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Home My WebLink About28892-ZFORM T0~ OF SOUTEOLD BUILDII~G DEPARTMenT office of the Building Inspector Town Ball Southold, N.Y_ CERTIFIC~5.TE OF OCCUP.~_NCY No: Z-30481 Date: 10/01/04 CERTIFIES that the building ADDITION/ALTE~ATION Location of Property: 1525 LEEWarD DR %HOUSE NO.) (STREET) County Tax Map No. 473889 Section 79 Block 7 subdivision Filed F~ap No. -- Lot No. SOUTHOLD Lot 19 ( H~2~LE T ) conforms subst~ntiall~ to 5he Application for Building Permit heretofore filed in this office dated OCTOBER 22, 2002 p%ucsuant to which Building Permit No. 28892-Z dated NOVEmbER 7, 2002 was issued, and conforms to all of the recfuiremenss of the applicable pro~/isions of the law. The occupancy for which this certificate is issued is ADDITION WITH SECOI,~ FLOOR BALCO~ TO A~ EXISTING ONE F~ILY DWELLING AS APPLIED FOR. The certificate is issued to DAVID & EVA/~GELIA TSOUMPELIS (O~a~ER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OFBEALTHAPPRO~Ln_L N/A ELECTRICAL CERTIFICATE NO. 1133519 10/10/03 PLI~4BERS CERTIFICATION DATED 09/20/04 ROBERT VA2~ ETTE~[ Re-/. 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 UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) ~E~'NO. 28892 Z Date NOVENfBER. 7, 2002 Permission is hereby granted to: SAVAS & WP KAPSIS 1525 LEEWARD DR SOUTHOLD,NY 11971 for : ALTEgATION AND ADDITION (SECOND PLOOR) TO AN EXISTING SINGLE PAMILY DWELLING AS APPLIED FOR at premises located at 1525 LEEWARD DR SOUTHOLD County Tax Map No. 473889 Section 079 Block 0007 Lot No. 019 pursuant to application dated OCTOBER 22, 2002 and approved by the Building Inspector to expire on MAY Fee $ 451.80 ~~7, 2004 ORIGINAL Rev. 5/8/02 Form No. 6 TOWN OF SOUTHOLD BUILDING D~:PARTM]~NT TO~H~L ~: ~ ~ u ~ ~ ,~. 765-1802 . , ............... m ~ ~j · : APPLICATION FOR CERTIFICATE OF OCCUP.~Y S~-P 2 I ~[ ~ i · · '~ '- ...... [ · 4 Thts apphcau~ must be filled m by ~exx~ter or mk and subdued to the Bmldmg Depa~en~ t~e~towmg: L_. TC'Z'~ L___ ' '-'~OLD ~ A. For new bulldog or new use: L Finfl 5u~'ey ofprope~ with accurate location of all hullings, prope~, lines, s~eets, ~d ~us~I na~al or ~po~p~c fea~res. 2. F~h~pprova~ ~om H~I~ Dept. of water supply ~d sewerage-disposal (S-9 ~b~). 3_ Approval of elee~c al ~st~on ~om Board of F~e Und~t~. 4. gwo~ ~a~e~ent ~om pie&er cerW~mg ~ta~ (~e ~!d~ ~6 ~ ~s~m cmtmins le~ ffn~q 2.' ~ 0 o~ 1% ica& 5. C?~ercml bml~ng, ~dffs~mi bmI~ng, muI~ple res~nces ~d si~lar buil~.gs ~d i~la~ons, a certificate of ~o~ Co~anc.e ~om architect ur ~eer responsible for ~e b~lding. 6. Sa~ng Board Approval of completed site pI~. rcq~ements. For e~,s~ buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. P~cer~e~ survey o f propc~y showing all property lines, streets, bmlding and tmusual nataral or topo~aphic features. 2. A P~Ot~er.l? completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is de~e~.tffe Building k~pector shall state the masons therefor in ~ting to the applicant. - 1. Ce~,-¢i~, F,ate of Occupancy - New dwelling $25.00, Addiv~orm to dwelling $25.00, Alterations to dwelling $25.00, Swim~ing pool $25.00, Accessory building $25.00, Additions to accessory building $25.00, Businesses $50.00. 2. CertifiCate o~ Occupancy on Pre-existing Building - $100.00 3. Copy0fCertificate of Occupancy- $.25 4. Up~l~t~d C&~ficate of Occupancy - $50.00 5. Temptrary Certificate of Occupancy - Residential $15.00, Commercial $15.00 New Construction: ofr Opmy: House No. O~vner or Ox~'~ers of Property: '/o4 Date. Old or Pre-existing Building: v/ (check one) Street Ha~et Filed Map. Applic~t: Unde~ters Approval: Suffolk Courl~y Tax Map No 1000, Section Subdivision Permit No. ~.~,? '~ 9 oQ Health Dept..~.pproval: Date of Permit. Lot: Planning Boated Approval: Request for: TemporaD, Certificate Fee Submitted: $ Final Certificate: (cheek one) Applicant Signature Town Hall, 53095 Main Rt2ad P.O. Box '[179 Soutkold, Ne,.v York IJ. YT1-09:~9 Fax (63_.) , 65-q Telephone. (631) BUILDINO DEPARTMENT TOWN O1' 8OLIrpIIOI.~D CERTIFICATION [ certi(v that the solder used in the water supply systetla conlahts les"} titan 2./10 of l% lead~ (Plumuers ~ignature) Sworn to before me this dayo ._, , 2O9 Nc taD, Pz~ bI~,q~fl~C cunt Y JANET E. STAPLES N~/~ Public,State of Nm~ - o. ~,831949~ Suf~lk Coun~- uommission Expires JuJy 31, 2~_~.~ BY THIS CERTIFICATE OF COMPLIANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET - NEW YORK, NY 10038 CERTIFIES THAT Upon the application of upon premises owned by PAUL R. BURNS DAVID TSOUMPELIS P.O. BOX 106t 1525 LEEWARD DR SOUTHOLD, NY 11971-0932, SOUTHOLD, NY 11971 Located at 1525 LEEWARD DR SOUTHOLD, NY 11971 Application Number: 1133519 Certificate Number: 1133519 Section: Block: Lot: Building Permit BDC: NS11 Described as a Residertt/al occupancy, wherein the premises electrical system consisting electrical devices and wiring, described below, located in/on the premises at: Basement, First Flora, Second Floor, Outside, Attic, was inspected in accordance with the National Electrical Code and the detail of the installation, as set forth below, was found to be in compliance therewith on the lOth Day of October, 2003. Name QTY Rate R.atin~ Circuit Type ;Marm and Emergency Equipment Sensor 2 0 Carbon Mono~de Sensor 7 0 Smoke Appliances and Accessories Exhatmt F~m 1 0 F.H.P. Wiring and Devices Receptacle 24 0 @one,al Puxpose Switch 17 0 G~aeraI Purpose Fixtm'e 12 0 incandescent Receptacle 4 0 ~-FCI Service 1 Phase 3W Service Rating 200 Amperes Service Discormect: l 200 cb Meters: 1 seal I of 1 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicatedl 323:NnL- Separation and Nor~separation of Occupa~zcies Occupancy Separation Table 302.3.3 TABLE 302.3.3 REQUIRED SEPARATION OF OCCUPANCIES iHOURSIa · ] 3 3 Page B7 Exterior W'alla-2 FiJ'e-Resi.,tance Ratings, Tables 601 and 602 ~_troduction, 'lablc~, 601 and 602 require fire resistance at extec.ior walls due w ~- f · ~r ~ ru' t ,n '].'his c[isu.['us Lhat the stm3cttra[ bu[hfing e.[ements are ;rotcct~d du.c to ~ntct'i,,~ f'kP ,~xposttrc (Lc. extc-rior bearing w:dt.~, and '[' ii',. sup:.traNon ,'Iisi.an.ce. q'ld. enstn'.s that thc exterior walls (bearing and. clo;lbeal'[ng) are ["-L, M_ .tn,] 5-I Lm,J,J,';',t[,,l: .ULd ali ukhm's [I,,w). Min. Fire Resistance Ratings Due to Fire Separation Distance & Type of Construction: [ __ _O_ cc_S~a.~y q_r_oup~ (nrc na~ara) I H F-.I, i~L S-'I Others (high) (moderate) (low) FSD ft.I Type of Construction Brg. Non. Brg. Non. Brg. Non. I I-A 3 3 3 2 3 1 I-B 3 3 9 '~ ? 1 < 5 III-A, III-B, IV 3 3 2 2 2 i ............ i'i'/.,Cq:X ................. 5 ............. 5 ....... I' -- 5- ...... '5- ......... ~ TM ...... i-'-' ..... t.:.~_ .................. ~ ...... 3 .... } ......... 5 ............... ~ ..... ! ....... ........ !:B~ .......... 2 2 2 1 2 1 I2 5. < 10 HI-A, III-B, Pd 2 2 2 1 2 1 ..... H-A. V-A 2 2 1 I 1 l II-B. V-B 2 2 I 1 i 1 [ I-A 3 2 3 1 3 ~ I-B 2 2 2 l '~ 1 :: 10. < 30 III-A, III B. IV 2 1 2 1 2 1 .................. _n-_a,~v_-A .................... 1__ _1 ...... _1 ...... ! ......... J. ............. ! .... II-B, V-B I 1 0 0 .0 0 ............ ~.:,~ ......... ~_~ .......... 0_% ............ ~ ..... 9_ ....... D ........ _0_ .... ........... !-_~_ ......................... ~_ ..... .o_ ............ 7- .......... 9_ ........... _2 ........ q ..... [ > 30 Ill-A, I/I-B, IV '> 0 9 0 '~ 0 I .................................... -- ...................... '~ ....................... -~ ............... ..... ~kS._v:.5 ................ ! ..... _o_ .... ~ ....... ~ ......... l ............... ~_ _.. II B, V~B 0 0 0 _ 0 0 0 "FSI)" mearis fire separation d/stance. "Brg." means bearing wall. , on. means nonbearing wall. See also Footnotes to Tables 601 and 602. hn,-,'nali,,,tal (h,,dm'en,:,' of l}nihting Officials Page 2,5 Permit Number Choked By/Date MECcheck Compliance Report New York State Energy Conservation Construction Code MECcheck Sof'zwar~ Version 3_3 Release lc Data filcname: Untitled TITLE: tsomnpe]is Resichmc~ COUN2~: Suffolk STATE: New York HDD: 5750 CONSTRUCTION TYPE: Detached 1 or 2 Family HEATING TYPE: Non-Electric DATE: 10/15/02 PRO~ECT INFORMATION: 1525 Leeward Drive S outj3aold, NY COMPLIANCE: Passes Maximum UA = 175 Your Home - 129 26.3% Better Than Code Gross Glazing Area or Cavity Cont. or Door Perimeter R-Value R-Value U-Factor UA Ceiling 1: Flat Ceiling or Scissor Truss Wall 1: Wood Frame, 16" o.c_ Wludow 1: Wood Frame, Double Pane with Low-E Window 2: Wood Frame, Double Pane with Low-E Window 3: Wood Frame, Double Pane with Low-E Window 4: Wood Frame, Double Pane with Low-E Door I: Glass Window 5: Wood Frame, Double Pane with Low-E 1082 30.0 0.0 38 1137 19.0 0.0 64 2 0.340 1 33 0.340 11 12 0.340 4 9 0.340 3 16 0.47O 8 1 0.340 0 COMPLIANCE STATEIVlENT: The proposed building represented in this document is consistent with the building plans, specifications, and other calculations submitted with this permit application. The proposed systems have been designed to meet the New York State Energy Conservation Construction Code requirements. When a Registered Design Professional has stamped and signed this page, they are arresting that to the best of his/her B~i~;~/c'~ibe~lie¢~ ~%~such plans or specifications ar~atineCO~pj?i~vv/,thj~ Code. MECcheck Inspection Checklist New York State Energy Conservation Construction Code MECcheck Software Version 3.3 Release lc DATE: 10/15/02 TITLE: tsenmpelis Residenc~ m~ D~pt. U~e [ ] [ ] [ I [ I [ ] [ ] [ ] [ ] [ ] [ ] Ceilings: I, Ceiling 1: Flat Ceiling or Scissor Truss, R-30.0 cavity insulation Comments: Above-Grade Walls: 1. Wall h WandFrame, 16" o.c., R-19.0 cavity insulation Comments: Windows: 1. Window 1: Wood Frame, Double Pane with Low-E, U-factor: 0.340 For windows without labeled U-factors, desert-be features: # Panes Frame Typo Thermal Break?. [ ] Yes [ Comments: ] No Window 2: Wgod Frame, Double Pane with Low-E, U-factor: 0_340 For windows without labeled U-factors, desen'be features: # Panes__Frame Type Thermal Break? [ ] Yes [ Comments: ] No Window 3: Wood frame, Double Pane with Low-E, U-factor: 0_340 For windows without labeled U-factors, describe, features: # Panes Frame Type Thermal B~eak? [ ] Yes [ Comments: ] No W-mdow 4: Wood Frame, Double Pane with Low-E, U-factor: 0.340 For windo~vs Without labeled U-factors, describe', features # Panes Frame Type_ Thermal Break? [ ] Yes [ Commeuts: ] No Window 5: Woo&Frame, Double Pane with Low-E, U-factor: 0_340 For windows without labeled U-factors, describe, features: # Panes Frame Type Thermal Break? [ ] Yes [ Comments: ] No 1. Door h Glass, U-factor: 0.470 # Panes Frame Type_ Comments: Thermal Break? [ ] Yes [ ] No Air Leakage: Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed_ Recessed lights musl be 1) Type IC rated, or 2) installed inside an appropriate ak-tight assembly ~vSth a 0.5" clearance from combustible materials. If non-lC rated, the fixture must be installed ~ifl~ a 3" clearance fi-om insulation. Vapor Retarder: [ ] [ ] [ ] [ I [ ] [ ] [ ] [ ] [ ] [ I [ ] [ ] [ ] Materials Identification: Materials and equipment must be installed in accordance with the manu/llgtlffer's installation instructions Materials and equipment must be identiiied so that compliance can be determined. Manufaeturer manuals For ali installed heating and cooling equipment and service water heating equipment must be provided. Insulation R-values and glazing U-factors must bo clearly marked on the building plans or specifications. l~ct Insulation: Supply ducts in unconditioned attics or outside the building must bo insulated to R-8. Return duets in unconditioned attics or outside the building must be insulated to R-4. Supply ducts in unconditioned spaces must he insulated to R-g. Return ducts in unconditioned spaces (except basements) must bo iusnl~ted to R-2. Iusulatio~ 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-embodded-fabric, or tapes. Duct tape is not permitted. Exceptiou: Continnonsly welded and locking-type longitudinal joints and seams on ducts oporating at less, than 2 in. w_g. (500 Pa). Duets shall be su~ every 10 feet or in accordance with tho manufactures's instructions. Cooling ducts with cx~ior insulation must be covered with a vapor retarder. Air filters are required in the retin-a air system_ Thc HVAC system must provide a means for balancing a'Ir and water systems. Temperature Controls: Each dwelling unit has at lesat one thermostat capable of automatically adjusting the space temperutm-e set point of the largest zone. Elect ric Systems: Separate elech-ic meters are required for each dwelling unit. Fireplaces: Fireplaces must bo installed with tight fitting non-c~nbustible fireplace doors. Fireplaces must be provided with a source of combustion air, as required by the Fkeplace cons~-uctioo provisions of the Building Code of New York State, the Resider~qal Code of New York State or the New York City Building Code, as applicable. Service Water Heating: Water heaters with vertical pipe risers must have a heat trap on both the inlet and outlet unless the water heater has au integral heat trap or is part ora circulating system. Insulate circulating hot water pipes to the levels in Table 1. Circulating Hot Water Systems: hisulate circulating hot water pipes to the levels in Table 1. Swimming Pools: All heated swimming pools must have an ordoffheater switch and require a cover unless over 20% of the heating energy is from 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 mu~ be insulated to the levels in Table 2. Table 1: Minimum Insulation Thickness for Cir~lating ltot Water Pipeg Insuiation Thickness in Inches by Pipe Sizes Heated Water Non-C'trculating Runouts Temperature(F) Up~ol' Up to 1.25" 170-180 0.5 1.0 1.5 2.0 140-I60 0.5 0.5 1.0 1.5 100-t30 0_5 0.5 0_5 1.0 Circulating Mains and Runouts 1.5" to 2.0" Owx 2" Table 2: Minimum Insulation Thickness for HVAC Pipes, Fluid Temp. lnsttlati~a Thickness in Inches by Pipe Sizes Piping System Types Range(F) 2"Runouts l"andLess 1.25"to2" 2.5"to4' Heath~ Systems Low PressuredT~mporature 201-250 1.0 1.5 Low. Temperature 120-200 0.5 1.0 Steam Condensate (for feed water) Any 1.0 1.0 Cooling Systems Chilled Water, Refrigerant, 40-55 0.5 0.5 and Brine Below 40 1.0 1.0 1.5 2.0 1.0 1.5 1.5 2.0 0.75 1.0 1.5 1.5 NOTES TO FlELD (Building Deparlment Use Only) Re: Kapsis Residence 1525 Leeward Drive Southold, NY 11971 JAMES J DEERKOSKI P.E. 260 Deer drive Mattituck, NY 11952 (631) 298- 5506 To whom it may concern; After an inspection of the existing septic system at the above named residence, this system will handle the added load of the proposed addition. Any Questions feel free to call. ~.~ Sincerely, Jan~es J'De-Xerk~ski PE BUILDING PERMIT EXAMINER CHECK LIST APPLICANT: DATE REVIEWED: 1~ ,'~-Z/~. DATE SUBlvlITTED: ~ /~'L /Z SCTM# DISTRICT: 1,000, SECTION: ~ , BLOCK: "~ LOT: ~ STREET ADDRE S S: ' ~'~'- [~:~1~ 1~ ~gK CITY~ SUBD1YISION: ~/* ' ' ' . t/ FASTT~CK?~ S~GLE & SEP~TE CERT~IeATION-~Q~D? fll NOTES' ~TS 40,0~SF -1 ~0-24. Lo rem~tton.(C~ATED Before June 30, 1983~, ~DE~ED [DT~ FROM J.~.1997 100-25. bI~ger.(A nonconf~m ng at any ~me a~er 5 ZO~G DIST~CTf~ ~q~ CO~O~'[~G? ~ ~Q. LOTS~E: ~0~ ,~CT. LOTS~:~,I[] ~Q. LOTCOV. ~ ACT. LOTCOV.~ PmQ. FR0~ ~Q. ~ ">'"~ PROP. FRONT / REQ SL~E v-)~ ACT. ~ ~ ~ PROP. ~ ~ ~Q. ~T PROP. ~tGHT ~/~ ~ESC~TION: ~ FLOODZ0~: ~ , ~ ~ - WATER FRO~T? PANEL #: .,.r,--~PRO'VALS REQUIRED SUFFOLK COUNTY HEALTH DEP TOWN SEPTIC RECEI?T: ¥ or N NEW YORK STATE DEC: PI~E-DEC 9/1}'75 YES SOUTHOLD TOWN TRUSTEES: YES or~5-- TOWN ZONING BOARD APPROVAL: YES or_~ TOWN PLAN. BOARD APPROVAL: YES TOWN ~STO~¢AL PRE (S?LL~); EGRESS (lg I-I mm.? 4 sq to~ta~37'~v~l~rr (SQ. FT. x 4 %) ~.~_ LIGItT (SQ. FT. x 8%)_ BUILDING PERMITS OPE~YEXPIRED: BP -Z / C/0 Z- rI V- PRECO'S:¥O! - ---z/c/0 --- OTES: / - -- FEE STRUCTURE: FOUNDATION: SF FIRST FLOOR: e-.:. SECOND FLOOR: ~ Z.~ SF OTI~R: SF INIT OTHER TOTAL TOTAL: ?-~ ~',~ SF FEE FEE FEE 2. ( SF)- ( SF)= SF X $__=$ +$ +$ = $ 7G5-1802 BUILDING DEPT. INSPECTION FOUNDATION 1ST [~ROUGH PLBG. [ ] FOUNDATION 2ND [ [ ~FRAMING [ ] INSULATION ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: ~ DATE INSPECTOR 765-t802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] FOUNDATION 2ND [ ] FRAMING [ [ ] FIREPLACE & CHIMNEY [ ]/~G~H PLBG. [~/~ INSULATION ] FINAL DATE I 765-'f802 BUILDING DEPT. INSPECTION ] FRAMING [ ]FINAL ] FIREPLACE~& CHIMNEY 765-1802 BUILDING DEPT. INSPECTION [ ]FOUNDATION 1ST [ ] I:OUNDATION 2ND [ ] FRAMING [ ] ROUGH PLBG. [ ] IN,>~L/~TION ~FINAL ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION DATE INSPECTOR / / ~,N OF-SOUTHOLD ,~UILD. IANG ~}EPARTMENT TO~,~qhr HALL ] SOUTHOLD, ~' 11971 TEL: (631) 765-1802 K~X: (631) 765-9502 ~v. no~hfork, net/Southol~' PER3IIT NO. c~:~ ~ ~ BUILDING PERM1T APPLICAT~0~ CHEC~([ Do you_have or need the follow'rog, before ~pplying. Board of l-[ealth 3 sets bf Building Plans ":Planning Board approval survey. Check Septic Form N.Y.S.D.E_C. / ' Trustees. i'~ Approved ¥/-7 ,20 3-' / ) lvlail to: Expiration ~"/,2 ,20 Inspector ..,q 5 i ' ~ ,'~-fi9 ~ ~APPLICATION FO~ BU~D~G PE~HT ( ~ -:M ~' Date ~O ,20~ .._~ ~STRUCTIONS a. ~s application MUST be completely filled in by t~ewfiter or ~ ~ ~d mb~aed m ~e B~&g ~e~or wi~ sets of plans, acetate plot plan to scale. Fee accord~g to sch~ule. b. Plot plan showing location of tot and of bulldogs on pre~ses, relatiom~p to ~joining pr~s~ or pnbhc s~eem or areas, a~ watem,ays. c. The work covered by riffs application ~y not be co~enced before issu~ce of B~g Pe~t. d. Upon approvaI of tlss application, the Bulldog hspector wflI issue a B~l&g Pe~t to ~e apphc~t. Such a p~t shall be k~t on the pre~ses available for inspection ~o~out the work. e. No buil&~ shall be occupied or used ~ whole or ~ p~ for any p~0se what so ever ~tfl ~e B~&g ~e~or issues a CeniScate of Occupancy. f. Eve~' b~l&g pe~r shall expire if the work auto'ed Ms not commenced within 12 mon~ aaer ~e &te of issu~ce or has not been complered witch 18 monks ~om such ~te. If no zo~g men,cuts or other relations ~g propetxy We been emceed m the intehm. ~he Build~g ~spector ~y an~o~e, ~ wring ~e e~emion of~e p~t for an addkion six months. Thereaker, a new pemt s~l be requffed. .~PLICATION IS ~BY kL~E to the B~lding Depment for ~e iss~ce ora B~l~g Pe~t pms~ to the BnSd~g Zone Or&~ce of the Tmon of Somhold, Suffolk Co~ty, New YorL ~d o~ apphcablc Laws, O~ces ar Re~lafions, for the consmxction of buil&ngs, ad&tions, or alt~adons or for removal or demohtion as hmein desc~be& applicant a~ees to comply with all applicable laws, ordin~ces, buildMg code, ho~g code, ~d re~fio~, attthodzed impecmrs on premses and ~ b~l&ng for necess~~ i~p~tions. (S~e of appH~t or'e, ifa co,or non) (M,ili,g ad.ss of appQ~t) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plnmb*r or builder Name of owner of prenfises (As on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No_ Plumbers License No_ Elect~dcians License No. Other Trade's License No. Location of land on which proposed work will be done: House Number Street County Tax tvlap No. 1000 Section Subdi;Ssion /9 Block Filed Map No. (Name) ~(at'c~sti gus andb~ZUpaney fpremi fp constmcttcm: ~ " 2'.J~ n e o ses and intended use and occupancy o roposed ' '~ : ~ a. Existing use and occupancy b. Intended use and occupancy. Nature of work (check which applicable): New Building Repair Removal Demolition Estimated Cost '¢'10 5 /rx D- llO 000. ~-Fee If dwelling, number of dwelling units If garage, number of cars [' Adchtion x// Alteration Other Work (Description) (To be paid on filing tiffs application) Number of dwelling units on each floor lt'business, commercial.or mixed occupancy, specify nature and extent of each type of use. Dimensions of existing sl~uctures, if any. Front Height Number of Stories Real' _Depth Dimensions of same structure with alterations or additions: Front Depth ', Height Number of Stories · Rear 8. Dimensions of entire new construction: Front Height Number of Stories Rear .Depth 9. Size of lot: Front 10. Date of Purchase Rear _Depth Name of Former Owner 11. Zone or use district in which premises are situated 12. Does proposed construction violate an3' zoning law, ordinance or regulation? 'tiS__ NO ~/ 13. Will lot be re-graded? YES NO V/ Will excess fill be removed f~om premises? YES NO__ 14. Names of Owner of premises_Tt~/3e~;l~Address~brPhone No. Ic?1,5-' Name of Architect ~'~t-tme&-12~e~k0sk'~~- ' --, {>.~. AddressoS~_ O ~,eer-19M4,:~o~-. PhoneNo ~q ~ -.~)('~ Name of Contractor Address Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO V/ * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS NL{Y BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? * YES__ NO V~ * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, to scale, with accurate foundation plan and distances to proper~y lines. 17. If elevation at any point on property is at l0 feet or below, must provide topographical data on su~'ey. STATE OF NLm0V YORK.) SS: COUNTY OF Z~EYV~"- ~//~ ~O 51 ~C being duly sworn, deposes and sa.~s that (s)he ~s the applicant (Name of individual signing contract) above named, (S)He is the 0 v~/I,5~ (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 file this application; that all statements contained in tiffs application are true to the best of kis lmowledge and b~lief; and that the work will be perfcrmaed in the mantlet set forth in the application filed therewith. Sworn to before me fids dayof O~v-z,~5..O _ 20. - (_~ Notal'y Public ' Si=mnaVsre ~' Applicant ELIZABETH A STATHI$ NOTARY PUBLIC, State of NewYo~k No. 01 ST6008173, Suffolk County Tram Expires June 8.20..~' 6:~ / / TITLE NO. 120-8989 ,28.0 z HEALTH DEPARTMENT-D~TA FOR APPROVAL TO CON$'~'RUCT ~ NEAREST WATER. IIIAIN ~-MI. -+ '~ SOURCE OF WATER~ PRIVATE ~/ PUBLIC- M SUFF CC-. TAX MAP ~IST- SECTION BLOCK LOT_ ~THERB AR~ gO DV/ELUNGS WtTHiN.IO0 FEET OF THIS PROPERTY OTHER THAN.THOSE SHOWN HEREON, ~DDRESS. TEL. 'NOTE:I =MONUMENT SUBDIVISION MAP FILED IN'THE OFFICE'OF THE CLERK OF SUFFOLK COUNTY ON JUNE4~ 1971 AS FILE NO. 5599 ~ THE LOCATION OF WEZ. L(W), SEPTIC ~'ANK(ST) 8, CESSFODLS(CP) SHOWN HEREO~ ARE.FROM FIELD OBSER¥~,TIONS. N~tO DR DATA OBTAINED FR'OM OTHER S SURVEY FOR SAVAS KAPSIS & EIREEN KAPSIS LOT $8 "LEEWARD ACRES AT BAYVlEW" AT BAYVlEW TOWN OF SOUTHOLD SUFFOLK CO[INTY, NEW YORK OCT. 28, 1980 DA~'~. · J~N.4, ~980 se~:~:?; ~": 5o' NO. 80 -8 GUA. RANTEE~;),.~TO THE TITLE GUA. RAN~E CO AND RIVERbOAt'SAVINGS B~NK AS SURVEYED OCT. I , 1979 ~0 4o0 ~ YOUNG e, ,YOUNG ,,VE. E RIVERHEAD~ NEW YORK ALDEi'~ W. YOUNG, PROF,._SSIONAL ENGINEER AND LAND SURVEYOR N.Y_S. UCENSE NO. 12845 HOWARD W..YOUNG~ LAND SURVEYOR N.Y.S. LICENSE N0.4589".