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