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HomeMy WebLinkAbout17212-z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-19247 Date JULY 26, 1990 THIS CERTIFIES that the building ADDITION & ALTERATION Location of Property 500 BAYER ROAD MATTITUCK NEW YORK House No. Street Hamlet County Tax Map No. 1000 Section 139 Block 3 Lot 20 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JUNE 29, 1988 pursuant to which Building Permit No. 17212-Z dated JULY 14, 1988 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 ADDITION & ALTERATION TO EXISTING ONE FAMILY DWELLING The certificate is issued to EDWARD F. & LYNN O. LENCESKI (owners) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A UNDERWRITERS CERTIFICATE N0. H-015735 - MAY 9, 1990 PLUMBERS CERTIFICATION DATED JULY 13, 1990 - EDWARD F. LENCESKI Tiding Inspector Rev. 1/81 1?OSM NO. TOWN OP SOUTHOLD BUILDING DEPARTMENT TOWN HALL 50UTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N 0 ~ 17 21.2 Z Dare ~t~ 19~fr.: Permission is hereby granted t/o: - l ~`.~..~.r..~ .,......r9S~-- fo ..hc'.''2'~.:~"'~•••1~7....~`2:5~~~~.~rd.Y/.: 'k~5~t~"7"'t.M.. ~ o ~ ~p ~ ct premises located of 'G.~........Q.........,7.~1..... ..7.1..~ .""Y" "(y .~.r .............................................................................q.................................................................................. County Tax Map No. 1000 Section ......f.~./....... Block Lot No....... pursuant to application doted .........`°..~~.~1..' 19.~~and approved by the Building Inspector. / a Fee $ v ..x.~ ~ftldin c of r ttv g/N~De Rev. 6/30/80 t u ~-a ~ Form No. 6 I~~~~~,~~'`.;i~~ r Lj?" TOWN OF SOUTHOLD ,l BUILDING DEPARTMENT ~ ~ ~ ~ 17;JU j I TOWN HALL ` ~ nl 765-1802 BLDG. DEp TOWN OF SOUTHOLD 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 2J10 of 17, lead. 5. ,Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineez responsible for the building. 6. Submit Pl^nnin~; Berard Approval of C6mpleted site pidr, requiremenes. 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 o£ 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 $15.00q Commercial $15.00 Date ....Qr~-/1:3:L.v........ New Construction........... Old Or Pre-existing Building..l~.,......... Location of Property...~r,Qa„ QA~~~, ~Q~ . J~~Z7ITUC,~ .../~,~,51 House No. Street t/ Hamlet Onwer or Owners of Property. ~p(~:R~,,qq,,~,,,,~„ ~V/VN. Q~ L~/YYCES~/ County Tax Map No 1000, Section...~%~{.......Block. 7Y~_ ,Lot...~U... Subdivision....,/n!1,7„7(?'(~GK,,,K/,~~(~X~S"....Filed Map...~gO.~', ,,Lat 1J J Permit No..~,7p~~~,7Y ,Date Of Permit,~ .............Appllcant~~f~Q,„F,~/j W~ //~f/(,En!~Si4( Health Dept. Approval...!~~'4. ...................Underwriters Approval..~p~'.,.~,!~lY Planning Board Approval..l?(i} Request for: Tempora9ry Certificate.........,, Final Certicate...~ Fee Submitted: $ 6Z.ec, 4 D 11 ~ C d 19a~P~ APPL CANT o~~SVFFl1C~~COr TEL. 7G5-1802 !.~~l TOWN OIL' SO~JTB~b,~ 1.::~" ~ L~!r~}s ~c OFFICE OF BUILDIPIG INSPECTOR ~E P.O. BOX 728 `n ~ ayc~" , -e TOWN HALL ~ 0~ SOUTHOLD, N.Y. 11971 ~~pl ~ Yob C E R T I F I C A T I O N ?ate ~ /3-9a f ~ ~ G~ I~I \~1 l~ X% l~lt4 Building Permit No._ Q~~o7/r~ y~ JUL f ~ i~yU ' .i owner__~Ald~¢RD ~ ~ ~~NN Q, ~~«~sK/ (Please print) BLrit,~ P`'ti ~ CPtCt't7~ P1ucWer ~()GV~~ ~ TpWhOFS{1i7~s„t_.m..».,.1 ~ cESk/ (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1g lead. (plumber' signature) Sworn to befor: m)`e-~~tl~'ps day of --_gd 1 19 Nota y Public notary Public, County P3ARBARJI i3A1R0 NOTARY PUBLIC, STATE aF NEW YUa No. 52-4510170 Qualified Pn~SuNolk County Commission Expires N~+~t ~ -3a-Y/ : -i THE NEW YORK BOARD OF FIRE UNDERWRITERS UlEljr<.f r'.'i _ ~ BUREAU OF ELECTRICITY 83 JOHN STREET. NEW YORK. NEW YORK 10038 MAY CK+,74iHi 58f; !7488 j1t fi kS OiL"13'. Date Applicotion No. on file THIS CERTIFIES THAT ~ only the ehxtrkd equipment as described 6ebro and introduced 6y the applicant named on the obooe application number in the premises of i. {1 btAH0 I.?'. tJ i,a'tiiCl, !'iqp PSAYI[R KDr4~~yU--,,, MAIIl1UCK, M.Y. f in thefollolcinq l~c~t' ~,B~~~nc LJ /st Fl. ? Pnd FI. Section Block Lot reas examined on and found to 6e in compliance with the reyuirements of this Board. pXTURE RXTURES RANGES- COOKING DECKS OVENS DISH WASHERS EXHAUST FANS OUTLETS EFTACLK SWITCHES INCANDESCENT-FLUp1ESCENT OTHER AMT. K.W. AMT. K.W. AMT. K.W. AMT. N.W. NAT. N.P. 'S h 1 9,7 - DRYERS RJRNACE MOTORS RITURE AFNIANCE FEEDERS S?ECIAI RECFT TIME CLOCKS YU UNIT t1EATER3 MULi1.0UTLET DIMMERS AMi. K. W, dl N. P. GAS N. P. AMT. NO. A. W. G. AMT. AMP. AMT. AMK. TRANS. AMT. N. P. SYSTEMS AMt. WATTS NO.Oi RET l Fi!}I} SERVICE DISCONNECT NO.OF S E R V 1 C E AMT. AMP. TYPE ~ / 1 X RW 1 X J`N 7 d 3W 3 X AW NO.O~gCYCOND. OF CC. COMD. NO.OF HFIEG MI'IEG NO. OF NENRAlS O~ EUTGMAI RT .OTHER A?PARATUS: ' G.f".C. f:-.? I i'AtK: f T6H11 Nf:~4 i. CigARI) LP NCi`. ;P! P. II_ N(IX 479 MA I I (f Uf, p. , NY, 1 Iv:i' OWIRAL MANMERR ).2 Per This certificate must not be altered in any manner; return to the office of the Board if inconecf. Inspectors ma be identified by their trodentials. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CER I MUST NOT E ALTERED IN ANY MAMl1ER. . i ~ n, ~ 0 1 L ~ r ~ C U Q~ h ~ rr . ~ ~ ~ u, ~ ~ ~1.. `p ~ v.;~, fin. ^ ~ Z ' J ',c~ ~ , ~ ~ ~ E'er . • ~ i,' s hb .,o .~.hn9 l~- Q M Z ~ ~ , . , h ' ~ ~ ~ . y~_-.. fir=--_ ..~Y1'` ~ 1 ` Q ~ ~ „~ov ~ g eti ..a~~^a:.trtt'~~~;~y ~yt-r: 09 t.v•7 : fib ~ I~ M ~ ~ UU44 ;0.l . , M fl W V° ~ "J Q n~~ ;.Z.a.. . i o•ot~i ~ .o.e, sr „Br N O ~ .v w ' TOWN OF SOUTHOLD ~ a OFFICE OF THE BUILDING INSPECTOR ~ aD a Po aox 72s J(/~ ~ SOUTHOLD, NY 11971 8 rOVFN OF , DEpp SOUYyOLD RE: BUILDING PERMIT l4 017212Z 500 BAYER RD., MATTITUCK, NY 11952 EDWARD F. & LXNN 0. LENCESKI ENCLOSED IS OUR APPLICATION FOR A CERTIFICATE OF OCCUPANCY FOR THE ADDITION / RENOVATION AT 500 BAYER RD., MATTTITUCK. OUR CHECK FOR THE $25.00 FEE IS ATTACHED. ALSO ENCLOSED ARE A SOLDER CERTIFICATE AS WELL AS COPY OF THE NY FIRE UNDERWRITERS CERTIFICATE. WE WILL CALL TO SCHEDULE A FINAL INSPECTION PRIOR TO 07-27-90. THANKYOU FOR ISSUING AND MAILING THE C.0. TO US AS SOON AS POSSIBLE. OUR BUILDING PERMIT WILL BE SURRENDERED TO THE INSPECTOR ON FINAL INSPECTION. THANKYOU. SI Y, EDWARD F. LENCESKI PO BOX 929-- 500 BAYER RD. MATTITUCK, NY 11952 1 ens u[ c~ ~i So(ct~er c~ d" C~;~ yh~ ~r~5"~~-613--~~ -1ELD I.:s:~~cTiu,~ ~puATF, ~ corr~cNrs e ~ S ~ ~ ~ ~ ~ FOUtdDATION (1st) ~ _ _ FOUNDATIO (2nd) m~' o P,OUGH FRAME ~ O PLUMBING ti~ ~ y 3 . x' cn IIdSULATI0A1 PER N. Y. y STATE ENERGY CODE x 4. r ~y FIi~AL Ane~ ~ ADDITIONAL COMMENTS: ~ ~ 1 ~ ~ i 4.,~ -f' 9..P~ L~ In /?xA'h Q~}G l 0 (`r1-,~-I .X/Q V ^ C+f ' x t1 i ?r H O 2 ~1 . ~ lT7 a - r~ H x 0 m - -o H R / - / ~X/sTiNb FiCCC ,(3 ASE/j~rv-s / ~j d / (7~OCK Foon/~~ro.J r / ~ / ~ / / / / / i/ / s/ / i?i d /r ? s s/ ~~.'i? / ! it sir?ti r UNDEBMIR~ flCA'iE - _ ~ ~~c'~y~">~1/ ._..CRAW1._SPACE.- v - b WcaoD ,FLOOFL . if oQpperiubi g is used /S ~a x. g /a A-2£9- - ~ ,2x8 " J-oysTS . -for watarrdi r utirig_-. ; ~ :Td.Gx'_C~.~c~~- - : _ ~ - • LN~inG -oq-.. system; pipin hall be SGR-~. (i^4SdanT~o~ 3 _ ~ - / ~ n^Q / bf types K oni-- ~ "Fo,gM} - - - ~o v6y /.nee/ ~ _ ~ - - - 7~"' /S if cslpper to ang s use .l+af . ~ ; a sr.yaBteT~distributing ~ - i -CC/~ tern p - - . /~/tom-- ~ ~ y ; pi Ict~shiali _ I ~ of ty~es K or onl ~ y ~ - - - ~ st . - 3 i i ~ r s vncF i C - ~ - i , ~ _ M - - - ---t - ~ -I--~ -r i- m--t f- ~ • - - - ~ ~ ~ i i ~ i .U' ELOiJ 6r,2AO'i To - _ ~'oorav6 _/ts R~"dJ ~ ~ Q~ `'bad~iio~y~ , , -ior?+? .Cod E s"Gk c~ / a~oc,e 1 ~'T.- _ 11pP U AS NOtEO DATE: ~B.R N 7~/ a FEE. NOTIFY~p~ AT L~iVG'ESfC( 766-1802 s AM Tp 4 1'M FQR THE SUo Qi4~ FOLLOWING INSPECTIONS: J t. FOUNDATION TWO REQUIRED I~~3t~/77JC// fL~,•? i:~yJ`y- FOR POURED CONCRETE t! 2. ROUGH - FKAMtNG & PIUMBfNG 3. INSULATION ~ ~cS30 'I. FINAL - CONSTRUCTION MUST ~,y~ BE COMPLETE FOR C.O, r ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N.Y. ~ STATE CONSTRUCTION & ENERGV g~ ~~pp--gyp COf:ES NOT RESPONSIBLE FOR { _ CS I:~IC7(u OR CONSTRUCTIUN ERRORS .r _ _ ~ ? f __a _ 1. 1 J _ _4 ~ _ _ _ _ _ ~~i ' ~ , i ~ i , \1 i ~ ~ ~ ~ ~ ~ OPEN- 02 'L,Vht£.xE a ~ ~ ~ ti f ~ i . , ~ I ~ ~ i i 1 _ i _f__ i.. _I__.___ ~arntr_ _ _ ~ t Cab . t a i Y- ~ _ _ Y I ~ . I _ 1_ _ L _ _ _ _ _ _ _ r y l i t f III I 7 i A I~ , I ' t ~ I t f l , _ .f ~ _._1 _ iii i i a.. 1 ` - f I i I f f ~ , ~ ~ I i a - ,f t w ~ v, .1:._ _ _ ~ _i_ _ _ ! ~ _ ~ I } ~ - - - ~ti.~ ~ - Y. ~.p..v ~y mmx _ ~ I_ i _ ~ r~ f . 'a- - - r~~-- - - - i I / ~ ~ f ~ 'SIN ~'r ~ ~ I i ~ ~r i ~ ~ I ch,. A 1 i ! ~ I I _ , T~ _ ~ ~ ~ 1- ~ I - I-~: f ' .S~rYQr i i 1 ~ _ _ L ~ ~ ~ ~ ~ ~ I ~ ,i i I ~i i . - f ~ , I } ~ m'o'v 0 n~ ~ ~ . ' ~ ~ DDS nma v J i f f - - r i x" ~Utt~ Ir` IIII~ ~ ~ yy it a r wr'+ ~ ~ ti~y°fi i2'i.,. r~ aY Td f"pt i$h~-°' ~ ~ ~ b F is y 7 ~ t i.. ~ ~ ~v~ ~ f t„'+ i . P~~~ ~ tip' ~ ~~~r A ~.~y~i ' .y l~ ~ i J ~y~,-~ t A..~ ~ x~~~i~ b i Py'~` '~,W! f tiN ~J ~ saF f ~ wr w y w / 4' L~ j e JANUARY 12, 1990 ~ ~W-~~ ! ~ ~ h ~~l~._J~A__N___I~ 81990 (j~f TOWN OF SOUTHOLD BUILDING DEPT. TOwNLDG: pUpT PO BOX 1179 SOUTHOLD, NY 11971 RE: BUILDING PERMIT Il 017212 Z ADDITION--ALTERATION IN ACCORDANCE WITH MY DISCUSSION WITH YOUR DEPARTMENT TODAY, WE HAVE NOT AS YET FINISHED OUR RENOVATION AT 500 BAYER RD., MATTITUCK. WE WOULD APPRECIATE YOUR EXTENDING THIS PERMIT UNTIL 07-14-90. WE UNDERSTAND THAT AN EXTENSION OF UP TO TWO YEARS IS AUTOMATICALLY GRANTED, WITHOUT ADDITIONAL FEE. SHOULD THERE BE A FEE REQUIRED, PLEASE LET US KNOW. IT WOULD BE APPRECIATED IF YOU COULD ACKNOWLEDGE THIS EXTENSION IN WRITING BY RETURN MAIL. THANKYOU FOR YOUR HELP. S NCERELY, EDWARD F. LENCESSKI NN 0. LEN ESKI 500 BAYER RD. MATTITUCK, NY 11952 CERTIFIED MAIL dt P508 613 431 ,s o~ c~ ~ r1 ~1,~.,~ ~ arc-~~s'.~o P.rs~ 1 ~/l7?i-3'~c/L ~ /79.52 w,~ 9.~6-r/1//9 / ~OPDbEO hcrEa.~-r.~a /gnr~~7~o..i io Soo eQ~~lz ,20 ~GZE-/rr~scrs - l.C(,~ZF.1UT SY'2UCTV/L~ /ylrjJ A cS/Ny~e ,~p~ ~Kq~~jp~jo.J OFD 'l~iE /1~ oG /{okse l~//iy,~ /s Cv//eaf/y 7'. w~o~. 7ii'/s ~ ~ cJ/QL f/vdsES ,g 7'x 9' c!'C~e~.veL4 /po/'cC y 9~ 'f~ ' ~L Q~~H /9tir.~ .~.9r~r U~ d~iE maxis r/wc /(iTCye~?, 1~~'(D~os~P <r~7~-/1Tio~ Gdogco /yOQ 3' T~ E'x/sTi.vc ~cp2. ~'X7f„n/ ?Td a . 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' .dG ~ hl/~DK ~¢s G/E y9~eF. ?1~~ ~ A/o7 ~-,p?~iN~ U ~odsn ~/E y/R~ ~f//11~Gy ~'t~l4f2lt~l-:~/a/.3/t rJ-n/O ~'Nc~q/z.c..?a p7Zs ~'~J7y~/1' I/ ~dofs/.r; G/~ /g2E ' ~p7Y//I/c' p6~/J,/y®.~/.C /J-P /m~t7G=il ,Ir2°e.ver~ ~~yP. /o ~r /,~~p?pijrc.,f /,S.U ~/CCl/n°~jjG~ N ~(JS ~R~ Jr~~f~i /J mac-- /~iVi'I //!/6 /~/~(3GE (%UN iQDd~J GrIH~j' G+d~/ //JL~ yam- ~D~~~. T~~ ~~,v ~ a!/yam r~~c~~ ,o.~d- `4 1 _'~r . yC"~~"~ /ys~ <.Gl~_ /7z / Z 765-1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST [G~OUGH PLBG. [ ] FOUNDATION 2ND [ NSULATION [ ]FRAMING [ ]FINAL REMARKS: _J~~~;~,c.",.~ DATE ~ ~ INSPECTOR ` 171 ~ 7ss-1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST [ }ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [~RAMING [ ]FINAL RE ARKS: ~i~,w.G , 1f 1 'f i 4 ~ _ DATE ~ INSPECTOR i ~ 6~12tZ~ rss-iso2 BUILDING DEPT. 1 NSPECTION [ ]FOUNDATION 1ST [ ] ROUGH PLBG. ] LLFOUNDATION 2ND [ ]INSULATION [t,}~FRAMING [ ]FINAL REMARKS: ~ t~ ItGG ~ DATE ~ t~ 1 NSPECTOR ~ ~ , 765-1802 BUILDING DEPT. INSPECTION OUNDATION i5T [ ] ROUGH PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING [ ]FINAL REMARKS: ~ G2~ DATE ~ l~ INSPECTOR ~ ~`2 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDA .ION iST [ ] 1R000FI PLBG. [ OUNDATION 2ND [ ]INSULATION [ 7 FRAMING [ ]FINAL REMARKS: il"i ~i/ ~ ~x~~~,~~ , G~ 'J_ S T' DATE ~ 8 INSPECTORS' 7a ~ ~ rsS-iso2 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST [ ) I2000H PLBG. [ ]FOUNDATION 2ND [ ]INSULATION [ ]FRAMING ~NAL REMARKS =~_z~ DATE l ~ ~ ~ INSPECTOR ii, i~; I 'fi ~'i ~ J a e'.'j;i~'~fG.`'~.~t1~ ~1 ri' fi,~ g ~ z#~ s~ a»~f ~z~ ~'c~a~~., ~ < jit - ~ : ~ ~ _ . ~ ~ ~ ' iil ' S { ,E ~ ~~a ` ~'1 ~ i ~ - - -'Ij z ss„ - ~i~ {1 j i~ ~ d.f"~~° ~A,i k ~~a~?..~$?~,k. -sr,.:S ~ f _ .._f f ~ea~3 'rj`~/' /f.,.., , - _ -3~ - r ~ - - ~ ~ _ _ _ I _ _ ~ _ _ _ . " _ _ ~I _ a ~ - - - E - - ~ ~ i. - - ~ - _ i 1 ~ ~i f ; -l f _ _ _ i f~ ilM 4i{{1 - - ~i _ s _ _ V°e. ~ f A ta'' O~x { ~ ' .a ~ ~ BOARD OF HEALTH I. ~ 3 SETS OF PLANS i p~ LLUI ~Q { ~ ~ ~ FORM N0. 1 SURVEY • . • , ' • . . \\\L,1 MAC U TOWN OF SOUTHOLD CHECK BLDl3.DE1'T. BUILDING DEPARTMENT SEPTIC FORM . TOWN OFSOLRHOLD TOWN HALL • SOUTHOLD, N.Y. 11971 NOTIFY Gj TEL.: 765-1802 CALL ..v`. ~~~v, , , , , Examined 19.j~.~ MAIL T0: Approved ..~r~........., 19~//. Permit No. 1 ff~ Disapproved a/c In ctor) APPLICATION FOR BUILDING PERPAIT Date ~v!?E a~ 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. '~f b. Plot plan showing ]ocation of lot and of buildings on premises, relationship to adjoining premises or public streets ~r ar ss, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- .,r•-.on. 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 Buildin; Inspector. APPLICATION IS HEREBY MADE to,the Buildin~n Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of tIle,Tovyn of Southold; Suffolk County;`Nea York, and other applichble LaNS, Ordinances or Re;ulations;.for the cohstruction of buildings, additions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinan u code .housing cod8,,and regulations, and to admit authorized inspectors,o`n premises and in building for nece 'n ec ' n . (Signature of applicant, or name, if'a corporation) PD OOX 9079 SOO ~QiF Cv2 /2.0 /l7R77/TUC/~ (Mailing address of applicant) NJ /~~SL State wheth"e'r applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Q~~V Fi~ Name of owner of premises ~.DW~:~...`L. , ~r, . L~/nJrJ ~~.i/C~~SK~ (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No. Dom. Plumber's License No. ....QW~~~ Electrician's License No. pGUn/£ ~ Other Trade's License No . . I. Location of land on which proposed work will be done. ~Ei9.2 oF• .."vp BNYC-%. , .~D /JI/17T/TdCK N //9s`~Z- House Number ~ Strcet\ amlet County Tax Map No. 1000 Section 1~'.9........... Block Lot Subdivision /!9H~TiT~/c,(' f/E/GNTS........... Filed Map No. ,/yz; Lot . ..(Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy I~J9/Y//<......:V~~~L/~?G y / Fi9/9lliy I~GJ~G.[.iivG4sI~Y'4'16" ~tl Blta,~'~.015 ,a~?<~' . b. Intended use and occupancy . • =.~;iaz~a8 s~-''°~_~' 3• Ret air of work (check whiReliapplicable): New Building , , , , Addition P, inoval Demolition . • ~ i~,l? Other \Vork a.,~..... . 4. Estimated Cost ¢ Soo•°~'~ ''~•,.k.'; , . y '("Dcs~ription) Fee tlr'~•t«; ;3 i i'1~ # (to be paid on filing this application) 5. If dwelling, number of dwelli~ units ~°U~, , , , , • , , Number of dwelling units on each floor , . , , , , , , , , , , If garage, nom ber of cars . 6. If business, commercial or miffed occupancy, specify n~ tore and extent of each ty e of use N,lh.: , , , , , , , , , • • • , g 7. Dimensrons of e; istin structumber of Stories . Tivo• , • • • . . Height a6 Ndres, if any: Front a?d........... Rear . a Depth . Dimensrons of same structure iwith alterations or additions: Front ....~`t/. asz ~ • • • • • ' Rear De tlt . . .............Height ,~6, , , Number of Stories ,Tw° . P Nutruction:Front,,,;~!/A a ~ /.13 • Rear t~ Depth . $ Henl tsr~ is f entire new conslruber of Stories ,qyE , , . • 9. Size of lot: Front . Rear . %L3 ?RR/~D • ~ • • • ~ • • •Depih • yyd yy£Ry6E 10. Date of Purchase , t~ ~'6 Name of Former Owner c ~ f ~ ~ • • • • • 1 I. 2one'or use district in which premises are situated . • • .y • • sT~;~ER • ro osed construction vt 12. Does p p bla e any zoning law, ordinance or regulation: , /yo • • • • • ~ • • • • • ~ • • • • • ' ' ' ' • • • ~ Yes No ] 3. Will ]oY be regraded o . ,Will excess 611 be removed from remises: /V /i' 14. Name of Owner of remi~/~ !moo F•f ~yNN a; 7.e.itPVk~Address . , S'Rn~E P P .Phone No. 0?96'~S3o Name of Architect .Address . .Phony No. . Name of Contractor •••~~~••,,,,,Address.••••.•.~•••••.•.•.PhoneNo...~••~••••••~~~ IS.Ts this property located with in~00 feet of a tidal wetland? *YES...,NO.>C. w *If yes, Southold Tow',n Trustees Permit may be required. . PLOT DIAGRAM Locate clearly and distinctly ajl buildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. Give street and blocl4 number or description according to deed, and show street names and indicate whether interior or corner lot. .SEE Copy vF o~~28~83 <S'uRUEy /lT7AcN~O ~T r G~~G~~ , I~ II I~ 'I . STATE OF NEW O COU `FY F , $•S ~ , • ' ' ' 1 • • • • • • • • • • • • • • • being duly sworn, deposes and says that he is the applicant (Name of individua si~ni'tg contract) above named. He is the d.G/~~~2.. ~F , I°G?-~'~-~'.YI ~s~S• . . . (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 61e this application; that all statements contai'ped in this application arc true to the best of his knowledge and belief; and that the work will be performed in the manner'sct forth in the application fjlcd thercwitlt. wom t o before me t} is Notary Public, , , , , ounty ISddplt NOTAIIIr INlB . . La:,3iATE OF t~W K . . N9.52.71lB/pta StttMMkQo. 1roR . CoromlSSion Explre~ t9a.~.. (Signature o f a pp lican t ) I