HomeMy WebLinkAbout29845-ZFORM NO. 4
TOWiqOF SOUTHOLD
BUILDING DE~A-RTMENT
Office of the Building Inspector
To~rn Hall
Southold,
CERTIFICATE OF 0CCUP~CY
No: Z-30330 Date: 08/05/04
T~IS CERTIFIES that the building ADDITIONS/ALTERATIONS
Location of P~operty: 41780 MAIN P~D PECONIC
(HOUSE NO.) (STREET) (HAMLET)
County Ta~ Map No. 473889 Section 86 Block 1 Lot 7
Subdivision Filed Map No. Lot No.
conforms substantially to the _Application for Building Permit heretofore
filed in this office dated OCTOBER 20, 2003 pursuant to w~ich
Building Permit No. 29845-Z dated OCTOBER 27, 2003
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 ADDITIONS & ALTERATIONS TO ~ EXISTING SINGLE FAMILY DWELLING AS
APPLIED FOR.
· ~he certificate is issued to SCOTT & MELISSSA DESIMONE
(OWlqER)
of the aforesaid building.
SuFFOI~K CO~ DHpis~RT%%~lqT OF B}L~J~TR D~PPRO~-AL R10-03-0118 07/27/04
ELECTRICAL CERTIFICATE NO. 85631C 07/15/04
PLUMBERS CERTIFICATION DATED 07/19/04 CUTCHOGUE EAST PLUMBING
Rev. 1/81
FORM NO. 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Hall
Southold, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES WNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
PERMIT NO. 29845 Z
Date OCTOBER 27, 2003
Permission is hereby granted to:
SCOTT DESIMONE
41780 ROUTE 25
PECONIC,N~f 11958
for
ADDITIONS AND ALTERATIONS TO Aiq EXISTING SINGLE FAMILY DWELLING AS
APPLIED FOR
at premises located at 41780 MAIN RD
County Tax Map No. 473889 Section 086
pursuant to application dated OCTOBER
Building Inspector to expire on APRIL
Fee $ 339.30
PECONIC
Block 0001 Lot No. 007
20, 2003 and approved by the
27, 2005.
ORIGINAL
Rev. 5/8/02
Form No. 6
TOWN OF SOUTHOLD
BUILDING DEPART3fENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be filled in by typewriter or ink and submitted to the Building Department with the following:
A. 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 sexverage-disposal (S-9 form).
3. Approval of electrical installation fi.om Board of Fire Underv~iters.
4. Sworn statemem from plmnber certifyiug that the solder used m system contains less than 2/10 of 1% lead_
5. Commercial building, industrial bu/Iding, mriltiple residences and s[milar buildings and instal2ations, a certifieate
of Code Compliance from architect o~- engineer responsible for the building.
6_ Submit Plaxming Board Approval of completed site plan reqtdrements.
B. For ex%ting buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses:
I. Accurate sun'ey of property showing all property lines, s~eets, building and marsuai natural or topographic
features.
2. A properly completed apphcation m~d consent to inspect signed by the applicant. If a Certificate of Occupancy is
deined, the Building Inspector shall state the reasons therefor in writing to the applicant.
C. Fees 1. Certificate of Occupancy - New dwell/rig $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00,
Swimm/ng pool $25.00, Accessory building $25.00, Additions to accessory binldh~g $25.00, Businesses $50_00.
2_ Certificate of Occupancy on Pre-existing Building - $100.00
3. Copy of Certifieate of Occupancy - $.25
4. Updated Certificate of Occupancy - $50_00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
New Construction:
Location of Property:
House No.
Owner or Owners of Property: ~ d77'~ ~ ~'~r-~.~
Suffolk Count3' Tax Map No 1000, Section
Old or Pre-existi~g Building:
Street
t,~ (chec~ one)
Hamlet
Block i (~ / Lot W
Subdivision
Permit No. ~] ~Z
Health Dept. Approval:
Date of Permit.
Filed Map. Lot:
Uudenvriters Approval: ~
Planning Board Approval:
Request for: Temporm3' Certificate
Final Certificate:
~(checkone)
Fee Submitted:
Issue Date Electrical Inspection Service, Inc. Application
7/16/04 375 Dunton Avenue 8563 IC
East Patchogue, NewYork 11772
(631) 286-6642
Issued To: Mr. DeSimone
Street: 41780 Route 25 Police Station
Village: Peconic Zip: 11958 Town: Southold
Section: Block: Lot:
Contractor: Brite Star Electric Lic.# 3398-E
Was examined and found to be in compliance with the National Electrical Code.
[] Commercial [] NVDefects --, Pool [] lstFIoor [] Indoor [] Basement [] HotTub
[] Residential [] Det. Garage ~X~ Attic [] 2nd Floor [] Outdoor [] Addition [] Survey
Switches Receptacles Fixtures GFI Heaters
48 58 75 12
Dishwasher Washer/Amps Dryer/Amps Oven Range/Amps
1/20 1 20 1 30 1 gas
Furnace Oil Gas Circulators Smoke Detector
2 air BY OTHERS
Meter Amps Phase UG/OH Jacuzzi Television
1 200 1 ,~
A/C Fans
2 5
Microwaves
Bell Transformer
CO Detector
Bldg. Permit:
Other Equipment
,50~20V a\c / ! 30',220V a\c / 1 50~2.20V
)ven/ 1 60\220V sub panel / 1 15\220V air
'~andler
Hugo S. Surdi
President
Rough fnspectJon: 03/30/2004
Inspector: John Mc Mahon III
Final [nspec-bion: 07/15/2004
Inspecbor: John Mc Mahon III
This certificate must not be altered in any manner. Inspectors may be identified by their credentials.
Town Hall, 53095 Main Road
P. O. Bc, x 1179
Southold, New York 11971
Fax I516) 755-1.~23
Talephons (516) 765-1802
OFF~CE OF THE ~IL;ILDING ~NSP~CTOR
TOWN OF '-SOUTHOLD
CER~2FI
CA~3ION
Building Permit No,
Owner.'
(please print)
I certify that the solder used in the water supply system
contains less thar~ 2/10 of
Sworn to before
Notary Public,
1% lead,
Qualified in @uffo{k County
Commission Expires May 20
County
Permit Number
Checked By/Date
REScheck Compliance Certificate
New York State Energy ConServation Construction Code
REScheckSofzware Version 3.5 Release lc
Data filename: CSProgram Fi/e~\Check~?dSScheck\deSIMONE.rck
TITLE: DE SIMONE
COUNTY: Suffolk
STATE: New York
HDD: 5750
CONSTRUCTION TYPE: Detached 1 or 2 Family
HEATING TYPE: Non-Eleetric
DATE: 10/17/03
DATE OF PLANS: OCTOBER 2003
PROJECT INFORMATION:
ADDITION
COMPANY INFORMATION:
CHARLES M. THOMAS
ARCHITECT
COMPLIANCE: Passes
Maximum UA = 231
Your Home UA = 225
2.6% Better Than Code (UA)
Gross Glazing
Area or Cavity Cont. or Door
Perimeter R-Value R-Value U-Factor UA
Ceiling I: Flat Ceiling or Scissor Tress
Wall 1: Wood Frame, 16" o.c.
Window 1: Wood Frame:Double Pane
Door l: Glass
Floor l: All-Wood JoistYTruss:Over Outside Air
676 30.0 0.0 24
1481 15.0 0.0 100
132 0.340 45
54 0.340 18
805 19.0 0.0 38
COIVlPLIANCE STATEMENT' The p~9o~'~7,.~.i,.~: t.e f_...'e :er. ted ~ this document is consistent w~th the braiding plans.
specifications, and other ca.cu! ~.,:,:,. ,~,,~.-.m~¢da. ;i~ Ir,,'c r"~-'..' 4. p!,c ation. The proposed systems have been designed to meet the
New York State Energy C,:.r.: e r, ~h~.h.&'~-!7 rYuc ?.::.r, ,~o& ~¢ciu~e,.,e r.i. When a Registered Design Professional has stamped and
s~gned tiffs page, they are ~.e:l.,', ~ ~:mc e_,.~ll~:.! hh: r..,~r L*.o., ~cd~e, behef~ and profess~o~aljudgme~t, such plans or
specifications are in comph ~r, cc
,., .' ,,
t~uuuevues,gner ' . '.a"-", ,,-
REScheck Inspection Checklist
New York State Energy Conservation Construction Code
REScheckSof~ware Version 3.5 Release lc
DATE: 10/17/03
TITLE: DE SIIvIONE
Dept.
Use
[ I
[ ]
[ ]
[ I
[ ]
[ l
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
Ceilings:
1. Ceiling 1: Flat Ceiling or Scissor Truss, R-30.0 cavity insulation
Comments:
Above-Grade Walls:
1. Wall 1: Wood Frame, 16" o.c., R-15.0 cavity insulation
Comments:
Windows:
I. Window 1: Wood Frame:Double Pane, U-factor: 0.340
For windows without labeled U-factors, describe features:
# Panes Frame Type. Thermal Break? [
Comments:
]Yes[ ]No
1. Door 1: Glass, U-factor: 0.340
Comments:
Floors:
1. Floor I: Ali-Wood Joist, rrruss:Over Outside Air, R-19.0 cavity insulation
Comments:
Air Leakage:
Joints, penetrations, and all other such openings in the building envelope that are sources of axr
leakage must be sealed.
Recessed lights must be 1) Type IC rated, or 2) installed inside an appropriate air-tight assembly
with a 0.5" clearance fi-om combustible materials. If non-lC rated, the FLxtare must be installed with a
3" clearance fi.om insulation.
Vapor Retarder:
Required on the warm-in-winter side of all non-vented fi-arned ceilings, walls, and floors.
Materials Identification:
Materials and equipment must be installed in accordance with the manufacturer's installation instructions.
Materials and equipment must be identified so that compliance can be determined.
Manufacturer manuals for all installed heating and cooling equipment and service water heating
equipment must be provided.
Insulation R-values and glazing U-factors must be clearly marked on the building plans or specifications.
Duet Insulation:
Supply ducts in unconditioned attics or outside the building must be insulated to R-8.
Remm ducts in unconditioned attics or our. side the building must be insulated to R-4.
Supply ducts in unconditioned spaces must be insulated to R-8.
Return ducts in unconchtinned spaces (except basements) must be insulated m R-2.
Insulation is not required on return ducts in basements.
Duct Construction:
All joints, seams, and connections must be securely fastened with welds, gaskets, mastics
(adhesives), mastic-plus-embedded-fabric, or tapes. Duct mpc is not permitted.
Exception: Continuously welded and lockin?3'pe lungitudinal joints and seams on ducts
operating at [ess than 2 in. w.g. (500 Pa).
Ducts shall be supported every 10 feet or in accordance with the manufacturer's instructions.
] Cooling ducts with exterior insulation must be covered with a vapor retarder.
Air filters are required in the ret~ air system.
The I-IVAC system must provide a'means for balancing air and water systems.
Temperature Controls:
Each dwelling unit has at lesat one thermostat capable of automatically adjusting the space
temperaatre set point of the largest zone.
Electric Systems:
Separate electric meters are reqfftred for each dwelling unit.
Fireplaces:
Fireplaces must be installed with tight fitting non-combustible fireplace doors.
Fireplaces must be provided with a source of combustion air, as required by the Fireplace cons~mctinn
provisions of the Building Code of New York State, fire Residenzial Code of New York State or
the New York CiO, Building Code, as applicable.
Service Water Heating:
Water heaters with vertical pipe risers must have a heat ~rap on both the inlet and outlet unless the
water heater has an integral heat U'ap or is part of a circulating system.
Insulate circulating hot water pipes to the levels in Table 1
Cirunlating Hot Water Systems:
Insulate circulating hot water pipes to the levels in Table 1.
Swimming Pools:
All heated swimming pools must have an om"off heater switch and require a cover unless over 20%
of the heating energy is fi-om non-depletable sources. Pool pumps require a time clock.
Heating and Cooling Piping Insulation:
HVAC piping conveying fluids above 105 °F or chilled fluids below 55 OF must be insulared to the
levels in Table 2.
Table 1_ Minimum Insulation Title,ness for CircMating Hot }rater P~pes.
Insulation Thickness in Inches by Pipe Sizes
Heated Water Non-Circulating Runouts
Temperature (F) Up to 1" Up to 1.25"
170-180 0.5 1.0 1.5 2.0
140-160 0.5 0.5 1.0 1.5 ' "
100-130 0.5 50.5~ 0.5 1.0
Circulating Mains and Runouts
1.5" to 2.0" Over 2"
Table 2: Mininmm Insulation Thickneks for IfI~AC Pipes.
· Fluid Temp. Insulation Thickness in Inches by Pipe Sizes
Piping System Types Range (F) 2" Runouts 1" and Less · 1.25" to 2" 2.5" to 4"
Heating Systems
Low Pressure/Temperature 201-250 1.0 1.5 1.5 2.0
Low Temperature 120-200 0_5 1.0 1.0 1.5
Steam Condensate (for feed water) Arty 1.0 1.0 1.5 2.0
Cooling Systems
Chilled Water, Refi'igerant, 40-55 0.5 0.5 0.75 1.0
and Brine Below 40 1.0 1.0 1.5 1.5
NOTES TO FIELD (Building Department Use Only)
9
Town Of Southold
P.O Box 1179
Southo[d, NY 11971
* * * RECEIPT * * *
Date: 10/20/03
Transaction(s):
Septic Permit - Construct - Resid.
Receipt~:
Check#: 670
Total Paid:
67O
Subtotal
$10.00
$10.00
Name:
Desimone, Scott
41780 Main Rd
Southold N, Y 11971
Clerk ID: BONNIED internal ID: 82952
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 10/20/03
Transaction(s):
Septic Permit - Construct - Resid.
Receipt~:
668
Subtotal
$10.00
Check#: 668
Total Paid:
$10.00
Name:
Desimone, Scott
41780 Main Rd
Southold N, Y 11971
Clerk ID: BONNIED Internal ID: 82951
BUILDING PERMIT EXAMINER CHECKLIST
APPLICANT~ e %~ ,ot,~ ,,k e
SCTM# DISTRICT: 1,000, SECTION: ~C.~ , BLOCK: __
XDDRESS: 41 tad,,
BUILDING PERMITS OPEN/EXPIRED: PRE CO: Y OR N
BP -Z / C/0 Z- , INFO / BP
BP -Z / C/0 Z- INFO / BP
., LOT: 2Cb
ZONING DISTRICT:
DATE REVIEWED:
DATE SUBMITTED: 20_/~o/03
SUBDIVISION: ~d jr4
CONFOP~IING?
-Z / C/0 Z- , INFO
-Z / C/0 Z- , INFO
SINGLE & SEPARATE CERTIFICATION-REQUIRED NOTES:
LOTS 40,000SF -100~24. Lot recognition.(CREATED bet'ore June 30, 1983 ), LrN33ERSIZED LOTS FROM JAN.1997 100-25. Merger.(A nonconforming at any time after 7/1/83)
REQ. LOT SIZE: ACT. LOT SIZE~ REQ. LOT COV. ~ACT. LOT CO¥.
REQ. FRONT ~/0 PROP. FRONT / /R~EQ SIDE /~7/,_~' ACT. S]I)E
REQ. REAR TT') PROE. REAR t/' REQ. HEIGHT PROP_ HEIGHT
PROJECT DESCRIPTION: ~ql~]~'l~ '~) %7~
COST:, ~H~T/ENGINEER:
ESTIMATED PROJECT ~
WATER FRONT? ~ DESC~TION: ~
APPROVzkLS REQUIRI~D
PANEL # FLOOD ZONE: .J~'
SUFFOLK COUNTY ItE~H DEPT~'~ or NO,
TOWN SEPTIC RECEII~.' Y)or N --
NEW YORK STATE DEC:' ~"'"~
SOUTItOLD TOWN TRUSTEES: YES
TOWN ZONING BOARD APPROVAL: YES
TOWN PLAN. BO.~RD APPROV)~L: YES o
TOWN ltISTORICAL PRE (SPLIA): YES
NEW YORK STATE CODE COMPLLAxNCE (SEE PAGE 2):'
(BED#): V DTE,.77 //~ /,,ff
/ /
B~E: __/__/__
/DTE: / /
DTE: / /
F'X , DTE: / /__
PERIVIIT #: ~/o- 0'3-~'r 3/
PERMIT #:
PERMIT #:
PERMIT #:
PERMIT #:
S or NO
NOTE S:
1.(
2.(
FEE STRUCTURE: FOUNDATION: 'f '-SF
FIRST FLOOR:
SECOND FLOOR: ~' ,'z~2 SF
OTI-IER: SF
TOTAL: / ,'~c/t~'[ SF
SF)-- '(3./ S X$
SF)- ( SF)= SF X $__=$ +$
INIT OTHER TOTAL
FEE FEE FEE
+$ = $
3. (_ .SF)- ( SF)= SF X $__=$ +$ +$ = $
FINAL TOTAL:
NEW YORK STATE CODE COMPLIANCE CHECKLIST
Ground Snow Load: 45 ~V~ind Speed: 120MPH
Vqeathering:Severe / Frost Depth:36"-~/Ter.mite:M-H-/Decay:S-M/~/
Design Temp: 11 ,/Ice Shield Underlay: YES ~ Flood Hazards:
USE/OCCUPANCY CLASSiFICATIOn( -J
iq]EIGHT/FIRE AREA: /
TYPE OF CONSTRUCTION: . /
DESIGN CRITERIA: ENGINEERE~ -~~_~~ L~-OX4
FULL FRAMING DESIGN ELEMENT',~ -
lt~AI)ERS: YfN xW.a~LL STUDS: YfN
CEILING JOISTS: Y/N FLOOR JOLTS: YfN
LUMBER SPECLES .S2qD GILa. DE: Y/N
GIRDERS: Y/N
ROOF RAFTERS: YfN
WINDOW AND DOOR SCH2EDULE:
LIGHT 8 ~':/Y/N~/
VENT 4,%:/]ZAN- ~
NAm~G/CONSTRLJ~ION SCHEDUL~'~'~~'
MEANS OF EGRE~/N / ,
LOCATION OF FIRE PROTECTION EQUIPMENT: Y/N
TRUSS DESIGN: Y/N
CERTIFICATION:~B2q
ENERGY CALC~/Y/N ~
TOTAL COMPLIENC~I~/N (RETURN TO PAGE
ONE)
765-1802
BUILDING DEPT.
INSPECTION
[ ~FOUNDATION 1ST ]ROUGH
[ PLBG.
FOUNDATION 2ND
[ ] INSULATION
[ ] FRAMING [ ]FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS:
/ii/ , - ,,~
DATE
INSPECTOR
765-Z802
BUILDING DEPT.
INSPECTION
[ ] F/OUNDATION 1ST [
/
[ ~/]/FOUNDATION 2ND [
] ROUGH PLBG.
] INSULATION
[ ] FRAMING [ ]FINAL
REMARKS:
]FIREPLACE & CHIMNEY
I /
! ~/
DATE
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [~ROUGH PLBG.
[ ]/~OUNDATION 2ND [ ] INSULATION
[[ '~~IN~,,~ FIREPL~& CHIMNEY [[]] ~iRNEA~AFETY INSPECTION
REMARKs:~
DATE ~ INSPECTOR
/ ~'
!
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ]RO~GHPLBG.
[ ] FOUNDATION 2ND [~J INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS: -'~/~~'/'-C~) ~(--' -
DATE
INSPECTOR ~~'
f /
765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [,~O'~UGH PL.G.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS: //,-~~~/~'~ -~ r
DATE INSPECTOR
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST
[ ] FOUNDATION 2ND
[ ] FRAMING
[ ] ROUG~BG.
[ ] I~SI.ILATION
[ ~'~INAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
J~EMARKS:~/'~;~/~ ./~//~¢;'~ ,~
,-~.~¢~). /
DATE
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [/~INAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS: %~/ ~?
DATE ~~~--INSPECTOR
-TOWN OF SOUTItOLD
BUILDING DEPARTMENT
TOX%~I HALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
Fz~X: (631) 765-9502
w~v. no~hfor~ne~athol~
Ex · // 7,20
Disapproved ~c
BUILDING PERMIT APPLICATION CHECKLIST
Do you have or need fl~e fo/loxxSng, before applying?
Board of Heahh
3 sets of Binldmg Plans
P/arming Board approval
Surx ey
Check
Septic Form
N.¥.S.D.E.C.
Trustees
Contact:
Mail to:
~-'-- ~,, ~ Phone:
APPLICATION FOR BUILD~
INSTRUCTIONS
a. This application IvFUST be completely filled in by typewriter or m Lnk 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, relationstfip to adjoining preihises or pubiic streets or
areas, and waterways.
c. The work covered by this application rna3, not be commenced before issuance of Bu/lding Permit.
d. Upon approx, aI of this application, the Building Inspector will issue a Building Permit to the applicam. Such a pen~t
shall be kept on the prem/ses available for inspection throughout the work.
e. No binlding shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector
issues a Certificate of Occupancy.
f. Every building permit shall expire if the work authorhed has not connnenced witbnn 12 months after the date of
issuance or has not been com4~ieted witkm 18 months from such date. If no zoning amendments or other re~m. dations affecting the
property have been enacted in the interim, the Buildhig Inspector may authorize, in writing, the extension of the pemfit for an
addition six months. Thereafter, a new permit skall be required.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Buildhig Permit pursuant to the
Building Zone Ordinance of the Toxsm of Southold, Suffolk Count),, New York and other applicable Laws, Ordinances or
Re~m. dations, for the construction of buildings, additions, or akerations or for removal or demolirion as herein described. The
applicant agrees to comply with ali applicable laws, ordinances, bhildmg code, housing code, and re~mnlations, and to adm/t
author/zed inspectors on premises and in building for necessary inspections.
(Mailing address of applicant)
State whether applicm~t is owner, lessee, agent, architect, en~neer, general contractor, electricim~, plumber or builder
Name of mvner of premises
(As on ~he tax roll or lat[st de~d)
If applicant is a corporation, si~mmre of duly authorized officer
(Name and title of corporate officer)
Builders License No.
Plmnbers License No.
Electricians License No.
Other Trade's License No.
Location of land on which proposed work will be done:
7
House Number Street
Tax 000 ?:11
Subdivision
(Name)
Hamlet
Block /
Filed Map No.
2. State existing use and occupancy ofprenxises and intended use and occupancy of proposed construction:
a~ Existing use and occupancy
b. Intended use and occupancy
3. Nature of work (check which applicable): N~W Building
Repair Removal Demolition
4. Estimated Cost '~/OO/ ,'~ - '~tZ~a~,,r_,~7 Fee
5. If dwelling, number ofdwelling units
~1[~ If garage, number of
cars
Addition t,/ Alteration
Other Work
(Description)
(To be paid on filing tiffs application)
Number of dwelling units on each floor
Ii, If business, cormnercial or mixed occupancy, speFi~ nature and exte2t of each tsl~e of use.
7. Dimensions of existing structures, if any: F~0nt ~'/~'; Rear _~¢ .~ Depth
Height Cfi, ~ ?, Number of Stories .12-
Dimensions of same struc~u.re with alterations or additions: Front .:5Z5' 7 '¢
Depth ? Height '~ ' ~ ~' Number of Stories
Rear ozT~ '7 '/
10. Date of Purchase
8. Dimensions of entire new construction: Front Rear Depth
,.~1~ Height j~.R) Number ef Stories
9. Size oflo,: Front ~ q.~ .O~" Rear ~. ~" Depth
cS'-/,i'qfi Name ofFormer Owner ,JT a
11. Zone or use district in which premises are situated R ~
l 2. Does proposed construction xSolate any zoning law, ordinance or regulation? YES NO J
13. Will lot be re-~aded? YES NO '/Will excess fill be removed from premises? YES NO /
14. Nmnes of Owner of premises
Name of.~:chitect
Name of ContractordD~7'-t4w~a~:
15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES
* IF YES, SOUTHOLD TOV~2xJ TRUSTEES & D.E.C. PERMITS ~vL&Y BE REQUIRED.
b. Is tltis property within 300 feet of a tidal wetland? * YES NO
* IF 5~ES. D.E.C. PERMITS h,L~Y BE REQLqRED.
Address qt 9,¢¢ ,'~,~ ad ~-e~¢c,z Phone No. 76~ - ~ ~'55~-
Address g-/Jv~zg~w. ~vev/~JPhoneNo %t?-ltCe3
Address Phone No_
16. Provide sum'ey, to scale, with accurate foundation plan and distances to property, lines.
17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey.
STATE OF NEW YORK)
SS:
COUNTY OF ;s 'ff- e q )
~' t~-~'/" "~ ~ being d~y sworn, deposes ~d says that (s)he is the applicant
~ame of in~xfidual si~ing contract) above named,
(SiHe is the
(Contractor, Agent, Corporate Officer, etc.)
of said owner or oxxmers, amd is dui3 authorized to perform or have performed the said work and to wake and file tiffs application:
that all statements contained in this application are m_re to the best of his lmowledge and belief; and that the work will be
perfmmed in the marmer set forth J2 the application filed therewith.
Sworn to before me tlzis
Nrta' Public
BON,IEJ. DOROSKI .
Public, State Of N~ York
OIDOE095'128,
20 05
S~~pplicant