HomeMy WebLinkAbout18256-z
- ~ FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No 7-20398 Date DECEMBER 10 1991
THIS CERTIFIES that the building NEW DWELLING
Location of Property 380 KIMBERLY LANE SOUTHOLD NEW YORK
House No. Street Hamlet
County Tax Map No. 1000 Section 70 Block 13 Lot 20.18
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JUNE 26, 1989 pursuant to which
Building Permit No. 18256-Z dated JULY 5, 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 ONE FAMILY DWELLING WITH GARAGE UNDER & ATTACHED WOOD DECKS
AS APPLIED FOR.
The certificate is issued to MOHRING ENTERPRISES, INC.
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 89-SO-75-FEB. 28, 1990
UNDERWRITERS CERTIFICATE N0. N-152094 - SEPT. 27, 1990 ~
PLUMBERS CERTIFICATION DATED SEPT. 24 1991 - CHAS.SANDERS PLUMB.&HEAT
P
uilding Inspector
Rev. 1/81
rows xo. s
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°- ~8~5b Z Date 19..d.~
Permission is hereby granted to:
. C..
............i.:.~...........
~p
at premises located at ....w~..Q.~......4 r"'.^:!.... ~!r.1.t~.......~`~~L!!`Gt?~.-...........
County Tox Map No. 1000 Section d..... Block ........I..~...(.~. Lot No.. a:~:.~.
pursuant to application doted ...~.~tf~Y~R,..,~C.~,,,,,,,,,,,,,,,,,,,,, 19.b.~„ and approved by the
Building Inspector,
i
Fee 5..~.7!~:s.S....
. .
Bu ding Inspector
Rev. 6/30/80
Form No. 6
' ' '
TOWN . SOL'THOLD ~ ~ ~
BUILD'.: ':F°ARTMENT ~a
'S5-18i_ ~
~
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 17, lead.
5. Commercial building, industrial building, multiple residences and similar buildings
and installations, a certificate of Code Compliance from architect or engineer
responsible for the building.
6, submit P1ancYiiig 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 Certificate of Occupancy - Residential $15.0770, GGCIIOm~Jmercial $15.00
Date
New Construction.... Old O~r~ Pre-existing B/uilding
l.ocatior. cf Property... ~~Q Fzfl,-!V,~........ `~O~S-r~r~~,.. l ~C~, _ ,
House Noy. Street Hamlet
Onwer or Owners of Property..//.ff~.~.~~Nrr~~.C...~l~T~(~.~FI'/,$'~.~',,-.~/,I/,~,,,,,,,,,,,,,,,,,,,,,
County Tax Map No 1000, Section....:l. .....Block.... I~ .Lot...c~(.1.:l~..
Subdivision.~qlQ!~f~Cq(~..~~.)~/...~1.4.y.........Filed Map..~'~.~-~...Lot..f~.'
Permit No.I~P.'{.~O.,Z..ppDagte Of Pe~j/rmit...~'.°~.'.~.~....Applicant ~Q~~p~l:U,6,,,~;t!T~, -~iYG
Health Dept. Approval...4.. l.. ;r ........Underwriters Approval. /.~!'!-I.i.•V.~
Planning Board Approval
Request for: Temporary Certificate........... Final Certicate..:~:~:,?~, ,
Fe/e,;ngSpu~bmitted1:
co ~ao3 9~ • APPLIC
QS~~~~G~' TE .765»1802
o"~! ~Q~, TOWN O>± SO~JT~OLO
't" ~ OFFICE OF BU
~ u• ILDIAIC INSPECTOR
rt*a~i TOWN HALL '
0~~~~ ~ ,~~Q SOUTHULD, N.Y. 11472
j
C E R T x F T CAT I O N
I I
Date ~ ~,z
I
t3uildirg Permit No. ~ ~~,/-~z
owner~m/~1p14 se~iVT~~~' ..s~5 I
print)-~-dive,
Plur„:ar~~~E-S .S'd..r`-,os ~ ~
(please prinkl i.3ao~
I certify that the solder useci in the water supply s stem
cpntains less than 2/10 of I" lead.
/ ! ,
(plumber's siynatu~~
e~
j
Swgrn to befoso me this ~"NE•~•~N~~o
kOTARY PUB61C.8ta4 d NowYdk
4~^~day of auai
aN
°n+~'auie
otary Pub c
ttotarl Public, /~c2uaactwCQUnky
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THE NEW YORK BOARD OF FIRE UNDERWRITERS ~AGr 1 i
1rlUUuHi BUREAU OF ELECTRICITY
83 JOHN STREET, NEW YORK, NEW YORK 70038
Date SFpTE'HRER 27>1990 gpplicationNo.onfile f,557'%7ft9/vt7 N ]5x(194
THIS CERTIFIES THAT
only the electrical equipment v described 6ebfo and introduced by the spplicont named on the above application number in the promises of
380
MfiHkINl3 @:NTFRPRtSF3, U/S h1MBERLY LANE, 5011THgl_D. N. Y.
Boeement GAR/Orl'I 7U ~3 ?D. SR _
in thejoBouinq location; ~ let FL ~ 2nd FI. Section ll Bice Lot `
SEPifMBEft 17,19yb
feea a:ermined on and found to be in cornpliancr with the fvyuiremente of thie Board.
HXTURE RXTURES RANGES COOKING WOKS OVlNS DISH WASNlRS EXHAUST PANS _
OUTLETS ACLES SWITCHES INGNDESCENT FIUOIIES[ENT OTHER NAT. K. W. MIT. N. W. AMi. K.W. AMT: K. W. AMT, N. P.
a ri r; I ~~.n , t.z 2 r
DRYERS FURNACE MOTORS 1UTURE AMIIANCI IEEWRS S?ECIAIRK'?T TIME CLOCKS pLL UNIT HEATERS AWLTWUTIET DIRSRARS
AMT. K. W. Oll N. P. GM N. P. AMT. NO. A. W. G. AMT. M11. AMT. AMN. TRANS. AMT. N. P. SYSttIMS AMT. WATTS
NO.O? 19T
4 f I a~ 1 a
SERVIC! DISCONNlCT tq. 0? S E R V I C E
AMT. AMI. IrPE MEaq?. 1 / eVI 1 / 3W 9 9 TV J M aW PER /COND. Of CC. COND. NO. OF N4U:G OG~ H ND. OI NEUIIINe ~ ~At
1 znla c~ 1 x a 4/n 1 Jo
OTHER AMARATUS:
3-TbN A1~ UNIT-I
3.(i-"TON A/i: UN I'!~•1
FftAC T. AIR HANDI FRS-2
Mi~TORS:I-. YS tl.P..
SMOKE' DFTEC,rOR:-2 ~
ffNF`.ftAl. Y`.LF17RlL'Ar. fONTKA 17f,.{Iy3S-!i
OG7 SHELLS"Y FI.ACE(
FAST MF:AOOW, NY, 11954 ~ OENRAI MANAOY
j 1 -
Per
This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their craderNiab.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFNaTE MUST NOT 9E ALTERED IN ANY MANNER.
~,~.Fpt
~ ) TEL. 7GS-1802
~~~~,,~~il c,~ s Toy rr or~ sou~or.~
=~6u:+1~• Y+ ~c Oi~f'K;I: TsUILDINC INST'I;CTOR
~ h : ~~a
~w~ ~ TOWNlfALL
.ty0 SOIJ"I'IIOLD, N.Y. 1 1971
1 7~
SEPTEMBER 25, 1990
MOHRING ENTERPRISES, INC.
347 GLENN COVE AVENUE
SEA CLIFF, N.Y. 11579
'J'o P7hcm This May Concern,
4Je are unable r.o complete your Certificate
of
O~c unancy because of the followiny reasons.
/r// n application for C~rtifi ,
cate of Occupancy
not nn fi].c. (ENCLOSED)
/ / ~1 Underwriters Certificate on file.
/ / f'he cbccl: .i;; (~>Z~:X?I~~a~($/nut on file.) $25.00
DJO tlcal.th Dept. Approval on file.
Ne final inst~,ec:t:ion has been made.
Plc;z_;r.. contact: our office on this matter. -
Thank you for your cooperation.
Iluildir,<~ Permit 11 1 8 2 5 6 Z
I3uildin DupL'.
tlo Plumber Solder Certificate on file. -
( a].1 permits involv.i.ny plumbiny beiny
i~sucd aft.cr ~1pri.:l 1,1984 )
NOTE: BEFORE CERTIFICATE OF OCCUPANCY IS ISSUED,
AMENDED FEE OF $52.80 REQUIRED FOR REAR DECK.
1ELD Ii:$:~~.:~Uii Jni:, ~I "OP{ME,NT^
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?OUtJDATION (1st) _ ~ - - ~
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?OUNDATIOIJ (2nd) m d
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?OUGH FRAME & .3X/L o O
PLUMBING
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3. ~
IIJSULATIOtI PER N. Y. . , y
STATE ENERGY
CODE
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765-1802
BUILDING DEPT.
INSPECT°I®N
[ ] FOU ATION 1ST [ ] ROUGH PLBG.
FOUNDATION 2ND INSULATI
L l ON
[ ]FRAMING [ ]FINAL
REMARKS: ~~J j~~
DATE 7 ~ INSPECTOR
~ ~ ~ 765-1802
6 BUILDING DEPT.
INSPECTION
[ FOUNDATION 1ST ( ] ROUGH PLBG,
[ ] FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ ]FINAL ~
REMARKS: ~c9-ur..y~u.~,~,~~ c9' /
+
DATE l~ ~ INSPECTOR
I 765-1802
~ ~ ~
BUILDING DEPT. ~~/f ,
INSPECTION
[ ]FOUNDATION i5T ~!:]~ffpUGH PLBG.
(]FOUNDATION 2ND (]INSULATION
[ FRAMING ( ]FINAL
REMARKS:
_
w~
~v '
_i/
DATE INSPECTOR
765-1862
BUILDING DEPT.
INSPECT101~
[ ]FOUNDATION i5T ~ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] IN ULATION
[ ]FRAMING [ FINAL
c
3
_ ~
~ nom..
DATE INSPECTOR
765-1802
BUILDING DEPT.
1 NSPECTION
[ ]FOUNDATION i5T ( ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ]INS CATION
[ ]FRAMING [ INAL
REMARKS: ~G G,~ S,~
DATE 1 NSPECTOR .
765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [v]' ROUGH PLBG.
[ ] FO NDATION 2ND [ ]INSULATION
[ FRAMING [ ]FINAL
REMA~KS: / ~ ,
~ - ~ _
c
DATE INSPECTOR
~ ~ 765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST ( ] ROUGH PLBG.
FOUNDATION 2ND [ INSULATION
[ ]FRAMING [ )/JFINAL
REMARKS: ~~~~-virc~f'
DATE INSPECTOR
~'Z- J- ~ ~ 765-1802
BUILDING DEPT.
INSPECTI®N
[ ]FOUNDATION 1ST [ ] ROUGH PLBG.
[ ~ FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ INAL
REMARKS: . ~ ~ ~
x,~~ x . In ~,~,p ~
DATE _ ~ oZ`~ ~ INSPECTOR
211-30 CHIMNEYS, FIREPLACES, VENTS AND SOLID FUEL BURNING APPLIANCES
material supporting masonry trimmer arches or concrete Chapter 8 Solid Fuel Burning Appliances
hearth extensions shall be located not less than 20 in. (508 1
mm) from the face of the chimney breast.
8-1 Definitions.
7-3.3.2 Spaces between headers or trimmers of com- Fireplace Stove. A freestandin chimne
bustible material and masonry fireplaces shall be fire- g~ Y'
stopped with noncombustible material. The material connected, solid fuel burning appliance designed to be
used for firestopping shall be galvanized steel not less operated with the fire chamber either open or closed.
than 26 gage [0.19 in. (0.483 mm)] in thickness or non- Room Heater, Solid Fuel. Achimney-connected,
combustible sheet material not more than t t
mm thick. / in. (12.7 solid fuel burning room heater designed to be operated
) ~ with the fire chamber closed.
7-3.3.3 Woodwork, such as wood trim and mantels, 8_2 Appliances. Solid fuel burning appliances shall be
and other combustible material, shall not be placed listed and installed in accordance with the terms of their
'within 6 in. (152 mm) of a fireplace opening. Combusti- listing.
ble material above and projecting more than 11/ in. 38
mm) from a fireplace opening shall not be placed less Exception: Unlisted appliances approved by the au-
than 12, in. (305 mm) from the top of the fireplace thorny having jurasdiction may be e'nstalled as speeafied in
opening. tha's chapter. Such installations shall also be in accor-
dance with the manufacturer's installation instructions tf
7-3.4 Accessibility. For cleaning purposes, means shall such instructions specify the use of increased protection
be provided for access to the venting area above and im- or greater clearances than specifzed in this chapter. This
mediately behind any movable damper valve plate in exceptzon shall not apply to mobile home installations.
masonry fireplaces and steel fireplace units.
8-3 Location of Appliances.
7-4 Hearth Extensions. 8-3.1 Every appliance shall be located with respect to
7-4.1 Masonry fireplaces shall have hearth extensions of building construction and other equipment so as to per-
brick, concrete, stone, tile, or other approved noncom- mit access to the appliance. Sufficient clearance shall be
bustible material properly supported and with no com- maintained to permit cleaning of surfaces; the replace-
bustible material against the underside thereof. Wooden ment of air filters, blowers, motors, controls, and
forms or centers used during the construction of hearth chimney connectors; the lubrication and servicing of 'I
and hearth extension shall be removed when the con- moving parts; and the adjustment and servicing of
struction is completed. stokers, if provided.
7-4.2 Where the fireplace opening is less than 6 sq ft 8-3.2 Solid fuel burning appliances shall not be in-
(0.56 m4) the hearth extension shall extend at least 16 in. stalled in confined spaces. The space or room shall be of
(406 mm) in front of the facing material and at least 8 in. ample size to permit adaquate circulation of heated air.
(203 mm) beyond each side of the fireplace opening. Exception: Solid fuel burning appliances lz'sted for in-
'7-4.3 Where the fire lace o enin is 6 s ft 0.56 m~ or stallat2'on in confined spaces such as alcoves shall be in-
P P g' 9 ( ) stalled in accordance with the terms of the listz'ng and the
larger, the hearth extension shall extend at least 20 in. manufacturer's instructions.
(508 mm) in front of the facing material, and a[ least 12
in. (305 mm) beyond each side of the fireplace opening. 8-3.3 Solid fuel burning appliances shall not be in-
stalled in any location where gasoline or any other flam-
7-4.4 Where a fireplace is elevated above or overhangs mable vapors or gases are likely to be present.
a floor, the hearth extension shall also extend over the
area under the fireplace. 8-3.4 Solid fuel burning appliances shall not be in-
7-5 Accessories. Factory-built accessories for 5replaces stalled in any residential garage.
include such devices as fireplace heater inserts, heat ex- $_4 Air for Combustion and Ventilation. Solid fuel
changers circulating air or water, etc., which may alter burning appliances shall be installed in a location in
the combustion or heating characteristics of the fireplace, which the facilities for ventilation permit satisfactory
Such accessories shall be listed and installed in accor- combustion of fuel, proper chimney draft, and mainte-
dance with the terms of their listing, nance of safe temperature under conditions of use. Ap-
Exception: Unlisted accessories that are acceptable to pliances shall be so located as not to interfere with proper
the authority having jurisdiction may be installed as ap- circulation of air within the heated space. Where
proved and in accordance with the manufacturer's zn- buildings are so tight that normal infiltration does not
slallation instructions. provide the necessary air, outside air shall be introduced.
8-5 Chimney Connections and Usage.
8-5.1 Al] solid fuel burning appliances shall be con-
nected to chimneys in accordance with Chapter 5. The /~6a~
chimney provided shall be in accordance with Table
1988 Etlition
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.;//,.u 2~~/ ~ ~ used sae .fr~"rl ~ ~ /
Jc/rn 4mem. ~Jr r~,/a<=r u~ nrrrn.5 ~ r o I ~ %JT ~
a,...~r..r y , .<r~G r.-
~ ~~th f`vJ// vz~s cJo he/anr/us ~ ~ {
tt _1
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fr/u<t. k+//,ou{ Dame/ f.. r/. .rr,, m•r(.', ,.nrr~r
rJo hers r..~./h ~ ¢"fu wood ehrdr or on fs 4"Almm~a,n i
P /2~if exfenor uJO// / ( I
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p/,+y r~ Aura (f"rarr». o-ts ~ : ' 'i,
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4nin~ ~ ~ _I?u/!h o%`1~j 6 " _ Mpg 'r' /
o uraad.e/uaU or ois/a~7 i BoekhPOr/oFlrii'i; ~ Jam/ -y Olinrm urn L,r,..,ys. -
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.S/ana, drink, Ccrn onf or Brvyucffcs. ~ I ut<r~d -S.i "
.~z>~~-~-~-~~.
Gbfo che. kedG/ {r~rr/G fi' 1?/rif/c'/, F'i= > r=on.SU///rJq dive/~/,ote ~nyJ.JOrr
/ofmna/ tloord o/ Tins 4ndaroriforv roeumnresndo/ion
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80ARD OF HEALTH ,
3 SETS OF PL.1NS
FORMN0.1 SURVEY
....4'• .
TOWN OFSOUTHOLD CHECK
BUILDING DEPARTMENT SEPTIC FORM
TOWN HALL
• SOUTHOLD, N.Y. 11D71 NOTIFY J -
' q TEL.: 765-1802 CALL ~ - ~ /
Examined . (9~ 1, MAIL TO: • .
'~P~ff ~.~.wxt,
~r qq V M, r~~i
Approved „ 19p I. Permit No. ~ ~
9
Disapproved a/c Y rr~~~/~;~rji4 ` I
i,,
- JUN 2 6i9~9 `;li
~is~,
w,~~.
F§LDG. Rkl'T. y
TOWN of 50U1'NOLtT V_.-.j
,tL
(Building Inspector)
APPLICATION FOR BUILDING PERMIT y
Date~~ 15 .
INSTRUCTIONS
a. Tltis 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 scale. Fee according to schedule.
b. Plot plan showing location of lot 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 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 Occupancy
shall have been granted by the B~~ilding 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
Re;ulations, for the construction of buildings, additions or alterations, or for removal demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, building code sing ode an regulati s, a to
admit authorized inspectors on premises and in building for necessary inspections.
(Signature of applicant, or na , if a p ration)
~ 3 G/eh , C~we. t~2
(Mailing addre of ap icant)
State whether applicant is vner, ssee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises `~!'!`'21~5. , , \ ~e~
(as on th tax roll or latest deed)
IF applicant is c p do atur (duly thorized officer.
r.
Name and title o core r to ficer)
Builder's Lirensr No. ~ fje: selea><t'c~
t. ti
Plumber's License No . .
Electrician's License No. ~t
...............1......
Other Trade's License No . . .
i?-N
1, Location of land on which proposed work will be done. /L
House Number Street ~ " " • '
Hamlet
County Tax Map o. 1000 Section Block 2d
Lot......
Subdivision 'q'... !Je, b ~'~te. Filed t<1ap No. , ~ s?-
Lot ~ G.t .
State existing use and occupancy of premises and intended use and Deco anc ~,f posed construction:
yy~~ tta~~iA1' a ~>S+NIIiQ
a. Existing use and occupancy (J~Qh...L,G/-G[C.,. rinYw~Htsgixi2,sikW4yyt~y9
/ • it+ClaB$~+A~ uM.
b. Intended use and occupancy !.tl~.m ~ ~~It$ . • • • • .
st,aa ~ ~~4a
S
I~ f
3. Ret of work (check whichlapplicable): New [3uilding , , , , Addition Alteration .
P R~~imoval Demolition Other 1Vork .
/ CJO (Description)
4. Estimated Cost......,(a9J.~ Fee.....................................
(to be paid on filing this application)
5. If dwelling, number of dwelling unfits / , , , , , , , , . Number of dwelling units on each floor , , , , , ,
If garage, number of cars , . • • • • • •
6. If business, commercial or mired occupancy, specify nature and extent of each type of use .
7. Dimensions of existing structyres, if any: Front . ,Rcar Depth .
Height Number of Stories . .
Dimensions of same structure ',with alterations or additions: Front • ~ • ~ ~ ~ ~ ' ' ' ' ' ' '
Depth ' . Ileight . Rcar .
Dimensions of ent~c new construction: Front , ' ' ' ' ' ' • • • • Nuntbcr of Stories , , , , • _
Rear
Height , Nti~ er of Stories . Z. . So. ' ' ' ' ' • • Depth ..~i{y, , , , . , , . .
9. Size of lot: Front Rear 2 Q: g .
10. Dale of Purchase U;S • • • • • Dgpth 2
.p y. l.Y,,~ .Y..... , ......Name of Former Owner GUS /~!'i~ct _ , LN, ~ ~ .
1 1. Zone or use district in which ,remises are situated • • ~ ~ ' ' ' '
' 12. Does proposed construction ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' • ' ' ' '
pl to any zoning law, ordinance or regulation:..4.Q ........................~I
'
l3. \Vill lot be regraded ~ , ,Will exc fll be removed from premises: Yes
~ s,~
14. Name of Owner of premises ~~.~.K~/ ~>lex ~%sas ~;C~ ~e
Name of Architect G(7tutYtlteS/OtiiGt ~kic.lr~~ ~ Address . ~ Phone No. ~q ?`l.':G!f~,(, , , ,
.Address Z~.ey~'acsr ~t~-'~~, Phone No. Gi2~"~gr~
_ Name of Contractor . ~lv,
ltp!R j , ~^n~ea~ti5~... ,Address 3 ~-~en ~ J/ ~ '
:Phone No. (o?r•;',4` Y~/.' , , •
15.Is this property located with in~00 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.
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STATE OF NE1V YORK,
COUNTY OF . ~/~•S
..........f.....• le Y P Y
~~u'~ ` r • ~~'a~~ being dul sworn de oses and sa s that he is the applicant
(Name of individual signih co tract) V
about named.
,~O'~,~, Imo. /
Ile is the /~Ge~~1'~?~
!T. („Contractor, agent, corporate officer, etc.) ' ' ' '
of said owner or owners, and is dulyi authorized to perform or have performed the said work and to make and Gle this
application; that alI statements contai'ined in this application arc true to the best of his knowledge and belief; and that the
work will be performed in the manner~sc[ forth in the application Gled therewith.
sworn to before me this
.....~~.l2GL day of..~
19
votaryPublic,~~6-~%!%2~';"'/1.j ~ 'V.~~.`~,~./~--
. 6f'IiMiTollt~ C ntY
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C~FINi M 8u11NldtowxY .
~gp~r (S' ure of applicant)
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