Loading...
HomeMy WebLinkAbout17998-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-25515 Date: 02/04/98 THIS CERTIFIES that the building ALTERATION Location of Property: RESERVOIR ROAD FISHERS ISLAND (HOUSE NO.) (STREET) (HAMLET) County Sax Map No. 473689 Section 9 Block B Lot 3.2 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated FEBRUARY 2, 1989 pursuant to which Building~Permit No. 17998-Z dated APRIL 7, 1989 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 ALTER CLOSET TO BATHROOM IN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to RICHARD C. GILBERT (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. PENDING 01/30/98 PLUMBERS CERTIFICATION DATED 01/30/98/RICHARD C. GILBERT / ~ ~ ui ing nspector Rev. 1/B1 rosa~ xo. s TowN of sourHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (Tk15 PERMIT MUST BE KEPT ON TtiE PREMISES UNTIL FULL COMPLETION Of THE WORK AUTHORIZED) N 017 9 9 8 Z Date .G1,~~.......'.~ 19.:~.~J Permission is hereby granted to: C ft I~t-~Zs,v(~ ..........~~j........'"~.~.~ ....G.........................A..................... ct premises located at ...........~..~1~.~.:Y;~~'?1... ...............................................~1. ~:?.r~ .~~r.~Y.....~.....~~......~........................................ . . . . . . ~'1. ~ : T ~ : : ' - . County Tox Map No. 1000 Section ...G~ Block Lot No....~i......~... pursuant to application dated 19..~f'..~and approved by the Building Inspector. Fee S..~l~.~..E!~.F.~ Building tnspector Rev. 6/30/80 . Form No. 6 • TOWN OF SOUTLIOLD BUILDING DEPARTMENT TOLJN HALL 765-1802 APPLICATION FOR CERTIFICATE OP OCCUPANCY This application must be filled in by typewriter OP, ink and submitted to the building inspector with the following: for new building or new use: 1. Final survey of property caith accurate location of all buildings, property lines, streets, and unusual natural or topographic Features. 2. Final Approval from Health Dept. of water, supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 17. lead. 5. Commercial building, industrial building, multiple residences and similar buildings and instaliation5, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. Far 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. Fces 1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00, Swimming pool 525.00, Accessory building 525.00, Additions to accessory building $25.00. Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Euilding - $100.00 3. Copy of Certificate of Occupancy - $5.00 over 5 years - $10.00 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential 515.00, Commercial $15.00 Date January 7,,,1998 ::ew Construction....X...... Old Or Pre-existing Building l.ocacien of Property....ono.jf)..,Resepyp~r,Rpad,,,,,,,,,;;,,,,,, Fishers Island House No. Street Hamlet Onwur or Owners of Property.....Bichard,C;,Gilbert.. t:auncy Tax Map No 1000, Section. , 009; 00, , , , , ,Block... ,OS ;00 „Lot 003: 002.. • , _ _ • . 5ubdivision...Robert W.. Brooks.._..,,,,.. „ .,,,Filed Map...1~4......Lot Permit No..1744~.Z.......Date Of Perm it April, p,,1g8~. „Applicant iiealtlt Dept. Approval... N~A ...................Underwriters Approval.... N~A.................. ilanning Board Approval. N/A request for: Temporary Certificate........... Final Certicate.. X........ Pee Submitted: 5..25 .Qa / ^C 25 - '89'?Eti BRGLE4 PEIG D1 i; - 1~: ,~i f~ll~ 'n -'aa - ~ _ , _ o~~SLF~ COO j . 7cwn Nall, 53095 Maln Rued ~ ti z 7 Fax (516j 765-1823 P. O. Box 1179 ~ ~ • Telep.rone (516) 765~18a2 Southold, New York 11971 ,y~Ol ~ ~aO~ OFFICE OF TtiE BUtt_DtNG INSPECTOR TOWN OF SOUTHOLD C E R T I F I C A T I O N DATE • . 3D / ~8 9uildinq Permit too. ~ _ U1 `G owner: ,~R ~ ~r'~1bed,! Q (please punt) to ~ T~ Oc.sosER: F, $ .r~Si ,r (please print} TowNOF'so::rwo~o__ ~-~8 I certify that the solder used in the water supply system contains less *_han 2/10 of 1~ lead. { Signature) o4~~S Sworn to before me this 3 .1 day of , 19 R Y Notary Public, ~ ~ ~ County j~r- ~ Notarlaf Seat Radnor wp r DaINo a e County Lly Commission Expiros March 13, 2000 P~unYtvaNa i155t>c6aticn of Notaries RICHARD G. GILBBRT 2805 Stoneham Dr. West Chester, PA 19382 ~ ~~r (~C~ ~ - G~ I~a9~~ ~ ~~~°d~~, ,D~'1 FEg 3'^,.., ~t..~ e~~l. MATTHEWS & HAM ATTORNEYS AND COUNSELLORS AT LAW 45 HAMPTON ROAD SOUTHAMPTON, N.Y. 11908 PHILIP MATTHEWS - (IBIP.IBB2) SlB-2 H3-2400 STEPHEF L. HAY, III TELECOPIER 518-28'1-IOO6 January 7, 1998 Bexaeae T. HAY Mr. Gary Fish, Building Inspector Town of Southold Building Department Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 11971 Re: Application for Certificate of Occupancy for Richard C. Gilbert (SCTM No. 1000-009.00-08.00-003.002) Dear Gary: Further to the applications for apre-CO for a dwelling and a CO for a shed which I sent to you on December 18, 1997, I have enclosed another application for a Certificate of Occupancy relating to an open permit for a bathroom in the dwelling on the referenced property, together with a check for the $25.00 fee. I understand that Bob Wall will inspect this property in the near future in connection with the enclosed and the other applications for CO's. Sincerely, y~~ i~ Stephen L. Ham, III Enclosures '~,7~~~~~d~ D JAN 9'-~3 ^~~ilG. DC-PT. -~'~~,:,t~IOESQ'JiHOLD ~ \J or ncr oer - - JtaN 30 ' 9S 12:54 - - - - ~ ` •6106881430 T0: 5167S878 `~~~o~o~eF~ot,~~o~ ~ ~ V 'fcwr. ~.aU, 53095 Main Road ~ ~ x J Fex (516) 755•t823 P,+7. Box 1174 ~.+d 7slep,~ona (5151 755~t802 SovthOlc` NewYorft 17977 ~ ,fool ~ ~~O!' OFI?'ICE OF THE BUIL[}ING INSPECTOR T01NN OF SOUTHOLD C E R T L_F T CAT I O N_ nATE: 7,D,1448 G 9tailding Permit xc. /~p9~'_,~ t),uner; ar~Al~r1 IbtK.'tJ (please print) C+~6.sEK: L c ~ll.~,~,.~- (pleaae print) T certify that the solder used in tha wat;er supply system contains 1esr~ than 2/10 of lh load. ( (Signature) ' dwu~z,S' ;3worn to before me this day of ~'ra ^-}~-a+-~. , 19 9 Y Notary Public, 1~County ~c.1•'~~ Notarial Seal Mary R. Harsh, Aoiary• Public Radnor'IWp , Ralavra•e County Aly Oommieslan Explrea March 13r 200D a As?ocJettoa of Notarlea _ 1::LD I;:S:'ECiIU;I { ~jUA2'E j COt`4MENT° ,t -o ~ m 1. _a. H~ _ H FOUNDATION , (1st) o c c FOUNDATION (2nd) m z 0 P,OUGH FRAME & PLUMBING y H 3. ~ m m IIdSULATIOCJ PER N. Y. • • STATE ENERGY CODE x r r I FINAL Q~ V~ ADDITIOPIAL COMMENTS: x , ~ m ' x - - - 'ti ~ H 9~ H H o~ m a • r H Z d m ~o H s ~r J n PLUMBtN(3 ~ ~ AI.i. PLUMBING VWASIE ~ i_ ' ~ WATER LINES NEED ~ ~ TESTING BEFORE CQVERtN3 •S ~ r ~ ~ 0 J ~Y 0 0 I ~ u tvi J ~ v a 7. ~ 7 ~r, t i ~ ~ ~ r= ® i ~ ~ d ~ W ~ W ' ~ ~ r, i li I 11 ~ I ~ ,r 1 a r-- - -----i J 1 ~ ' Il 1 ~ `c ~ J , ~ ~ r H ~ 7- Z .I ~ 1 'i i~i _ - ~ i i t ®I p I ~ ~ 1._. U z ' n H S . ~ Y ,G', ~~~JtS~r~c• s'~~rv~,,P ~~r.,~.~~f~- ~o~oSUFFOt~-moo ~ oy~~ Town Hall, 53095 Main Road ~ P. O. Box 1179 y = Fax (516) 765-1823 Southold, New York 11971 WO ~ ~ . Telephone (516) 765-1802 y~ol ~ ~~oe OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD January 29, 1998 MATTHEWS & HAM, ATTYS STEVE HAM, ATTY 45 HAMPTON ROAD SOUTHAMPTON, N.Y. 11968 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 (not on file.);25.00 No Health Department Approval on file. No final inspection has been made. XX No Plumber Solder Certificate on file. (All permits involving plumbing being issued after April 1, 1984). BUILDING PERMIT # 17998-Z (GILBERT) Please contact our office on this matter. Thank you for cooperation. SOUTHOLD TOWN BUILDING DEPT. *BATHROOM ALTERATION IvIATTFTEWS 8c HAM ATTORNEYS AND COUNSELLORS AT LAW 45 HAMPTON ROAD SOUTHAMPTON, N.Y. IIOHa PHILIP B. MGTTHEWS - (101E-1092) 538-283-2400 STEPHEN L. HAM, III TELEGOPIER 518-2B0-IO'18 HereseHe T, Hato December 18, 1997 Mr. Gary Fish, Building Inspector Town of Southold Building Department Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 11971 Re: Application for Certificate of Occupancy for Shed far Richard C. Gilbert {SCTM No. 1000-009.00-08.00-003.004) Dear Gary: My client Richard C. Gilbert, who owns the referenced property at the corner of Reservoir Road and Winthrop Drive on Fishers Island, applied for and was issued a building permit for a shed for that property in 1995 (No. 23090 Z). Apparently, he never applied for a Certificate of Occupancy to cover it. I am therefore filing on his behalf the enclosed Application for Certificate of Occupancy for that shed. I have also enclosed a check to the Town of Southold in the amount of the $25.00 fee. Please have Bob Wall inspect the shed at the time he inspects the single- family dwelling on this property for the pre-existing Certificate of Occupancy for which I am applying simultaneously. As I mentioned in my cover letter with the pre-CO application, a prompt inspection would be most appreciated due to the anticipated closing in the second week of January. Sincerely, Stephen L. Ham, III Enclosures H S i m ~ p 0'-~ y ~ ~ 3= m NC Z~ > y ~ m h ~ N ~ S y VI IY IN Y'f O h Hpx! S m A Nm A FI A n b Ql ~ C'F r~ fD C N A s 0 H ~ O CZ `0 m A ~.l ~ ® N ro r~ to O C v O m 0.~ ~ i 01 3 M U+ Z~ y Cy s. O o a A W 'n ~ T m w H ro a r. F~-~ Uri t'~ ~ 2 s ~ ° H n pl m ~ 9 p ~ 6 N O s07. N p• b t3 m~ 2 N 4a ~ b• Z M ~ t7 M rf r~ N ~~++yy H w a xa M K n it H M D f 3 D LA C m by R~ Y~ O L*! H • r e H O ~t fe rt 2S O z m ~ '.ti 7. r~ ~ rf ~D O p H A. ~ Z v S O cn r* a m ~ ~ ~ © m m - r' r• O ~ ~ i Om ~j j ~ 'L' '3 pr' ~ M F Nm `71 m ° i O tr ~ y m m C rn~ W ; Ax ?H a O Y m ~ O u ~ F~'• £ y 9 ~ A 4 ~ 0. T = c `q .G7 G O N z ~ z y ~ .'x7 ~ C ~ cn 3 ¢ .t r ° o a r~ C 'va y O n O m ~ C O C ~ ~ °y ' m o a ~ ~a D m m o° ~ a 'n Z m 0 O o m y i ~ A' 77 m c ~ T v p = c a ~ " D c ,g °a z m ~ m ~ ztr, ;m ~ m 0 CJ D OT ~ n H ~ Q A ~ i ~ n "En 9 s £ O ~ ~~'A m o~ s~ b A N~ C'1 ~ [fit o ; ~3.. > O p m X2-1 N ~ p 3 0 1 0. N~ j m ~ m ~ s O y2 ~ A TO z ° m O ~ ~ lD w Z o n o S C OY ~ ° ° f n tr ° ~ ~ Z m n - - ~m ' ° ~ O a ~ ~ z ~ m -0 ~ A a a ~ m 3 s y < °a m'. ~ m C p m m 3 E i D f Lay = o. _ n C41 v N ' -rv. z m y v ~ ~ ~ a m o o~~ s ~ • ~ O u+ O 4fl D `C D ~ mHS F x n " 7.r Z r 5 ~ j 'T z ~ ~ i m D ~ G y m d ~ /Q o ; ~ ; D m 'Y 5 x S ~ 3 y ~ ~ nY cf m rt a' D N ? D y N w 9 y x m ~ 3 m ; O Dy v ~ H A p (P ~ < m y A q ~ {ry~~! ~ N } ° m ~ y a ~ ~~7• n O v O y Hp 3 N £ a C UI ^ A rt 6l O m c 9 9 n ~ ~ m 0. ~ H ~ N < N H 0 6 y Z o s ~ ^ T ~ ~ ~ CO d7 7 n c H a ~ N c m i~7! ~ O n ~ Ca°J A MW m n ~ ~ ~ omo ~ ~ m ~ p ~ [ m a ~ 9AO N O Zy ~ R ~ Z n ^ U!a y m m ~ ~ ~ u x p' i 61m F m ~ ~ £ v ~ R W C ~ ~ z ~ - a n_ lp~. n. 1-~ c ~ fl «C ~ ~ O~ M '0 l~L~ ~ m T z m Qj ~ i s ~ ? H ~ ~ ~ y d m px. a a ~ m ~wp o f D ^ m d a r ~ 2 C 9~ ' y y T C'I C fJN ~ ® O D O 3 9 n o F m M1 „mod R O C ~ O ~ z N p A? e ~ = A ~ m p a m s 3 rt a N m { ~ r p ~ 3 y 0. p ~ A ~ m H a^ ~ A a ~ 2 m O~ n O CZ O m D a 3 0. ~ ~ 1 T Q 9 ~ ~ ~ n D O a ~ 2 m ~ ~ N ~ ~ 2 ~ y"*~~yj M1 ~ ~ m 0 T u m o s m x m ~ Gyy] G1 ^ m j A T a tJ N ~D ~o ° ~ £ H o Z7 ~ n ~ A _ f ~ 7'1 $ a F+ ~ A ~ ~ z~ ; m n ~ ~ H 9 !JI 2 -1 ~ Q ~ ~ ~ n i n n ~ 0. N m 1 m < D O a z p z ; " E 'b ~ l0 ~ C O o '9" n o Ul a m ~ ~ ° H £ x $ H a ~ Z Co A ~ a " ~ ~ o ~ O y~ c ~ O a rl 3 ; ~ m ° ~ S m p_ ~ Z p n 11 < Qs n ~ y O z o m ~ a £ ~ a ~C a. _ ~ A a z m N D° 7. e ~ < m i o f~ ~ A z ~ a m r• o OAT D n~ ~ ~P a a ~ y `c D ~ mw~ F m A & 'P z r v T 2 m i ~ ~ y N A A r h ~ n N i ~x ~ v ro m' ~ ~41 ~ 'rm0 Z D N ~i ~ N 41 v N M w Z N i m ; p 0'~ Q ~ ~ _ v m H m A w '•.11' n b n n s H £ a' o ~ ~ A m Q ~ m c lV 9 n m q, a• ~ 1 Q ~ 3 t9 "'0 ca z ° ~ °a t~-i ~ O ~ CH° 4 R+ fZ ~ c m a W b N ~ E a cv 2 c m ai o n p ~ H ?r' OJ m 0 m n~. i C m o. na cn o w ~H~»+ a ~ Z °m Q ~ a i w i w9m Ctl " 6~ m ~ c ~ ~c n E ~ x7 ~ c ~ ° ~ ~ ~ a 9 ~ m~ y ~ ~ ~ Z m ~ ~ 3 c c" ? H E ~ C ~ c ~ m O X ~ m W y ^ c r N = o ~ 2 c' ~ F = v z ti ,y,~ ~ 0. C o D Ut ~ n ° f m H S. b O C W o ~ ° a ?ro e ~ zm O V m p N a m s S n ~ N ~ ~ H ° £ o ~ ~ ~ a, o a D a ~ m k" p~ m y A ~ a. C7 `e s m O ~ H a a 'if 2 m 0 O !Z o m D v ~ A m ~ y~ 0 ~ 3 xc ~ s ~ "y o ~ ~ zm m u7 ~ ~ z 'n `y m m O (7 O ~ o^ ~ A m O R n ~ Cf ~ 1 n! £ N C ~ ~ n n' z ~ c H w O A m s F.J °f ~ x ~ - T~ O~ D ~ ~p a i-~- Q ~ O v ~ m D O S• m X2-1 ~ m < s o i m c i-.: o o x ° a^~ ~ C ~ S ° f~ a• m W Z m m sm x a w m ° ~ z~ ~ ~ 0° C a " ~ ~ z ~ m D ° ~ ~ a y a icc0 m 3 ; m ~ n b C 31 ~ os n y i H Q. o ° o m ~ =f > F ny ~ c ~c 9 N ~ ~ z m H y o ° a ~ 3 n• ~C a a ~ D K D ~ mHO F z ~ y ~ Z m 3 s ~ ~ N m y ~ ~ S, ~ m ° n ~ i x Re M a ~ ra ° o s ~ ~ m g ° t~ F p i y h+ H H ~ J { r ' rtp ~~2r ANN -t yT p fAO-D..tt 41 t'•UOTZ 17T~nr ~t' ~m m Z fAm>Anm DC C 7o~.!OO < nmOprt-L7roz'~ ~ 1y ~mz ~ ~ T~ m O ~ D O O ~ Cm~O pOZ~'SZ rn k' ~ri ~ 'n z ~ ~ m -I 0 C k. ~ Z'"Z~~ ~pO< y as I j~ Oy• C {l~m~zvD ~ ~ ~TxO~ 70 0 gym, iz~ Q ~m70~r3 0 ~m ~ 3 M~n z ~ ~z i ~ ~~iLS?~ N z m I N 1 G1 p m i ~ N ~ Y' ~ II 1 ~~1 'I 111,1{'1,1, M t-1 w\ I _ ~ j I TLg ~ ~ ~ i ~ ~ I I_ ~ ' e ~ S o~~i r~ ~ ~ ~ ~ ~ ~ ~ ~ D i ~ ` Q ~ ~ A f t, i ~ ~ i BOARD OF HEALTH 3 SETS OF PLANS FORM NO. 1 SURVEY . TOWN OFSOUTHOLD CHECK BUILDING DEPARTMENT SEPTIC FORM ' TOWN HALL SOUTHOLD, N.Y. 11971 NOTIFY TEL.: 765-1802 CALL ,19 MAIL T0: Examined .......~.j. ~~jj Approved..../ 1 'Permit No.. ~ /j"! Disapproved a/c . ................................~~~rxr.-y~•••!!~.•~ (Building Inspector) APPLICATION FOR BUILDING PERMIT Date Z~ 15 INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with = sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public street or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this apply cation. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issued a Building Permit to the applicant. Such permi shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupanc shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Btrilding Permit pursuant to th Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances o Regulations, for the construction of buildings, additions or alterations, or for iemoval or demolition, as herein describe The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and t~ admit authorized inspectors on premises and in building far necessary inspections. ~3W~.WPx~ Cot~S'Z. 'Z,4JC. (Signature of applicant, or name, if a corporation) • (Mailing address of applicant) bl°~` State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder ....G ~?~?E:~~-.. ~QN'T~-{FEZ oZ . ~ i ~ Name of owner of premises ~ ~/~.'/.NC:e%N4'...C~, •~!L pl,~.T... . (as on the tax roll or latest deed) If applicant is a corporation, sQignature of duly authorized officer. (Name and title of corporate officer) Builder's License No. :.~~~~:.lj:•~'......... Plumber's License No. . •Z.•(Q,~•OP . Electrician's License No . . Other Trade's License No . . 1. Location of land on which proposed work will be done. ~~".~l`.~ RvO1R, , .................................................................t=l.sti~~.s. T,,.~,~.ti.~..... House Number Street Hamlet County Tax Map No. 1000 Section Block ~ Lot r7 . . Subdivision Filed hlap No. Lot . (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~ C~ • • • • • • • • • • . . . . b. Intended use and occupancy ~~~-t't~O~w~• • • . Y-~ a.~ 3. Nature of work (check which applicable): New Building Addition - Alteration . ~ . Repair . Removal , Demolition Other Work . /fir ,y (Description) 4. Estimated Cost dr' ~ °O......... Fee ~Y..•.f~ . . (to be paid on filing this application) S. If dwelling, number of dwelling units .......-d.--...... 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 ...............NumberofStories....................................................... 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 ...............NumberofStories....................................................... 9. Size of lot: Front Rear - Depth . 10. Date of Purchase .............................Name of Fnrmer Owner , 11. 'Lone or use district in which premises are situated . 12. Does proposed construction violate any zoning law, ordinance or regulation: N.o . 13. Will lot be regraded ............................Will excess fll be removed from premises: Yes N~ 14. Name of Owner of premises ~-:tcH*~?. t?~~~~-?. Address I.SF.t,~Wy~?,.t~........ Phone No. Name of Architect ...........................Address ...................Phone No.............. . Name of Contractor 31~YE`~?~E~ Address o:3cRbW. F~:i N;Y,, ..Phone No.S:/`. 7~.&.`~0.~~ . . 15.Is this property located 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 fro;i property lines. Give street and block number or description according to deed, and show street names and indicate whethe interior or corner lot. STATE OF NEW Rl~,~ ~ S.S COUNT OF~ /...,~uti~•~l~'-4!~ • • • • • • • • ; .ntlt~!1~. • •1 • • • • . • • being duly sworn, deposes and says that he is the applicar _ (Name of individual signing contract) , above naf,yeu. He is the (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 the application; that all statements contained in this application are true to the best of his knowledge and belief; and that th work will be performed in the manner set forth in the application filed therewith. Sworn to before me th~is~ C ~ g, ~ d~". "..day of '-~h`R!~.u,cv`l'.. 19~,./ Notary Public, ..,,:`~W1!`:~!':`:~..~.~... Y'!~'~...... CouUnt ffILEEiV G. WALT NoMY Pu61ic, Sfei• of N.w Yo11 Pb. 52-9504t85 L :..~+-.-:'r`:- .~.•.+-r-= . gwsrd ~ s.ttoik ceunty~ p (Signature of applicar' jmm Fapk~r hlwrii 3fi, t9- C90i- .