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Home My WebLink About24258-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-25548 Date: 02/23/98 THIS CERTIFIES that the building ~DITION & ALTERATION Location of Property: 6635 NEW SUFFOLK RD NEW SUFFOLK (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 117 Block 5 Lot 24 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JUNE 16, 1997 pursuant to which Building Permit No. 24258-Z dated JULY 18, 1997 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 AS APPLIED FOR. The certificate is issued to MICHAEL J WITHERS (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. N-444071 01/26/98 PLUMBERS CERTIFICATION DATED 02/10/98 MATTITUCK PLUMB.&HEATING /~B~i 1 d/i~'~g~Ig i n s pe c t o r Rev. 1/81 lS'OR,M NO. J TOWN OF $OUT]'JOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL CO~PL~T~ON OF THE WORK ^UTHOR,ZED~ N.°2~t258 Z ~,e ..... .~.-.~.Z.~.... ................ ~...~~~....,.~~ ~~~.:..~...~ ................ ,o ~~..~..~.~....~~ .~.~.....~...~~~...~.~...~ ~..~...~...~.~~~.~~..~..~ ~, ~,,~,,,, ,_.~ ~, ................. .~..~...~~.~...~~~ c~,,~ ~ ~ ~. ,ooo ~,~,,~, ....... ~.~ ...... ,,~ ...~ ............ L, ~o...~...........'"~":~"'~"~'~.'" ~a~i · ' ...... Rev. 6/30/80 FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall ~outhold, N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions in duplicate A. This application must be filled in typewriter OR ink, and submitted, V, :to' zhe Building Inspec- tor with the following; for new buildings or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic feat~ res. 2. Final approval of Health Dept. of water supply and sewerage disposal-(S-9 form or equal), 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa- tions, a certificate of Code compliance from the Architect or Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan requirements where applicable. Co For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of pzoperty showing all property lines, streets, burn--nd unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, occupancy an~i ~dr~i~[~Jj.[L~n~l~. 3. Date of any housing code or safety inspection of buildings or prem'~'~ ~r other p~t~r e- tlon required to prepare a certificate. 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-exmt~ng dwelhng $1 5.00 ~ OWN OF SOur~n~ 3. Copy of cert~hcate of occupancy $1.00 4.Vacant ~and C.O. $5.00 Date . .~e..b??.a.~.¥..[.~.~. New Building. .... ., . . Old or Pre-existing Building ............× Vacant Land .. ......... . . Location of Property 6635 New Suffolk Road New .S.,u.~.~.q~,]5, House No. Street Ham/et Michael Withers Owner or Owners of Property .................. County Tax Map No. 1000 Section .,..~,~,7. ........ Block .... 0,5, ......... Lot ..... 2.4, ......... Subdivision ................................. Filed Map No ........... Lot No .............. Permit No.2,4.2, ,5.~,~. .,. Date of Permit ,7/.~,8, ,/',9,7..Applicant . ,N.a,~, ,cy..S,~ .e ,e,~,m.a, 91 ,A,~.qh, ~ ~,e,c,t;, )... Health Dept. Approval ........................ Labor Dept. Approval .................. Underwriters Approval ........................ Planning Board Approval ............... Request for Temporary Certificate ..................... Final Certificate ............ X. .......... Fee Submitted $ ~.5...QQ ....................... Construction on above described building and permit meets all applicable codes and regulations. Applicant .~.O.~.C..K.~.A.~..~.U.I.b.D ~ [q.G..~9]F~,~BUQ~.z. Qt~. g.q[~?, ......... Rev, 10-10-78 I;~P 06 '95 16:Zl ~IA.IIt ,_.F '~ ,13' H~LD F'.~. ~ Town Hall, 530§5 Main Road P. O. Box ! 179 Soulhold. New Yon~ 11971 Fax (516) 765-1823 Telephone (516) 765-1802 OFFICE OF THE BUILDING INSPECTOR TOWN OF $OUTHOLD ,CERTIFICATION DATE: Building Permit No. 24258Z owner: b,J , (please print) contains less than 2/!0 of certify that the solder used in the water supply system 1% lead. ~ ~Pihmbers Sworn to before me this '/.D. , day of Notary Public, ~ County · .PP.~ ./~ ., ." No. 01KE60e12~7 New Yo k State Department of Environmental Conservation Division o Environmental Permits Building 4 - SUNY. Stony Brook, New York 11790-2366 Telephone [516) 444-0365 Facslmile 5161 444-03B0 Mr. Mich el Withers 20 East t inth Street Apt. 12N New Yort NY 10003 LETTER OF NONJURIS -- July 10, 1997 RE: 1-4738-01461/00004 Withers Propertv 6635 New Suffolk Road New Suffolk SCTM #1000-117~05-24 John P. C~hill Dear Mr, Vithers: Based on EnvJronm~ by Samue greater th .he information you have submitted, the New York State Department of ntal Conservation has determined that the p_r_oje.~ as shown on the plan prepared s & Steelman dated March 31, 1 997 located landward of the functional bulkhead ~n 100 ft. in length is beyond the jurisdiction of Article 25 Tidal Wetlands. Therefore, Pert 661 ) that no ec the tidal ~ in accordance with the current Tidal Wetlands Land Use Regulations (aNYCRR ~o permit Is required under the Tidal Wetlands Act. Please be advised, however, mtruction, sedimentation, or disturbance of any kind may take place seaward of etlande jurisdictional boundary, as indicated above, without a permit. It is your responsibi ty to ensure that all necessary precautions are taken to prevent any sedimentation Or other al arstlon or disturbance to the ground surface or vegetation within Tidal Wetlands jurisdictior which may result from your project. Such precautions may include maintaining adequate ~/ork area between the tidal wetland jurisdictional boundary and your project (i.e. a 15' to 20' wide construction area) or erecting e temporary fence, barrier, or hay bale berm. Please be ~ jrther advised that this letter does not relieve you of the responsibility of obtaining any neces,' :Jry permits or approvals from other agencies, Very truly yours, Permit Administrator MMR 5~arnuei, & Steelmen BMHP File ELEVATION CERTIFICATE Expires May FEDERAL EMERGENCY MANAGEMENT AGENCY NATIONAL FLOOD INSURANCE PROGRAM ' ATTENTION: Use of this certificate does not provide a waiver of the flood insurance purchase requirement, This form is used only to provide elevation information necessary to ensure compliance with applicable community floodplain management ordinances, to determine the proper insurance premium rate, and/or to support a request for a Latter of Map Amendment or Revision (LOMA or LOMR). Instructions for completing this form ~an be found on the following pages. SECTION A PROPERTY INFORMATION BUILDING OWNER'S NAME Michael Withers STREET ADDRESS (Including Apt.. Unit. Suite end/or Bldg. Number) OR P.O. ROUTE AND BOX NUMBER 6635 New Suffolk Road O3~IER DESCRIPTION (Lot and Bh3ck Numbers. e~c.) 1000-117-5-24 CITY STATE ZIP CODE New Suffolk NY 11956 SECTION B FLOOD INSURANCE RATE MAP (FIRM) INFORMATION Provide the following from the proper FIRM (See Instructions): 7. I~dicate the elevation datum system used on the FiRM for Base Ftood Elevations (BFE): [] NGVD '29 [] Other (describe on b~ck) 8. For Zones A or V, where no BFE is provided on the FIRM, and the community has established a BFE for this building site, Indicate the community's BFE:! I t I I I.b_J feet NGVD (or other FIRM datum-see Section B, Item 7). SECTION C BUILDING ELEVATION INFORMATION 1. Using the Elevation Certificate Instructions, indicate the diagram number from the diagrams found on Pages 5 and 6 that best describes the subject building's reference level 2(a). FIRM Zones Al-A30, AE, AH, and A (with BFE}. The top of the reference level floor from the selected diagram is at an elevation of l I I I 1 81 .L.SJ feet NGVD (or other FIRM datum-see Section B, Item 7). (b). FIRM Zones V1-V30, VE, and V (with BFE). The bottom of the lowest horizontal structural member of the reference level from the selected diagram, is at an elevation of I I I I t I.LJ feet NGVD (or other FIRM datum-see Section B, Item 7). (c). FIRM Zone A (without BFE). The floor used as the reference level from the selected diagram is I I I.LJ feet above [] or below [] (check one) the highest grade adjacent to the building. (d). FIRM Zone AO. The floor used as the reference level from the selected diagram is I I I.LJ feet above [] or below [] (check one) the highest grade adjacent to the building. If no flood depth number is available, is the building's lowest floor (reference level) elevated in accordance with the community's floodplain management ordinance? [] Yes [] No [] Unknown 3. Indicate the elevation datum system used In determining the above reference level elevations: [] NGVD '29 [] Other (describe under Comments on Page 2). (NOTE: If the elevation datum used in measuring the elevations is different than that used on the FIRM [see Section B, Item 7], then convert the elevations to the datum system used on the FIRM and show the conversion equation under Comments on Page 2.) 4. Elevation reference mark used appears on FIRM: [] Yes [~ No (See Instructions on Page 4) 5, The reference level elevation is based on: [] actual construction [] construction drawings (NOTE: Use of construction drawings is only valid if the building does not yet have the reference level floor in place, in which case this certificate will only be valid for the building during the course of construction. A post.construction Elevation Certiticate will be required once construction is complete.) 6. The elevation of the lowest ~ade immediately adjacent to the building is:l I I I 17 t.L0J feet NGVD (or other FIRM datum-see Section B, Item 7). SECTION D COMMUNITY INFORMATION 1. If the community official responsible for verifying building elevations specifies that the reference level indicated in Section C, Item is not the "lowest floor" as defined in the community's floodplain management ordinance, the elevation of the bufldlng's "lowest floor" as defined by the ordinance is: I I I I I I.LJ feet NGVD (or other FIRM datum-see Section B. Item 7). '~ D,~te of the start of construction or substantial improvement FEMA Form 81-91~ MAY 90 REPLA(~ES ALL PREVIOUS EDITIONS SEE REVERSE SIDE FOR CONTINUATION Board Of $outhold Town Trustees SOUTHOLD, NEW YORK ISSUED TO Pursuant to the prov;slons of Chapter 615 of the Laws of the State of New York, 1893: end Chapter 404 of the L.aws of the State of New York 1952; end the Southold Town Ordinance tiffed "REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, GRAVEL OR OTHER IvlATERIALS FROid LANDS UNDER TOWN WATERS:" and in accordance with the Resolution of The Board adopted et a meeting held on . 19 c)7, and in consideration of the sum of $ I50~00 paid by Samuels & Stee!man pn behalf of M.. W!!h~rs ......... of N.Y. and subject to the Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: to construct a 950 s.f. one story additionto an ekisting 1 112 story wood framehouse , a dormer addition to an existing garage gravel parkign area, two 6t high fences as per site palnd da~ed 3131197. all in accordance with the detailed specifications as presented in the originating application. IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be affixed, and these p.resenh to be subscribed by a mejorlty of the sa~d Board as of th~s dat~. Albert J. Krupski, President John Holzapfel, Vice President Jim King Martin H. Garrell Peter Wenczel Town Hail 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) 765-1892 Fax (516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD May 2, 1997 Samuels & Steelman Architects 25235 Main Road Cutchogue, NY 11935 Re: Mike Withers SCTM #117-5-24 Dear Ms. Steelman: The following action was taken bY the Board of Town Trustees during its regular meeting held on April 30, 1997 regarding the above matter: WHEREAS, Samuels & Steelman on behalf of MIKE WITHERS applied to the Southold Town Trustees for a permit under the provisions of the Wetland ordinance of the Town of Southold, application dated April 4, 1997, and, WHEREAS, said application was referred to the southold Town Conservation Advisory Council for their findings and recommendations, and WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on April 30, 1997, at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standard set forth in Chapter 37-18 of the Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees grant a Wetland Permit to construct a 950 s.f. one story addition to an existing 1 1/2 story wood frame house, a dormer addition to an existing garage, gravel parking area, two 6' high fences as per site plan dated 3/31/97, and, BE IT FURTHER RESOLVED that this determination should not be considered a determination made for any other Department or Agency which may also have an application pending for the same or similar project. Permit to construct project will expire two years from the date it is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Two inspections are required and the Trustees are to be notified upon completion of said project. FEES: None. Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/jmd PI~ANNING BOARD MEMBERS BENNETT ORLOWSKI, JR. Chairman WILLIAM J. CREMERS KENNETtt L. EDWARDS ¢;EORGE RITCttIE LATHAM, JR. RICHARD G. WARD Town Hall, 53095 Main Road P.O, Box 1179 Southold, New York 11971 Fax (516) 765-3136 Te]ephone (516) 765-1938 May 13. 1997 PLANNING BOARD OFFICE TOWN OF SOUTHOLD Nancy Steelman Samuels & Steelman Architects 25235 Main Rd. Cutchogue, NY 11935 Re: Request for site p~an waiver for Withers Residence/Marina, New Suffolk SCTM# 1000-117-5-24 Dear Ms. Steelman: The following resolution was adopted by the Southold Town Planning Board at a meeting held on Monday, May 12, 1997: WHEREAS, Michael Withers is the owner of the properly known and designated as SCTM# 1000-117-5-24 located on New Suffolk Road in New Suffolk; and WHEREAS, this site plan is for an addition to a residence and to expand an existing marina parking lot, and to create ,~ new entrance to the parking area, separate from the entrance to the residence; and WHEREAS, the residence and marina would require 12 parking spaces; and WHEREAS, provision has been made for 12 parking spaces; and WHEREAS, an examination has been made of all uses and the existing parking was determined to be adequate for all uses; and WHEREAS, 'the proposed changes of an addition to the residence and expansion of the parking lot will not be a more intensive use of this property; and WHEREAS, the subject property is 1.62 acres, and has been improved by a pre- existing 1-1/2 story residence, five floating docks, and one stationary dock; and Page 2 Site plan waiver for Michael Withers May 13, 1997 WHEREAS, both the residence and the marina are permitted uses in this Marine I (M-I) zone; and WHEREAS, any violation of the conditions of this resolution may be grounds for rescinding this waiver; be it therefore RESOLVED, that the Southold Town Planning Board grant a waiver of site plan requirements. Please contact this office if there are any questions regarding the above. Sincerely, Chairman cc: Building Department Zoning Board of Appeals Ed Forrester, Town Investigator ~7f:)~p 765-1802 BUilDING DEPT. INSPECTION [ ] FOUNDATION 1ST [~UGH PLBG. [ ] FOUNDATION 2ND [] INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: ~~~ /~ ~~- ~~~~(iPR/ ' f4y'j1 ~~-. ~~ DATE ~# - ~.. ~ ., ~ d->L d- r~ c 765-1802 UILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] FOUNDATION 2ND [ 4RAMING [~GH PLBG. [ ] INSULATION [ ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: ;;; < INSPECTOR - --- -------- - --- .d~bJj2c - 765-1802 BUilDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] FOUNDATION 2ND [ ] FRAMING [ ] FIREPLACE & CHIMNEY [ ] ROUGH PLBG. [ ] INSU l'ION ? REMARKS: oa DATE I It l/Jj) / ' INSPECTOR - ~ y; ;).:s cE':C:- 765-1802 BUilDING DEPI'. INSPECTION [ ] FOUNDATION 1 ST [ ] F~DATION 2ND [ vrFRAMING [ ] FIREPLACE & CHIMNEY ~ ~ ~ [~GH PlBG. [ ] INSULATION [ ] FINAL - DATEjr)/~!r7 INSPECTOR ~JIJ5g1? 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [] ~UGH PLBG. [ ] FOUNDATION 2ND [0INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY ;2 ;-vr/ ? RE~K~: ~ ~' '1~;2 :+1"U-,{d.~ 01< ' DATE II /7 /'11 INSPECTOR ~~. / / ~41--58~ 765.1802 BUILDING DEPT. INSPECTION [ ~OUNDATION 1ST [ ] FOUNDATION 2ND [ ] FRAMING [ ] FIREPLACE & CHIMNEY REMARKS: ~ /L~ ~ ~:-( ~ 1::;,)- ;t.:-~~6 CJ ~ ,OK ;L c,.. -:t=- ~. M1M fRAMING UNTIl. SURVEY Of~N HAS BEEN A~D [ ] ROUGH PLBG. [ ] INSULATION [ ] FINAL DATE t;,h f7 INSPECTOR ~~ ~. ! ~!:!!. 11I:i 1'1' \ I I ._.....""_ \111 II __.._..~r\llll ...,....-....... . FIll ,". ' . 1I1"flTIII/-' ( ': i .~: ! ':!!U!!II^TIUI/ . __"."...._(21111) .......... ......__-:__ 1 '11JlIl:1I rr 11M l!~ " "1.1111111'1(: . 11::11\ ^TI . . 011 "I:;n II ':T^Tl' . . 1',III:;l\ny r:mw y ............. ............- .............. ................................ ...-......-...-... I 7------. I~ . l; ._. _I., ,. I"' II"!. ......-... ...........-............ ...--.........-..........- ----- .------- -..._--......_--......_----~...~~...---_.._------- -- - --~--~~~~~~;~~~~~~II^~-~----_._------------------ /p "" <$'? -------,-~''''''''".". ---------. ......_--......~---------_..._... ...-...................... .~ ~o ~ L..- .:z55'(g ~,).J.."'JJq 7" ~cI\ I . '~...u nhJ ~"'~ - "'~. M ~ ': t ~" ;f:",:' ,;' ~ ~ ~ ~ ~~ ~'-\'~ v C:::; :z: " ~ ~ ~ f ~ ~ ~ ~ o ~I @. ~. 1,1 "- ~, ~ ~ ~J ~ I:I...=>- t>~ '\ r'O " ~, ~ '" 1'1 " -'I -..,........--...-...- " [1. if: I" P " :r:- ..., i" . . [) FORM NO.1 BO'\~D'Of IIEALTlI ......... J SETS Of PL~NS .. ....... SURVEy.................. CIICCI( ...... _ . . . . . . . . . . . . SEPTIC fOIW ...:......... /~~i. TOWN OF SOUTHOLD BUILDING DEPARTMENl: TOWN HALL SOUTHOLD. N.Y. 11971 TEL.: 765-1802 , Iff?l ' :::. i?::: ::1}permit No.r7~~cf? _.__...__~'.,-'".~ __J \ \ - -(;-. "! '. Examined , I nOT 1 FY : . CHL 7.3.1-;-~4:1s......... HAIL TO: . .2~~~e>hn Rd. . . . . . .q,)Q,~ .t\J+ '. Jl<0.$ Disapprov . F . ;-)..... AP fCATlON FOR BUILDING PERMIT Date. . . . .cP/L(a .. . . . ., 19 el7 INSTRUCTIONS a. This 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 preniises, 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 Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Penn it pursuant to the Building Zone Ordinance of the Town ,of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or lOlition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, buildin de, hous 19 ode, and regulations, and to admit authorized inspectors on premises and in building for necessary in c 1S. ( plicant, or name, if a corporation) .~5)30. f':1-.o..;.0.KdP".c!. .W~h.~Cf!i~ Ny.... (Mailing address of applicantY 1/905 State whether applicant is owner, lessee,agent, architect, engineer, general contractor, electrician, plumber or builder. . . . . A re.h.;. f.e(:. f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . Name of owner of premises .. M i .c, h a. ~.1. . W.i.thf.f1? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized orricer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . (Name alld title of corporate officer) Builder's License No. ..... _ -:-: . . . . . . , . . . . . . . . . . Plum ber's License No. .............. " . . . . . , . . . Electrician's License No. ... ~. . . . . . . . . . . . . . . . . Olher Trade's License No. .................,... I. Location of land ou which proposed work will be done. ................................................. . .~(P? ~..... .I\J.",W .s"{rdk..B.~.... .1'k..v. Su.fG .u~-J. NV..... .d............... 1I0use Number Street Hamlet!' County Tax Map No. 1000 Section ... J /.7. . . . . . . . .. Block.. .0.5 . . . . . . . : . " Lot...:).. 4. . . . . . . . . . . Subdivision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filed Map No. .............. Lot............... , (Name) , I State existing use and occupancy or premises and intended use and occupancy of proposed construction: S,r-:j/e +a.m;/l,f. f't'sicLer1ce ............. '1. Existing use and occupancy ......... .............. '/ . . . . . . .; . . . . . . . . . . . . . . . . . . . SIY1,o,/~ -h......,,(I'>-I ((''i/cU-t1.Ce ' ............... 'tended use and occupancy ...... '0' . . . . . . . . . .. ..f......................... ---- 9. 10. II. 12. 13. 14. 3. N"lure of work (check which applic"ble): New Building. . . . . . . . . . Addition... .~.. Alteration .. v.:-:~ . . Repair .............. Removal. . . . . . . . . . . . .. Demolition ....:......... Other Work. . . . . . . . . . . . . . . . - .. .. .. (Description) - . , #' I::> o OOZY .. _ 4. Eslllnated Cost. . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . Fee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (to be paid on filing this application) 5. If dwelling. number of dwelling units. . . . . . ./. . . . . .. Numbcr of dwelling units on each noor. . .~. . . . . . . . . . . If garage, number of cars ........................................................................ 6. If business, commercial or mixed Occupancy, specify nature and extent of each type of Use .... .7-:.............. 7. Dimensions of existing structures, if "ny: I'ront . . . :1~~'. . . . . . . . Rear ..:t. ~.'. . . . . . .. Depth . .3~.'. . : . . . . . . . 2b' . . ./' lIelght ... . .:t. . . . . . . Number of Stones. . . . .. ,2, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimensions of some stn/cture with alterations or ,,"ditions: Front .....::J.t.......... Rear. . 10.'... . . . . . . . . Depth. . . .5.1.'. . . . . . . . . . . . . . Height. . . . . .'4$.' ,1::. . . . . . . . ... .. Number of Stories. . . . .1ft. . . : . . . . . . . . . . 8. Dimensions of entire new constn/ction: Front. . . . .-:-; . . . . . . .: Rear.....-:-:-........ Depth . -:-. . . . . . . . . . . . . lIeight ........-;...... Number of Stories. . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Size of lot: Front . . . Sa:. 'j,lt!!:. Plat:>. . " Rear...................... Depth ...................... Date of Purchase .. 1~7.'i:l r<. . . . . . . . . . . . . . . . . . . Name of Fonner Owner ............................. Zone or use district in which premises are situated. . . . . . . M:-: I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Does proposed constructiA>9 violate any zoning law, ordinance or regulation: .NO,........................... Will let be regra.ded .. ./.Vo... . . . . . . . . . . . . . . . . . . . . Will excess fi~ be removed ~ro n premises: Yes. ~ Name of Owner of premises .I)'J.~ P.1q~/.W~'I:1u r$. Addresi>7a .if, . ."!'. "f NIl-! . Phone No."V~ :7( ~ .4. ~'!. . . . Name of Architect~~(S. 't-:~r.~ . . . . . . Address .;;l5;;l3.5 JJ..Alt:I.RcI. ..1t!Jt,one No. .73",.f.;,...,P$; .. . Name of Contractor. . .-:-. . . . . . . . . . . . . . . . . . . . . . Address. . :-;- . . . . . . . . . '..;--' . . Phone No. . . . . . . . . . . . . . . . Is this property within 300 feet of a tidal wetland? *Yes...~... No......... *If yes, Southold Town Trustees Permit may be required. s..a Rr~..t: PLOT DIAGRAM 15. 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. . . 'See cs',+e- p (Qt') . ;TATE OF NEW YORK, S S ;OUNTY Clt' r . . . . . . . . . . . . . .. . . . ~ . . . . . . N.().(\.~. . .S.t.eef.mo..r\ . " . . . . . . .. being duly sworn, deposes and says that he is!'pe applicant I' (Name of' dividual signing contract) " hove Jl<.J III cd. [e is the.... .Ar.<:;-h'd~f.. ~.+................ ................................................... (Contractor, agent, cofporate officer, etc.) .. r said owner or owners, and is duly authorized to perform or have perfonned the said work and to makeimd file this pplic"tion; that all statements contained in this application are true to the best of his knowledge and belief; and thai the 'ork will be performed in the manner set forth in the application filed therewith. . worn to before m~ '} . / 1& - 0.--,./ -., .. . . . . . . . . . . . . . . . . . . . . .day of.. .~........ 19.7." / (,I OlarYPUblic'~Ud:X~~ty.../.r '.'. ))/~.I.. II HEtF.NE O. HORNE l. .li:Jt.rJ.t '~r?M~.. IIIntarypu1Jlic, Slo;e "fNewYork (SignallJre of ~Jo. 4"51 ;lfJ4 . ~ t!un!ifirJ(f in S'tffo"'< County Pj! C'-'Jlnm,,;,"'t~n r"':,j'f'" f. 'I""''' 'J .;; 1<) . I ..:>, 4" ._~.. . _ _ - . ~ w.d/ 444<",.. ""- ~ ,... , JUDITH T. TERRY TOWN CLERK REGISTRAR OF VlTAL STATISTICS MNmlAGE OFFICER RECORDS MANAGEMEI'IT OFFICER FREEDOM OF INFORMATION OFFICER Town Hall. 53095 Main Road P.O. Box 1179 Soulho1d. New York 11971 Fax (516) 765.1823 Telephone (516) 765.1801 OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION WAS ADOPTED BY THE SOUTHOLD TOWN BOARD AT A REGULAR MEETING HELD ON AUGUST 24, 1993: RESOLVED that the Town Board of the Town of Southold hereby adopts two (2) new forms to be used under the Flood Damage Prevent regulations of the Code of the Town of Southold: "Floodplain Development Permit Application" [FDP(93)], and "Certificate of Compliance for Development in Special Flood Hazard Area [C/C(93)]. .-'1 ~ - _ J ;;1' " _.._,..-~' 8L.~\3. Dr.: PT. TOWN OF SOUlHOLD ~~ . ~T.T~ Southold Town Clerk August 25, 1993 ........ . APPLICATION # PAGE 1 of 4 TOWN OF SOUTHOLD FLOODPLAIN DEVELOPMENT PERMIT APPLICATION This form is to be filled out in duplicate. SECTION 1: GENERAL PROVISIONS (APPLICANT to read and sirn): 1. No work may start until a permit is issued. 2. The permit may be revoked if any faIse statements are made herein. 3. If revoked, all work must cease until permit is re-issued. 4. Development shall not be used or occupied until a Certificate of Compliance is issued. 5. The permit wilJ expire if no work is commenced within six months of issuance. 6. Applicant is hereby informed that other permits may be required to fulfill local. state and federal regulatory requirements. 7. Applicant hereby gives consent to the Local Administrator or his/her representative to make reasonable . inspections required to verify compliance. 8. I, THE APPLICANT, CERTIFY THAT ALL STATE . THIS APPLICATION ARE, TO T T OF MY (APPLICANT'S SIGNATUR NTS HEREIN AND IN ATTACHMENTS TO o EDGE, TRUE AND ACCURATE. DATE 7i9.J/Q7 / SECTION 2: PROPOSED DEVELOPMENT (To be comoleted bv APPLlCANTI NAME ADDRESS TELEPHONE APPLICANT BUILDER ENGINEER PROJECT LOCATION: To avoid delay in processing the application, please provide enough information to easily identify the project location. Provide the street address, lot number or legal description (attach) and, outside urban areas, the distance to the uearest intersecting road or well.known landmark. A sketch attached to this application showing the project location would be helpful. FDP(93) ~l. :1 APPLICATION # PAGE 2 OF 4 DESCRIPTION OF WORK (Check all applicable boxes): A. STRUCTURAL DEVELOPMENT ACTIVITY STRUCTURE TYPE o New Structure o Addition o Alteration o Relocation o Demolition o Replacement o Residential (1-4 Family) o Residential (More than 4 Family) o Non-residential (Floodproofmg? 0 Yes) o Combined Use (Residential & Commercial) o Manufactured (Mobile) Home (In Manu- factured Home Park? 0 Yes) ESTIMATED COST OF PROJECT S B. OTHER DEVELOPMENT ACTIVITIES: o Fill 0 Mining 0 Drilling 0 Grading o Excavation (Except for Structural Development Checked Above) o Watercourse Alteration (Including Dredging and Charmel Modifications) o Drainage Improvements (Including Culvert Work) o Road, Street or Bridge Construction o Subdivision (New or Expansion) o Individual Water or Sewer System o Other (Please Specify) After completing SECTION 2, APPLICANT should submit form to Local Administrator for review. SECTION 3: FLOODPLAIN DETERMINATION (To be comnIeted bv LOCAL ADMINISTRATOR) The proposed development is located on FIRM Panel No. , Dated The Proposed Development: o Is lli2I located in a Special Flood Hazard Area (Notify the applicant that the application review is complete and NO FLOODPLAIN DEVELOPMENT PERMIT IS REQUIRED). o Is located in a Special Flood Hazard Area. FIRM zone designation is lOO-Year flood elevation at the site is: Ft. NGVD (MSL) o Unavailable o The proposed development is located in a floodway. FEFM Panel No. Daled o See Section 4 for additional instructions. SIGNED DATE . APPLICATION # PAGE 3 OF 4 SECTION 4: ADDITIONAL INFORMATION REOUlRED (To be comoleted bv LOCAL ADMINISTRATOR) The applicant must submit the documents checked below before the application can be processed: o A'site plan showing the location of all existing structures, water bodies, adjacent roads, lot dimensions and proposed. development. o Development plans, drawn to scale, and specifications, including where applicable: details for anchoring structures, proposed elevation of lowest floor (including basement), types of water resistant materials used below the first/loor, details of /loodproofmg of utilities located below the fifst floor and details of enclosures below the fifst /loor. Also, o Subdivision or other development plans (If tbe subdivision or other development exceeds 50 lots or 5 acres, whiehever is the lesser, the applicant must provide 100-year flood elevations if they are not otherwise available). o Plans showing tbe extent of watercourse relocation and/or landform alterations. o Top of new flll elevation Ft. NGVD (MSL). o F1oodproofing protection level (non-residential only) Ft. NGVD (MSL). For /loodproofed structures, applicant must allach certification from registered engineer or architect. o Certification from a registered engineer that the proposed activity in a regulatory /loodway will not result in !!!l\' increase in the height of the 100-year flood. A copy of all data and calculations supporting tbis fmding must also be submitted. o Other: SECTION 5: PERMIT DETERMINATION (To be comoleted bv LOCAL ADMINISTRATOR) I bave determined tbat tbe proposed activiry: A. 0 Is B. 0 Is not in conformance with provisions of Local Law # , 19 . The permit is issued subject to the conditions attached to and made part of this permit. -- SIGNED ,DATE If BOX A is checked, the Local Administrator may issue a Development Permit upon payment of designated fee. . If BOX B is checked, the Local Administrator will provide a written summary of deficiencies. Applicant may reVlse and resubmit an application to the Local Administrator or may request a hearing from tbe Board of Appeals. r &~, APPLICATION # PAGE 4 OF 4 APPEALS: Appealed to Board of Appeals? 0 Yes 0 No Hearing date: Appeals Board Decision no Approved? 0 Yes 0 No Conditions SECTION 6: AS-BUILT ELEVATIONS (To be submitted bv APPLICANT before Certificate of Comoliance is issued) The foDowing information must be provided for project structures. This section must be completed by a registered professional engineer or a licensed land surveyor (or attach a certification to this application). Complete 1 or 2 below. 1. Actual (As-Built) Elevation of the top of the lowest Ooor, including basement (in Coastal Hi2h Hazard Areas, bottom of lowest structural member of the lowest Ooor, excluding piling and columns) is: FT. NGVD (MSL). 2.' Actual (As-Built) Elevation of OoodprooflDg protection is FT. NGVD (MSL). NOTE: Any work performed prior to submittal of the above information is at the risk of the Applicant. SECTION 7: COMPLIANCE ACTION (To be com DIeted bv LOCAL ADMINISTRATOR) The LOCAL ADMINISTRATOR will complete this section as applicable based on inspection of the project to ensure compliance with the community's local law for Oood damage prevention. INSPECfIONS: DATE DATE DATE BY BY BY DEFICIENCIES? 0 YES 0 NO DEFICIENCIES? 0 YES 0 NO DEFICIENCIES? 0 YES 0 NO SECTION 8: CERTIFICATE OF COMPLIANCE(To be comoleted bv LOCAL ADMINISTRATOR) Certificate of Compliance issued: DATE: BY: o. . Attachment B SAMPLE CERTIFICATE OF COMPLIANCE for Development in a Special Flood Hazard Area . .., . TOWN OF SOUTHOLO CERTIFICATE OF COMPLIANCE FOR DEVELOPMENT IN A SPECIAL FLOOD HAZARD AREA (OWNER MUST RETAIN TIllS CERTIFICATE) PREMISES LOCATED AT: PERMIT NO. PERMIT DATE OWNERS NAME AND ADDRESS: CHECK ONE: o NEW BUILDING o EXISTING BUILDING o VACANT LAND TIlE LOCAL ADMINISTRATOR IS TO COMPLETE A. OR B. BELOW: A. COMPLIANCE IS HEREBY CERTIFIED WITIl TIlE REQUIREMENTS OF LOCAL LAW #_,19_ SIGNED: DATED: B. COMPLIANCE IS HEREBY CERTIFIED WITIl TIlE REQUIREMENTS OF LOCAL LAW # ,19_, AS MODIFIED BY VAR1ANCE # DATED SIGNED: DATED: C/C(93)