . . . . . . . . . . . I . . . . . . . . . . . . . . . . (Name and title ojf�corpora�e officer) Builder's License No. . �kT�. . . . . .%), ASVG:Gi. . . . l t�I Plumber's License No. . . . . . . . .' Electrician's License No. . . . . . . . . . . . . . . . . Other Trade's License No. . . . . . . . . . . . . . . . . 1. Location of land on which proposed work will be done. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4. YA .C� �^�. 1 . .1.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . �.•. . . . . . .. House Number Street Hamlet County Tax Map No. 1000 Section . . . . . . . . . . . . Block . . . .D. .U(7 Lot f1 u u Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..Filed Map No. . . . . . . . . . . . . . . Lot . . . . . . . . . . . . . . . (Name) 2. occupancy f premises and intended se and occupancy of proposed construction: a. Existinguse and occu anc . . ; , ....41 �i`-. .,. . . . . State existing use and occupancy o, _ b. Intended use and occupancy N t\ . . .�I G+' 1° ' 1/ r ro69 . . . . . . . . . . i b�'�tt ,i F.B.'!n;tur•+aai'b° i r`n� ,mmn7