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Home My WebLink About21366-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-22877 Date FEBRUARY 17~ 1994 THIS CERTIFIES that the building. Location of Property 28905 MAIN ROAD House No. County Tax Map No. 1000 Section 102 Subdivision ALTERATION CUTCHOGUE~ NEW YORK Street H~mlet Block 5 Lot 24 Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated APRIL 19, 1993 pursuant to which Building Permit No. 21366-Z dated APRIL 26, 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 ALTERATION TO EXISTING RETAIL BUSINESS BUILDING AS APPLIED FOR The certificate is issued to (owners) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL UNDERWRITERS CERTIFICATE NO. PLUMBERS CERTIFICATION DATED Rev. 1/81 COLGATE DESIGN CORP. N-288514-9/3/93 & N-295529 - 11/12/93 FEBRUARY 16~ 1994 - RICF~qD MORANO TOW'N OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. ¥. No_N.o BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 2136l{ Z Dot, ...~, ........................................ . ~.~.~.. 19 ......... ond approved by the Fee ,......~..-- .~.Y · · ..~.~ Rev. 6/30/80 THE NEW YORK BOARD OF FIRE UNDERWRITERS ~.[9~(,}2~ BUREAU OF ELECTRICITY ~- 85 JOHN STREET, NEW YORK, NEW YORK 10038 Daw [90VEHBE~ 3~,1992 ~ppl~cat~on~o. onfHe 76~4~192/92 ~ ~58473 only the electrical equipment ~ ~scribed be~w and introduced by t~ applicant ~med on the a~ve eppl~cat~n n~mher i~ the premises of in thefottowi.~ t,,catlo.; ~ B~sement ~ Ist FI. ~ 2nd FI. OiI~ Section Bilk Lot . [~O~{~E~ ~3 ~.99'~ ~'~ u 'o' m m 'anceutt' there{utret n s ~ sB r' FIXTURE FIXTURES RANGES COOKING DECKS OVENS EXHAUST FANS OUTLETS SWITCHES FLUO~ESCfiNT OTHER DRYERS SYSTEMS NO. OF FEET E R 500 OTHER APPARATUS: V I C E P, O,BO~{ 500 This certificate must not be altered iff any manner; return to the office of the Board Jf incorrect. Inspectors m~d by ~heir credentials. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY ~NN~. THE NEW YORK BOARD OF FIRE UNDERWRITERS )t q¥i ~ BUREAU OF ELECTRICITY 8S JOHN STREET. NEW YORK, NEW YORK 10038 THIS CERTIFIES THAT o~y th~ electrical equipment ~ ~scrlbed be~w a~d i~troduced by t~ applicant ~med on the a~ve application number in the premises in thefollowln~ location;. ~ Base,ne~t ~ 1st FI. ~ 2nd FI. O[{T Section Bilk Lot wasexami~edm~ 0 ~('¥~]~ }'~ {,~ ~,i , '{ 99'{ andfoundtobeincooplaneewththerequirements~fth~sBoard, FIXTURE OUTLETS SWITCHES RXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS DRYERS FURNACE MOTORS TIME CLOCKS UNIT HEATERS MULTI-OUTLET DIMMERS SYSTEMS NO, OF FEET SERVICE DISCONNECT S E R V I C E GENEI~AL MANAGI~R-'~, This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified b~,.tli~ir credentials. COPY FOR BUILDING DEPARTMENT.,'THi:S'COPY OF CERTIFICATE 'MUST NOTBE ALTERED IN ANY MANNER. FROM 50UTHLAND CORP. TI] 5637727 P. 07 Form No, 6 TOWN OF SOUTHO%D BUILDING DEPARTMEL~;~ TO~.HALL 765-1802 : A~FLICATION FOKCBRTtFICATE OF ),~''~:"",, This application must be filled in by t?pewriter OR ink a~l~k sn,g~t,:?J ~,~ ~he ~uildio~ ?~nspector with the following! for new building or new ~trea~$, and unusual natural or t6pographic feature~, Final Approval from ~eat~h Dept. of water ~upply and ~c~,,er¥'e~'~epo~a((~9 3, Approval of electrical inmtallation from Board of Fmc,- 4, Sworn statement from plumber certifying that the sol~e~ ~i~u~l ~t ~y~t~m contains less than 2/10.o£ 1% lead~ ~.~ Co~ercial building, industrial building, multiple ¥¢sid~n~,eo =u.l similar buildings a~ i~$talla~ion~, a certificats.~f Code Compliance f~om responsible for ~he building. 6, Submit Planning Board Appgoval of completed site pI~n requirement?. For existin~ buildings (prior to Apr~ 9~ i~57) ~, ~conforming use=~ er 5ui3diogs and "pre-exi~ng" land u~es~ ~, Accurate survey o$ property showing all, property lines, street~ !.uildP~ an~ I. A properly t ~mpl~ga~ appiica~{on and ~ consent to inspect sianed ? ~he ~pplica~t. ~aso~% ~harefOr in writing ~o the a~p]icanc. 1. Certificate of Occupancy - New dwelling $25,00~ Additions to dwelling Alterations ~u dwellin~ $15.Q0~ Swiping pool $25.00~ Accessory buildin~ $25.00, A~ditions to accessory building $25.00. Businesses $50.00. 2. Certificate of Occupancy on Pre-existin~ Building - $10O.OO Copy of Oertificate of Occupancy - $5.00 over 5 years ~ $]0.00 4. Updated Certificate of Occupancy - $50.00 Temporary Certificate of Occupancy - Residential $15.00, Commercial ......... .................... X~w¢onstruction. ........ ~. Old Or ~r¢-e×istin8 Building ..... ,~. House No. Street Onwer or Owners of Proper~y,. . ................................ 000. se¢ ion..l ..... B,oc .... ........ .............. J Healt% Fee )ep~. Approval Underwriters Approval $Oard Approval Lo.r~ lempor:,ry Cerrificat~ ...........Final Certicat, ~e~ $... bO~Oo. ............... TOTF~I_ P. 07 INSPECTORS Thomas Fisher Building Inspector Gary Fish Building Inspector Robert Fisher Assistant Fire Inspector Telephone (516) 765-1802 OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD DA'I'B: Building Permit No. ~ (please print) Plumber: (please print) SCOTT L. HARRIS, Supervisor Southold Town Hall P.O. Box 1179, 53095 Main Road Southold, New York 11971 Fax' (516) 765-1823 Telephone (516) 765-1800 I certify that the solder used in the water supply system contains less than 2/10 of I1 lead. (PI,ambers SignaturE) Sworn to before me this d.y of £ _45ev e( , ,9 Notary Public, S3~/)~%k~ COunty / JUSTUB R BROWN, JR. NOTARY PUBLIC, State of New York No, 52~0452740, Suffolk Count. ~ Commission Expires Aug. 31. 1~ ') INSPEC~ Thomas Building J Gary Building I Roberl Assistant Telephone (5 Plt SWO Not~ 758-1531 ithari 7.q[l rano CUSTOM PLUMBING & HEATING 162 PINE NECK AVENUE M EAST PATCHOGUE, N. Y. 11772 Date S~-~)~'''' "~ 19 ?5 ....... Plt ....... Building Department, Town ry Publ£c~ County I$, Supervisor vn Hall 15 Main Road 'ork 11971 5-1823 765-1800 Notary Public INSPECTORS Thomas Fisher Building Inspector Gary Fish Building Inspector Robert Fisher Assistant Fire Inspector Telephone (516) 765-1802 OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD SCOTT L. HARRIS, Supervisor Southold Town Hall P.O. Box 1179, 53095 Main Road Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 CERTIFICATION DATE: Building Pemlt No. Owner: (please print) Plumber: (please print) I certify that the solder used in the water supply system contains less than 2/10 of [% lead. (Plumbers Signature) Sworn to before me this day of , 19 Notary Public, County Notary Public ~alJG~-25-i993 16:30 FPOM INSPECTORS P~i~:ipal Building Cu~is Horton ~omas ~i~ing Im~ct~ ~ry Fish Baaing l~pect~ Vincent R, Wie~oeek Ord~e Ro~rt Fisher Mr. Rich Bradley The Southland Corp. 732 Smithto~ ~y Pass Smitht-.~ ~ N.Y. 11787 SOUFHL'~HD CORP. TO OPP1CE OF BUILDING INSPECTOR 56,7,7727 P. 86 SCOTT 1,. HARRIS, Supervi-~or Sou~%ld Town Hail gO, Box 1179, 53095 Main Road Sou~hold, New York 11971 Pax (516) 765-1823 Telephone (516) 765- TO Who~ This May concern: We are ullable to ~omplete your Certificate of O~c~palley becauae of the following reasons: An application for Certificate of Occupancy is not on file. (E;lclosed) No Underwriterz Certificate on file. The check is riot No Health Depar~ No final inspection '. $50.00 each applieaeioa ..oval on file. ,, been made. NO Pl~n~er Solder Certificate on file. (Ail permits involving plumbing being issued after April i, 1984). Please contact our office on this matter. cooperation. Thank you for SOUTHOLD TOWN BUILDING DEPT. NOT~: A FINAL INSPECTION ALSO NEEDS TO BE DONE ON THE GREENPORT STORE. THE ENCLOSED ?PLICATIONS CAN BE FILED WHEN INSPECTIONS HAVE BEEN INSPECTORS Victor Lessard Principal Building Inspector Curtis Horton Senior Building Inspector Thomas Fisher Building Inspector Gary Fish Building Inspector Vincent R. Wieczorek OrdinaT~ce Inspector Robert Fisher Assistant Fire Inspector Telephone (516) 765-1802 SCOTT L. HARRIS, Supemist~ Southold Town Hall P.O. Box 1179, 53095 Main Road Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD August 27, 1993 Mr. Rich Bradley The Southland Corp. 732 Smithtown By Pass Smithtown, N.Y. 11787 Re: Cutchogue 7-11 Store 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.)$50.00 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 ~. 21366-Z ** Please contact our office on this matter. cooperation. Thank you for SOUTHOLD TOWN BUILDING DEPT. *NOTE: THE UNDERWRITERS CERTIFICATE & PLUMBERS CERTIFICATION STILL HAS NOT BEEN RECEIVED FOR THE GREENPORT 7-11. PLEASE SUBMIT THE NECESSARY PAPERS SO THAT WE CAN ISSUE THE CERTIFICATES OF OCCUPANCY. INSPECTORS Victor Lessard Principal Building Inspector Curds Horton Senior Building Inspector Thomas Fisher Building Inspector Gary Fish Building Inspector Vincent R. Wieczorek Ordinance Inspector Robert Fisher Assistant Fire Inspector Telephone (516) 765-1802 SCOTT L. HARRIS, Supe~viso~ Southold Town Hall P.O. Box 1179, 53095 Main Road Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD June 18, 1993 Mr. Rich Bradley The Southland Corp. 732 Smithtown By Pass Smithtown, N.Y. 11787 To Whom This May Concern: We are unable to complete your Certificate of Occupancy because of the following reasons: XX An application for Certificate of Occupancy is not on file. (Enclosed) No Underwriters Certificate on file. The check is not on file. $50.00 each application No Health Department Approval on file. No final inspection has been made. No Plumber Solder Certificate on file. (All permits involving plumbing being issued after April 1, 1984). BUILDING PERMIT $ 21366-Z Please contact our office on this matter. cooperation. Thank you for SOUTHOLD TOWN BUILDING DEPT. NOTE: A FINAL INSPECTION ALSO NEEDS TO BE DONE ON THE GREENPORT STORE. THE ENCLOSED APPLICATIONS CAN BE FILED WHEN INSPECTIONS HAVE BEEN DONE. 'OUND ATIO:I f 2nd ~ ~UGH FRAI-~E & .PLUMBING ~SULATIO~I PER N. Y. STATE EHERGY CODE FIHAL ADDITIOHA'L COM~4E~;TS: 765-1802 BUILDING DEPT. INSPECTION FOUNDATION 1ST [~ROUGH PLBG. FOUNDATION 2ND [ ] INSULATION [ ] FRAMING REMARKS: [ ] FINAL 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL REMARKS: THE NEW YORK BOARD OF FIRE UNDERWRITERS [1~)(;.~? ~J.~ BUREAU OF ELECTRICITY ~- B5 JOHN STREET, NEW YORK, NEW YORK 10038 Date THI~ CERTIFIES THAT only ~he electrical ~ulpment ~ ~scrib~ be~ow and int~uc~ by t~ appllcon~ ~ed on the a~e applicatio~ number in the presses of in the following locatlon; ~ Basement ~ Ist FI. ~ 2nd ~7. Section BIm~k ~s examined on Jl~h~ 0~ ~ [~9~] and found to be in compliance ~ith the Na~onal Elect~cal Code. Lot FIXtUK~ FtXTURE$ RANGES OVENS DISH WASHERS EXHAUST FANS 40 DRYERS FURNACE MOTORS FUTURE APPLIANCE PEEDERS TIME CLOCKS UNIt HEATERS MULTI-OUTI.~T SYSTEMS NO. OF FEEt DIMMERS SERVICE DISCONNECT $ E R V I C OtNER APPARATUS: NO. O~E~C~COND' OF ACC. CoNpW O. t NO, OF HI.LEG / AW.G, OF H~-LEG NO. OF NEUTRALS GENS, EAt MANAGER This certificate must not be altered in any manner; return to the office of the Board if incorrect, Inspectors may be identified by their credenfiais. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER. THE NEW YORK BOARD OF FIRE UNDERWRITERS I. [~ ~. 1. '! '~ BUREAU OF ELECTRICITY ~ 85 JOHN STREET. NEW YORK, NEW YORK '10038 Date ~OVf'~,~I[ ~2,~.~'3 ~pplicationNo. onfile ~3[1~/~3 ~ ~9~ o~y the electrtc~ ~uipment ~ ~scrib~ be~w and intr~uced by t~ applicant ~med on the a~ve application number in the prem~s of in the/oilowing location; ~ Basement ~ Ist Fl. ~ 2~*d ~. Section Bilk Lot u~sexaminedon ~0 ~E HI~I~ O~ ~ ~.~ and fo~nd to be i~ compliance ~ith the Na~o~al Elect~cal Code. FIXTURE FIXTURES RANGES COOKING DECKS OVENS EXHAUST FANS OUTLETS SWITCHES FLUO~E$¢~N~ OTH~ DRYERS DIMMERS OTHER APPARATUS: t' [XT[IRtl RIll: Replacement, E R V I C NO. OF HI-LEG OF HI-LEG NO OF NEUTRALS OF NEUTRAL C-h~l 0 PALf~BR BR~N~'[gOO[) , &[, 11717 O~N~AL MANAGER Pet' This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their credentia{s. INSPECTORS Victor Lessard Principal Building Inspector Curtis Horton Senior Building Inspector Thomas Fisher Building Inspector Gary Fish Building Inspector Vincent R. Wieczorek Ordinance Inspector Robert Fisher Assistant Fire Inspect~ Telephone (516) 765-1802 OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD June 18, 1993 SCOTT L. HARRIS, Supervisor Southold Town Hall P.O. Box 1179, 53095 Main Road Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 Mr. Rich Bradley The Southland Cor'). 732 Smithtown-By-tass Smithtown, N.Y. 11787 Re: Building Permit ~21366-Z Premises @ 28905 Main Road, Cutchogue, N.Y. surf. Tax Map ~1000-102-5-24 Dear Mr. Bradley:i We made a Scheduled final inspection of the 7-11 store at 28905 Main Road, Cutchogue, N.Y. on June 17, 1993. The followin~ items are required to be correoted before we can issue a Certificate of Occupancy. 1. Emergency lighting has not been installed acoording to approved plans. 2. Mount 10~b ABC fire extinguishers near front exit, rear exit and storage 1105. Call for re-~inal inspection after these items have been corrected, and when the necessary paperwork and fees have been submitted we can then issue the Certificate of Occupancy. Very truly yours, SOUTHOLD TOWN BUIL~ING DEPT. Thomas J. Fisher Building Inspector TJF:gar BUTT. OTRUBA-O'CONNOR ARCHITECTS, AIA 2 South Bayles Avenue, Port Washington New York 11050 Tel. (5161 883-0880 Fax. (516) 883-0981 April 21, 1993 Town Of Southold Town Hall/Building Department Main Road Southold, NY 11971 Attn.: Tom Fisher Re: 7-Eleven Main Street Cutchogue, NY 11935 Dear Mr. Fisher, As per our phone conversation on April 21, 1993, I am issuing a check for 9549.50 to your office. I understand that the amount is greater than your fee of 9178.00. Please put the remainder of the check toward any community funds that may be available. Our client has authorized this action. Sincerely, Michael Rubinstein Butt. Otruba~O'Connor Architects INSPECTORS Victor Lessard Principal Building Inspector Curtis Horton Senior Building Inspector Thomas Fisher Building Inspector Gary Fish Building Inspector Vincent R. Wieczorek Ordinance Inspector Robert Fisher Assistant Fire Inspector Telephone (516) 765-1802 OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD August 27, 1993 Mr. Rich Bradley The Southland Corp. 732 Smithtown By Pass Smithtown, N.Y. 11787 SCOTT L. HARRIS, Supervisor Southold Town Hair P.O. Box 1179, 53095 Main Road Southold, New York 11971 Fax (516) 765-1823 Telephone (516) 765-1800 Re: Cutchogue 7-11 Store 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. XX The check is ~not on file.)$50.00 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 ~ 21366-Z ** Please contact our office on this matter. cooperation. Thank you for SOUTHOLD TOWN BUILDING DEPT. *NOTE: THE UNDERWRITERS CERTIFICATE & PLUMBERS CERTIFICATION STILL HAS NOT BEEN RECEIVED FOR THE GREENPORT 7-11. PLEASE SUBMIT THE NECESSARY PAPERS SO THAT WE CAN ISSUE THE CERTIFICATES OF OCCUPANCY. FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 /, approved a/c ..................................... o · ( ~/ n-k._.9, ~t~/r) APPLICATION FOR BUILDING PERMIT BOARD OF HEALTH 3 SETS OF ?LA;IS SURVEY CIIECK .................. SEPTIC FORH CALL HAIL INSTRUCTIONS a. This application must be completely filled in by Wpewriter or in ink and submitted to the Building Inspector, witl~ 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 stre~ or areas, and giving a deta/led description of layout of property must be. drawn on the diagram which is part of this apl: 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 pern 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 Occupan 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 t Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein describe The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and admit authorized inspectors on premises and in building for necessary inspections. .... .... -- q.~ .(Signa_ture of applicgo~, or nam. e, if a corporation) .. . .~n~...~...~..,..~. :.~... ~.~.~.~..~. .......... (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builde ,,'~ame o[ owner o[prem~ses .... 3d~-x ..... ~.) .' .... ~ ................................................ J fl (as on the tax roll or latest deed) If applicar~orpor, ation~060f duly auth~orized officer. ....... ..,?./. ...... fName and ti~c of corporate officer) ' Builder's License No .......................... Plumber s License No ......................... Electrician's License No .......... - .. Other Trade's License No ...................... 1. Location ofland on which ro osedwor will be' done I~]~q ~. '.~O~-~Z;~O.~...~q-~... p p ~k ., .................. .~.'; .................. .... ............. ......... · / .2;,;i ........... County Tax Map No. 1000 Section .... ./.~:~. ~ ........ Block ..L~.~. ............ Lot.~---~- ........... Subdivision ..................................... Filed Map No ............... Lot ............... (Name) L State existing use and occupancy of premises and intended use and occupancy of proposed construction: a Existing usc and occupancy 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteratmn Repair .............. Removal .............. Demolition .............. Other Work ' (Descn 4. Estimated Cost ............................. Fee ............................. (to be paid on filing this applicatic 5. If dwelling, number of dweiling units ............... Number of dwelling units on each floor ....... If garage, number of cars .: ....... ' ' ' 6. If business, commercial or mixed occupancy, specify n~tur,e, and extent o f each type o,f, use ............ r · ..; 7. Dimensions,~'gxi,s, tingstru6tures, ifany: Front..~x:~..-~. ...... Rear . .~.-c> ... Depth Height ../.~..'-?. ....... Number of Stories ....... ~ ........ ' ............. Dimensions of~,sa~, e s. tructu~e with alterations or, ad0itions: Front ~'.Q~7*". . Rear'' i~i~'~ .~.' ~''' Dimensions of entire new construction: Front Rear Depth " Height ...;...-.~ ...... Number of Stories... ~ ................................ 9. size of lot: ............. Rear.............. Depth ~"~.~/~"Y... 10 Date of Purchase ~' Name of Former Owner 11 Zo d' ' ' hihp is ituated · ne or use lstrmt in w c rem es are s ........................... 12. Does proposed constructionI violate any zoning law ordinance or regulation: 13. Will lot be regraded ..... } ...................... Will excess fill be removgd from premises: Yes 14. Name of Owner of oremises'C~°C'q~.. &~.~. ~_ .roA~.. a~,~ .... N~e of Contractor ..... ~ .................... Address ................... Phone No ..... 15. Is chis property within 300 feet of a tidal wetland? *Yes. ....... No ......... · If yes, Southold Town Trustees Permit may be required. PLOT DIAG~ Locate clearly ~d distinctl ~1 bulldogs, whether existing or proposed, ~d. indicate M1 set-back d~ensions frc propegy ~nes. Give street ~d bl >ck number or description accorded to deed, and show street nines and indicate wheth inteflor or coruer lot. ;TATE OF NEW YORK, S.S ~OU~Y OF ................ ' ~ ' being duly sworn deposes ~d says that he is the applica~ (Name of individual s~gning contract) bore named. (Contractor, agent, corporate officer, etc.) f said owner or owne~, ~d is duly authorized to ~erfom or have perfo~ed the said work and to m~e and file thi ~plication; ~hat all statements cdntained ~ this application are true to the best of his knowledge and belief; and that th 'ork wgl be perfo~ed in the m~ner set forth in the application filed therewith. worn to before me this .............. .aay or.. ........ ,