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HomeMy WebLinkAbout17852-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Ha11 Southold, N.Y. CERTIFICATE OF OCCUPANCY No 219162 Date JUNE 21, 1990 THIS CERTIFIES that the building ALTERATION Location of Property 680 LOCUST LANE SOUTHOLD House No. Street Hamlet County Tax Map No. 1000 Section 64 Block 02 Lot 54 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated FEB. 15, 1989 pursuant to which Building Permit No. 178522 dated FEB. 16, 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 RENOVATE ROOM OF EXISTING ONE FAMILY DWELLING. The certificate is issued to MS. JOAN ARNSTEIN (owner) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A UNDERWRITERS CERTIFICATE NO. N094738 SEPT. 29, 1989 PLUMBERS CERTIFICATION DATED THOMAS MC SHANE May 24, 1989 y~ V Building Inspector Rev. 1/81 voeai xo. s TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MU5T BE KEPT ON 7HE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N 017 8 5 2 Z Date . U.....~. 19$`x. Permission is hereby grante(d,to: w ~X.Kw4CL!~^....~...t,l:'+.Y`...r`:~.'..ll.a:4.(!`........... f g ..............A........................ ct premises located at ....~.....1~...~'-~.~.r......,~~-nx> ....1...~. G~~...... Block .....C?..2.-...v. Lot No....~ County Tax Map No. 1000 Section pursuant to application dated 19.4..., and approved by the Building Inspector. Fee 5~.:... Building Inspector Rev. 6/30/80 TOWN OF SOUTIIOLD ~ ~ ~ ~~j~ ~ BUILDING DEPARTMENT 1y ~ MAY 2 519f~9 Z~ TOWN HALL ~,.~~•y„_ ' BLDG.OE'i''i. SOUTHOLD, NEW YORK 1 197 1 TOW.fV OF S~ O ~ly 765 - 1802 APPLICATION FOR CERTIFICATE OF OCCIIPANCY /J~~ D/ATE . !'11.~Y• ~~s ,I9. NEW CONSTRUCTION .......OLD OR PRE-E%ISTING BUILDING..~/,..pACANT LAND........ Location of Property..~~Q...~QGds?J~,1~~•,.,,,._sGr1r~61-~____._... HOUSE NO.y{~ STREET HAMLET Ovaer or Owners of Property.../.~/.~:,~0~~,._~~'~~~~~~ County Taa Map No. 1000 Section (/S~.~QO Block ~1o?~.a~. Lot Q~7:~ Subdivision Firyryle//d MapQQ ......_.Lot.~~li®6 d PermiC No. ~~LQ~`?l.Z.Date of Permit aS ?.~.b'7. ~ ~ f ~ .Applicant ~~r~d19!~~/.i~.J,/(~~,~ll°~~ Health DepC. Approval ........1/ Underwriters Approval....!, Plaaniug Board Approval Request for Temporary Certificate Final Certificate Fee Submitted: $„o2,f:,U~? APPLICANT..,P~„G ~ C 7 / <i93/ rev. 10/ 14/88 l~ ti ' . ' FORM N0. 6 TOWN OF SOUTFIOLD 1-n i BIIILDING DEPARTMENT TOWN HALL 765 - 1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY INSTRUCTIONS A. 'This application must b~ filed in typewriter OR ink and submitted to the Building Inspector with the follpwing; for new buildings or new use: ' 1. Final survey of prop~rty with accurate location of all buildings, property lines, streets, and unusual, natural or topographic features. 2. Final approval of Hey~lth Dept. of water supply and sewerage-disposal(S-9 form). 3. Approval of electric~1 installation from Board of Fire Undezvriters. 4. Sworn statement fromiplumber certifying that solder used in system contains less than 2/10 of IZ lead; 5. Commercial buildingsi industrial buildings, multiple residences and similar, buildings and installations, a certificate of code compliance from the Architect or Engineez 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" landl,uses: 1. Accurate survey of property showing all property lines, streets, buildings and unusual natural or tgpographic features. 2, A properly completed application, a consent to inspect signed by the applicant and a certified abstract of title issued by a title company which shall show single and separrate owership of the entire lot prior to April 9, 1957. ' If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons theYefdr in writing to the applicant. 3. Date of any housing bode or safety inspection of buildings or premises, or other pertinent information's required to prepare a certificate. C. For Vacant Land Certificate of Occupancy: I. An application for vacant land Certificate of Occupancy shall be submitted, and a certified abstract of title issued by a title company showing single and separate ownership ofi, the entire lot prior to April 9, 1957 shall also accompany the application. If A Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant, D. FEES: ' 1, CERTIFICATE OF OCCUPANCY - New Dwelling $25.00, Additions to Dwelling $25.00, Alteration to Dwelling $25.00, Swimming Pool, $25.00. Accessory building $25.00 Addition to Accessory buildings, $25.00 - Businesses $50.00. 2, Certificate of Occupancy on pre-existing dwelling - $100.00. 3. Copy of Certificate of Occupancy - $5.00 - over 5 years - $10.00 4. Vacant Land Certificate of Occupancy - $20.00 ~ 5. IIpdated Certificate of Occupancy - $50.00 6. Temporazy Certificate of Occupancy - $25.00 Residential $50.00 Cotmmercial II, ' APPLICATION ON BACK ~I zev. 10/ 14/38 I 2 ~l"~b~~ rtzmzr~ TEL. 7G5-1802 ~~Ffotkc ~p OG TOWN OF SOUTIIOLI9 O ~ OFFICE Or BUILDING INSPECTOR o ~^j R^ ~ ~ P.O. BOX 728 y ~ ~~11 ~ T01VN FiALL ~ _~',p~}~j~(~~ O SOUT[IOLp, N.Y. 1 1971 Bf°°°°~ i G , ,~Ol ~ ~aO June 1 1 , 1990 ~ J~~ Z ( ~ ! SLOG. OcP7. William J. Breithack TOWN OPSOUTHOLO P.O. Box 2057 Aquebogue; N.Y. 11931 RE: JOAN ARNSTEIN 3RD NOTICE To Fihom This May Cohcern, We are unable to complete your Certificate oL- Occupancy because of the following reasons. An application for Certificate of Occupancy is not on file. / / No tJndcrwriters Certificate on file. /The check is (ck$~IXC$/not on file. ) $25.00 / / No Ilcalth Dept. l:pproval on file. No final ins.pecCion has been made. Please contact our office on this matter. Thank. you for your cooperation. Building Permit if 1 7 8 5 2 2 Buildi.ny Dept. ***/~o Plumber So.l.cler Certificate on file. ( all permits involving plumbing being iasucd after April 1,1984 ) ENCLOSED OCCUPANCY OR USE IS UNLAWFUL WITHOUT A CERTIFICATE OF OCCUPANCY. YOH ARE TN VIOLATION OE THE CODE OF " THE TOWN OF SOUTHOLD THIS MATTER HAS TO BE CLEARED UP IMMEDIATELY. cc to: Joan Arnstein 10 Downing St. Apt. 2R N.Y., N.Y. ]0014 j ~ yA~ I ~:i ~ +i ; ~ ~J17 ,Q,~iio~, 077 I ~ . , ~l ~ ~ /6~~~.~. it / t ~am~ 0 ~ C~~/S~"?c'//CT~ d~ i c;~FFO(~h~~< TEL. GS-1801 c; To~rrr or souruor,o :.•"~'"L;;;~ ' Oltf'iCJ; OP TsUILDING INSI'F.CT02 o~ ~~N x P.O. Ii0`C 1 1 7 9 ~ ~ TOWNliALL SOli1'ilOLD, N.Y. 1 1971 1 ~17~ June 23, 19$9 WILLIAM BREITHACR P.O. BOR 2057 AQUEBOGIIE, NEW YORK ii931 RE: JOAN ARNSTEIN 'Po 4ihorn This, May Concern, 4.e are unable ro complete your Certificate of occunancy bvcausv of the fo11o~•ring reasons. An application for Certificate of Occupancy ~ is not nn file. *!o t)nderwriters Certificate on file. / / 'Phe check .i;:(nutdatvd/not ou file.) No llval.th Dept. Approval on file. No final 1RSpC(:t1.011 has been made. Pleaae contact our office on this matter. Thank you for your cooperation. Ihi.ildinrJ Pcrm.ii•. f! 1 7 8 5 2 Z Duildinq Dept. ''`*/~tlo Plumber ;;older Certificate on file. ( al.l permits involv9.ng plumbing being i~sucd aft.r_r April 1,1984 ) 2nd NOTIPICATION . ~ i i ~ 'S, sM1 C~V'FF~(,~(d' TEL. 765-1802 . o~p OG TOWN OF SO~JTHOLD ~c OFFICE OF BUILDING INSPECTOR o m P.O. BOX 728 'r'y ~ ~ TONN HALL Py'~ol ~ SOUTHOLD, N.Y. 11971 ~ C~ ~ ~f,~ ~ , IU~I 2 i 19~? ~ 6 . ~ .AO ~ _ ~ . „m_~A2=wc.ra+kr~*'$2.„'°wna~!~. .n3E"st}P+~$ +s 4`a~. -j; _ ~ Ci R T I F I C A T' I N i i Date p~ ~ Building Permit No. Owner -V ~A - ~ ~ ~ (please print) } - . ~ ~ c.' (p'Tease print.),,.,. r - I certify that the solder used in .the water supply ~sys'tern caiitains less than 2/1J of 18 1ea.d. ~ ~ ~ ~ u ~;a t ~.x, J3.. - ~ ,~(plaamber'~s i~cmature) _ ..-d- ~,>na~~~,~.,n..,.. r , ~ e^, Swor to befor me this ~ ~ ~~,r. _ F . day of ~ S~ ~ ~ ~ ~ ; _ 1_ , ~ I .I. •I h rl Y ~ ( y 19;~. ~ } ~ ~ai.I . Notary Public ~Count,y , t ) ~ f 411LL1At~3-9h1i~f4 NOTP.RY PU84IC R. 00 - ~ ~ ~ ~ ~ ~ ~ SU!°FOLK CN7Y.EX~r/37~~ ~ ~ ~ ~~f 4, art '4 _ ~ ~ ~ ~ a , ~ ~ , ~ . f . r lELD I,:S: ~;.::u;~ ~~D;,TE ~ co.KM~:rrrs 1 . ~ s! H - y N FOUNDATION (1st) ~ ~ c ~ r FOUNDATION (2nd) - - z. 3 z o ~ P,OUGH FRAME ~ 6 -PLUMBING s . 3 ~ z - J~ y n"b , ~ IIJSULATION PER N. Y. we ~ l J VI~QQ,~' - ~ H STATE ENERGY ~.3 ' CODE x a ~ m 4. H FINAL Q 2, .e o ADDITIONAL COMMENT`S: ./cam x ` ' ~ ~ x '.J H ~ _ S+ H O .,p 2 C [T1 A r ,_q.~. H 4 Cy . m v H F oc~~fF01Kco ~ ~ VICTOR LES5ARD ~ Town Hall, 53095 Main Road PRINCIPAL BUILDING INSPECTOR `'g P.O. Box 1179 ~ ~ Southold, New York 11971 (516) 765-1802 yiO ~ FAX (516) 765-1823 ~O~ ~ OFFICE OF BUILDING INSPECTOR TOWN OF SOUTHOLD March 5, 1990 William J. Breithack Promenade Drive Aquebogue, N.Y. 11931 Re: Building Permit #17852-Z-JOAN ARNSTEIN Premises: 680 Locust Ave., Southold, N.Y. Suff. Co. Tax Map #1000-64-2-54 Dear Mr. Breithack: During a review of our files, it was noted that a Certificate of Occupancy has not been issued. According to the Code of the Town of Southold Article XXVIII 100-281 and 100-284 a building permit is needed for construction and alterations to an existing dwelling. It is unlawful to occupy a dwelling until a Certificate of Occupancy has been issued. Your final inspection has been made. Your check that we have is outdated. We return it herewith. We have received the Underwriters Certificate, but still need a Plumbers Certification. Please send us a new check in the amount of $25.00 along with the Plumbers Certification so that we may issue the Certificate of Oocupancy. Kindly clear up this matter as soon as possible so that legal action does not have to be taken. Thank you for your cooperation in this matter. Very truly yours, SOUTHOLD TOWN BUILDING DEPT. Vincent R. Wieczorek, Ordinance Inspector t,~ _ L. c ~ ~ o N _ `\y'~ ' `o Lod 7 a ~ o Y it,, 1- fa' f. . - ~ ' . ~ ~ 1 - , LL, ^ y / / / _ _ / s.icm a ' ~ L /"Y~: Y~'1-~L~ L J ~ l . L ~ ~ . .n,,~.i rt.q 7ew 1'ak Stetf ' °<rn'c Ynnyy mb. rUl b9afl SPaI rh U' nbt . r .i1io nue rnpr ~ fxin9id9n~ _ ear /nQ~ or,~.,i'nf ei hor ~»t aon ~a u`+arh+Garaon fo. 'nom Smarr hl0 . 1u~~.. a 6'nLLaryM ' ~.Mpr'T_i~. dY.O Yafgr/n0n~a aearyN' [rf to the ase 9~nurron Nero./ Aeraon nd ~ '9neaa Iflyrr~/. M~{~'~ efliay b nqr tp~l__.. . ~ ` MMtlvglgq Oe TanN ~ ~ot.1 THCL ten/ ; o ~P~P~~K Vq,i, yO,p y p 'f' r x - i ..fia. ~No~~ : Lod avir,~ic.;; S/7ClW)/r ~r'f r r a~. ~ ~~2 ~~CSJ26 ry~ ~ /Y/Gt~! G~J~ r"'Q(.//1(~Ea•'S ~/,~T~ f' ~ ~~"r!' / SE~IAND °'J4a Cr/e7r~;e11'~r;«: }.i 7,'IC T~~~GUJI'tlK17CB ~1`n~a7r' ~t- y fzSrZ858 t..ice.iscd La..d' urvsyvrs l Z v T6S-1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST [ ] ROUGH PLBG. ] FOUNDATION 2ND [ ] IN ULATION [ ]FRAMING [ FINAL REMARKS: DATE ~ S~ ~ INSPECTOR . ~..,r. C Z ~ 765-1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST [ ] ROUGH PLBG. [ ]FOUNDATION 2ND [SULATION [ ]FRAMING [ FINAL} ~j REMARKS: t~-~t ~ ` ~ ~..e.- ' /J `~i~l~, r~~ . nryn', ~ r DATE ~~9f~~ INSPECTOR ' l~~~z- 765-1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST ( ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IIySULATION [ ]FRAMING [~/]/FINAL REMARKS: O DATE ~ l ` INSPECTOR J -Y"- ~8~~ I 765-1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST [ v}~iOUGH PLBG. ( ] FOUNDATION 2ND [ ]INSULATION [ ]FRAMING [ )FINAL REIIAAR~~K/lS: ~,1,'~u.,,„~1r-~ C7'~ DATE ~ 3 INSPECTOR G ~~5 Z T65-1802 BUILDING DEPT. 'NSPECT'oN [ ]FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ]INSULATION [ ?jFRAMING [ ]FINAL REMARKS: ._.1~~ ~ DATE J~ INSPECTOR THE NEW YORK BOARD OF FIRE UNDERWRITERS I'li<°'`~ ~ t(IU~~ta ESUREAU OF EiLECTRICITY BS JOHN STREET, NEW YORK, NEW YORK 10038 Date SItiFtTEMBIsR APPlecationNo.onfile Ci69ii~$9/$9 ~ ii947~f1 THIS CERTIFIES THAT only the a/ectrico/ equipment to described below oral introduced 6y the app/icons named on the above opplication number in the premises of ~ J~AId FaRF1NS1'2~Flp ILUff3ST, Ft~L,I3 ~7, u4)04'fIC?7tL1, N,Y. in thefo[lawinq [ncation• ,,ggas a t~` /xt F'l. ? 2nd F'l. Section Block Lot SF;I(79;T~F~R 5~,~ 98 woe examined on and found to be in compliance with the reyuirernents u(thie Roard. FI%TURE ECEPTACIES SWITCHES FI%7URE5 RANGES COOKING DECKS OVENS DISHWASHERS E%HAUST FANS OUTLETS INCANDESCENT FLUORESCENT OTHER AMT K W. AMi. K. W ~ AMi N.W AMi. K W AMT. H P ~b e) ~ Il } DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS REII UNIT HEATERS MULTI.OUTtET DIMMERS AMi K. W. OIL H. P. GAS H. P AMT. NO. A W. G AMi qMP. AMT AMPS TRANS, AMi H. P SYSTEMS pMT WATTS NOAF FEET SERVICE DISCONNECT NO.OF S E R V 1 G E METER NO. OF CC COND. A W. G. A W. G. A. W G. AMi. AMP. LYPE EQUIP 1 ~0' RW 1 ,e 3W 3,a 3W 3,9 4W pER A OF CC. COND NO. OF HI-LEG OF HbIEG NO OF NEUTRALS OF NEUTRAL OTHER APPARA7U5: 13~f) ItQQM ki;Ntsy~'1'.#.CSN 4)NLY-{ SHCJKE; Ilh;7'1~4;'I'4~R.-'1- [3.:f, F•~LFC'TR7t: CQ• IF;IC.~2~i707~, C/~~~ R4% l~i,ST'Thh~Ix~'1'1<:R AVT?. Cf1TY'ffflfltrl, FaY,. i I13~~S GENERAL MANAGER Perk ~ ~ This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their credentials. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANh1ER. Cj ~OGT ~ 1 ~C~l Ura'l IJao~ ~y~oViivG- ~wo ~a'i ~T~.iJC~- Gt/~.c~ S `l p ~yi~~.C ~N~ ~6~'f ~ „ occuPANCY oR USE IS UNLAWFUL WITHOUT CERTIFICATE APPROVED AS NOTED OF OCCUPANCY GATE' 8,P N ~ FEE: aS~~ 8Y y .L NOTIFY 8UIl01NG DFF'u'trn~~:n!i +.r 765•t802 8 AM TO a' r~nr! r-r;s ,E ~~-7-- FOLLOWING INSPF.ClK)!+„: I 1. FOUNDATION TWL) RirC)'t. ` d FOR POURED CONCRETE ~ I 2. ROUGH • FRAMfNG & i !MatNG j 3.INSULATIQN ` 4. FINAL - CONSTRUC N nn ! i ~ a ` BE COMPLETE FOR C.O. ~ ALL CONSTRUCTION SH L MEET ~ ~ ~s THE REQUIREMENTS OF HE STATE CONSTRUCTION ENERGY p CODES. NOT RESPONSI E FOR ~ ~ ~ ~ J fi c~ / 7 DESIGN OR CONSTRUCTIO ERRORS I f ~ _ t~ ,,I~ 'mil ~ ~ _ ~ ii y.. ~ - J ~ ~ i r ~ ; r~ ~ ~ C~ ; I i W r i i c 4 ~ F- y'p„ ` ~ ~ ~ I r 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 C~ TEL.: 765-1802 CAL , , , , , MAIL T0: Examined ...~.(D., 19~~. Approved~~~M7-~.~10.,19~q.PermitNo.~;7L~,~2'~, D~e~pp Disapproved a/c FCD ~ 'S LDO.DEPT. ' , • • . • . • TOWN OF SOtfTFIOLD W., (Building Inspector) APPLICATION FOR BUILDING PERMIT Date !.'r/Sk'U'/~~Y 15 INSTRUCTIONS a. Tlus 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 br 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 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 Re;ulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housinry co e, and regulations, and to admit authorized inspectors on premises and in building for necessary insp ins. ~j • (Si~ t pplicant, or name, f a corporation).. . ' (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises d~1!~ . s~S./~.~/. M . (as on the tax roll or latest deed) If applicant is a corporation, signature of du]y authorized officer. (Name and title of co`rporate~o/f/fi~cer) Builder's License No. . Plumber's License No . . Electrician's License No . . Other Trade's License No . . 1. Location of land on which proposed work will be done . . ~/,t~~?..lo/2f~ Elouse Number Street. ~ Hamlet County Tax Map No. 1000 Section ~(ii. BI'e~ck ..D~;.~(~. Lot~~.~,7 t~Q 4 Subdivision F.ilcd 1<1ap No. Lot . (Name) State existing use and occupancy of~Qpremises and intended use and occupancy of proposed construction: mss, Existing use and occupancy ~ )~~.SI ~ ~!~r . b. Intended use and occupancy /.1.~~•l. 1J C 3• Repair of work check whiRh~, applicable): New Building ( • • Addition . Alteration . y, , , , , ~moval Demolition .Other Work . ~ (Description} 4. Estimated Cost ~~,66C5•C5f5 Fee . (to be paid on 61ing this application) 5. If dwelling, number of dwelliing units , , , , ~ N ~ , , , , , Number of dwelling units on each floor S5!V~. , If garage, number of cars I 6. ILbusiness, samm~rcial oy mii'xed occupancy, specify nature and extent of each type of"use . . . . 7. Dimensions of.exrstmg st~ctktres, if any: Front . .Rear Depth . kiefght h( m ber of Stories ..*1~1 O . Pensions o~s~me.Siru~t~i;with alterations or additions: Front • •Rear . • • , c th . ;,tt. .Height . ..Tk~~.. 8. tm nsi ~ ••••.••..NumberofStories. ea - Sits ofent(re~t~e~ o)r~~truction: Front , Rear . .Depth .:7:. N _mber of Stories,.. .rG,?.o 9. Size of lot: Frorit ...6 Rear . ............Depth . 10. Date of Purchase • ,Name of Former Owner • • ~ ~ • • P p • 11. Zone or use district in which ~trcmises are situated . ,/'j k'$,i,t1~ti,,T/i9,.~„ 12. Does ro osed construction v olate any zoning law, ordinance or regulation: 13. WIlI lot be regraded ~0 r" 14. Name of Owner of remis ~s ~ry+,1, rlt~ • ' ' • • \Vrll excess fill be removed from premises: Yes P p • . • ..Address 680.~{~~sr, ,,Cn1 , , ,Phone No. ~~tJ , , Name of Architect .(,~[4~/3R~%~.~TCN9C~1(• ,Address Pv~4~l:~0s7, f~Qt/E"~"~~h • • Name of Contractor .(~/17; ('i~n'Rf0~M. , , , , , , , , , ,Address PU dgj'~, ft~UE}4Ww~Phone No. ,'7oi,1,-, 0~3', , , , , 15.Is this propertq boated within ,'300 feet of a tidal wetland? *YLrS....NO.... *If yes, Southold Totrn Trustees Permit may be required. PLOT DIAGRAM • Locate clearly and distinctly all bulldings, whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and block number or description according to dead, and show street names and indicate whether interior or comer lot. i i li STATE OF NE1V YORK, COUNTY S.S • • • •r''6y~H"r~b :...~•4J being duly sworn, deposes and says that he is the applicant (Na~f individual signing contract) above named. He is the ........~~19~g~........ (Contractor, agent, corporate officer, ete.) • • • of said owner or owners, and is duly authorized to pe~rfq~;m or have performed the said work and to make and file this aPPlication; [hat all statements contained in this applicat}`on 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 fjlcd therewith. Sworn to before me this ~ • , ..day ofi.....,~,.,l~-/~':........ , 19 Notary Public, . , , , , ,~~-,L;; ,7~,r, , , ~;t, (J¢~ , , , County HELEtd K DE VOE ! • ' ' NOTARY PUBLIC, State of NBw Ywk No. 4707878,SuflalkCopnry (Signature of applicant) Tmm Expires Marsh 30,19;.