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HomeMy WebLinkAbout30386-Z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-30589 Date: 11/23/04 THIS CERTIFIES that the building ADDITION & ALTERATION Location of Property: 830 TARPON DR GREENPORT (HOUSE NO. ) (STREET) (HAMLET) County Tax Map No. 473889 Section 57 Block 1 Lot 9 Subdivision Filed Map No. Lot NO. conforms substantially to the Application for Building Permit heretofore filed in this office dated JUNE 8, 2004 pursuant to which Building Permit No. 30386-Z dated JUNE 8, 2004 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 SINGLE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to EDOUARD & CAROL BEAUGARD (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO_ 0601 10/02/04 PLUMBERS CERTIFICATION DATED 10/15/04 JOHN W. REICHERT A iz Signature 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 UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 30386 Z Date JUNE 8, 2004 Permission is hereby granted to: EDOUARD & WF BEAUGARD PO BOX 902 SOUTHOLD,NY 11971 for ADDITION AND ALTERATION TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. THIS PERMIT REPLACES BP#28004 . at premises located at 830 TARPON DR GREENPORT County Tax Map No. 473889 Section 057 Block 0001 Lot No. 009 pursuant to application dated JUNE 8 , 2004 and approved by the Building Inspector to expire on DECEMBER 8 , 2005 . Fee $ 419 . 10 4th'o�iV�edSiture ORIGINAL Rev. 5/8/02 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) PERMIT NO. 28004 Z Date JANUARY 14 , 2002 Permission is hereby granted to : EDOUARD & WF BEAUGARD 56 SPRING VALLEY AVE RIVER EDGE,NJ 07661 for ADDITION AND ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR W/ TOWN TRUSTEE ' S AND NYS DEC APPROVALS at premises located at 830 TARPON DR GREENPORT County Tax Map No. 473889 Section 057 Block 0001 Lot No. 009 pursuant to application dated DECEMBER 27 , 2001 and approved by the Building Inspector. Fee $ 419 . 10 Authorized Signature ORIGINAL Rev. 2/19/98 q1 '1 - 5 9 �)3 Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 6 2004 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: I. 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 2,10 of l% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. B. For existing buildings(prior to April 9, 1957) non-conforming uses,or buildings and"pre-existing" land uses: L Accurate survey of property showing all property lines, streets,building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of 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- $100.00 3. Copy of Certificate of Occupancy-$.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy- Residential $15.00, Commercial $15.00 Date. Y New Construction: �... Old or Pre-existing Building: (check one) Location of Property: sSa /' R P91PJ ip 2[ V P- S enz T 11044 House No. Street Hamlet Owner or Owners of Property: E 0 Ll A R L� F W 8 E L[ Ci 14 R 6 Suffolk County Tax Map No 1000, Section �Z� g rJ y o Block 0001 Lot 0009 / Subdivision 3n 3�� (P/14i Filed Map. Lot: Permit No. 001V Z Date of Permit. Applicant: Health Dept. Approval: S Underwriters Approval: F S Planning Board Approval: Request for: Temporary Certificate Final Certificate: IV\ (check one) Fee Submitted: $ E]S7 Applicant Sign r �73 ys Co X305 3-� SUFFOLK+(3 BUREAUof `a E L E C TR i C A L _ I M S P F C T u R S, n j 40 Nottingham Drive, Middle Island, N.Y. 11953 Telephone: 1 631 495 8136 ■ Fax: 1 631 980 6455 ■ Email: SBEI1@hotmail.com J CERTIFICATE OF ELECTRICAL COMPLIANCE L Applicant: Beaugard Rough In Inspection Date: 10/2/04 Final Inspection Date: 10/2/04 ` ; Application N': 0601 Certificate N°: 0601 L Suffolk County Tax Map N°: Building Permit N°: 28004 Z This Certificate of Electrical Compliance is limited to the inspection and compliance of electrical '- equipment and/or work described below and installed by the Applicant named above, and located at the `- premise of: L Owner: Beaugard Address:830 Tarpin Drive, Southold, NY 11971 Address of Inspection Site: 830 Tarpin Drive, Southold, NY 11971 L X Residential Indoors X Basement Service Only Hot Tub Commercial Outdoors 11t floor Pool Garage New Renovation 2nd floor Attic Addition Inventory i Service lid 11 Duplex Receptacles 2 Ceiling Fixtures HID Fixtures Service 30 GFCI Receptacles Wall Fixtures 1 Smoke Detectors Main Panel Single Receptacles 12 Recessed Fixtures CO Detectors Sub-Panel Range Receptacles Fluorescent Fixtures Pumps Transformer Appliances Dryer Receptacles Emergency Fix. Disconnects 4 Switches Twist Lock Exit Fixtures Heat Hot Water A/C Cond 1 A/C Blower Time Clocks GFCI Breakers TVSS Other Equipment: The electrical work and/or equipment described above were inspected and appear to be in compliance with local, state and national electrical code requirements and this office. Applicant: Beaugard License N°: Home Owner Inspected By: Gene S i Certificate Date: 10/3/04 Signature: G L f\- D rJ�rnrJ@PrJ@ncnr�rJ�rJ�rJ@nrJ@PrJ�rJ�r.nrJ�r�rJ�rP�nrJ@PcPrJ�rJ�rlarlr�rJ�r�rJ�rJ�r.nrJ�rJ�rJ@nrJ�rJ�rJ�u�rJ�c.nrJ�rJ@nrJ�IcPr�cPr�rJ�rJ�rJ�rJ�rJ@nrJ�r�cPrJ� �o 5 BY THIS CERTIFICATE OF COMPLIANCE THE l r) J 5 5 NEW YORK BOARD OF FIRE UNDERWRITERS 5 5 BUREAU OF ELECTRICITY 5 5 40 FULTON STREET — NEW YORK, NY 10038 5 5 CERTIFIES THAT Upon the application of upon premises owned by 5 GOODALE ELECTRIC ED BEAUGARD 5 5 5 7255 MAIN RD. 830 TARPON DRIVE 5 MATTITUCK, NY 11952, GREENPORT, VILL, NY 11944 5 5 5 Located at 830 TARPON DRIVE GREENPORT, VILL, NY 11944 5 Application Number: 1044728 Certificate Number: 1044728 5 5 5 55 Section: Block: Lot: Building Permit-.447 BDC: NS11 CS 5 Described as a Residential occupancy, wherein the premises electrical system consisting of 5 electrical devices and wiring, described below, located inion the premises at: 5 5 Basement,First Floor,Outside, 5 5 5 5 5 was inspected in accordance with the National Electrical Code and the detail of the installation, as set forth below, was 5 found to be in compliance therewith on the 12th Day of July,2002. Name OTY Rate Ratine Circuit Tym 5 5 Alarm and Emergency Equipment 5 5 Sensor 2 0 Smoke 5 rj Wiring and Devices 5 5 Receptacle 13 0 General Purpose 5 5 Switch 4 0 General Purpose 5 5 Fixture 12 0 Incandescent 5 5 Dimmers l 0 5 Paddle Fan I 0 5 5 Receptacle 2 0 GFCI 5 5 5 5 seal 5 5 I of I 5 5 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. J 5 5 l7 rJ@PcPrPrJ�rJ�rJ�rJ�r PrJ�rJ�rJ�rJ�rJ�rJ�rJ�rlcPrJ�rJ�tPr�rJ�rJ arPrPrJ�r:11 :1 l 1pLrL3�c.PcP�rJL3rL3 JIrJ�cPr�r�rJ�rJ�rJ�rJ�rJ�rJMPLrL3L3rL3r3r PrJ�rJ�rPrJ�rJPL Albert J. Krupski, President 0�0 CQ Town Hall James King,Vice-President = G'y� 53095 Route 25 Artie Foster h - P.O. Box 1179 Ken Poliwoda x Southold, New York 11971-0959 Peggy A. Dickerson cif. Telephone 1631) 765-1892 1 `1 Fax(631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0019C Date Nov. 15, 2004 THIS CERTIFIES that the one-atony addition to dweUi.ng At 830 Tatpon Dn., Southo'ld Suffolk County Tax Map # 57-1-9 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 10/11/01 ursuant to which Trustees Permit# 5447 Dated 11120101 Was issued, and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is aoh the one-atony addition do the dueU_i-ng The certificate is issued to Edouard 9 Caro f Beaugand owner of the aforesaid property. Authorized Signature o�0g11FF0(,��0 � x Town Hall,13095 Main Road O Fax(631) 765-9502 P.O. Box 1179 A 0� Telephone (631) '.65-1802 Southold, New York 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATION Date: /aA1112 Building Permit No. Owner: ZQ. (Please print) Plumber: soi/.-1 GA1 . (Please print) I certify that the solder used in the water supply system contains less than 2,110 of I'/'0 lead. (Plumbers Signature) Sworn 119 before me this day of 20 ' r 11 Notary Public, /' County Board Of Southold Town Trustees , SOUTHOLD, NEW YORK ` ° PERMIT NO. . ' 1 DATE- ...Nov.ZQ, 2.0.01 EDWARD & CEAA ISSUED TO ...................... .. .............. ..A....ROL..........BUGRD .. ... .. ......... ........ ........ . .. gip. , � .�utl�ort�tt�inn • Pursuant to the provisions of Chapter 615 of the Laws of the State of New York, 1893; and Chapter 404 of the Laws of the t ` State of New York 1952; and the Southold Town Ordinance an- titled ."REGULATING AND THE PLACING OF OBSTRUCTIONS A IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;•.'. and in accordance with the Resolution of The Board adopted at a meeting held on ...Nov...20.,..- s4 ' 2001., and in consideration of the sum of $... 2.0.0..0.0. aid b P Y f .�' Edward...& Caro1...Beaugard ... . ... _. . ................................ .............. M+ of ....Southold, N. Y. and subject to the Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: s` Wetland Permit for a one story addition / living room and dining room with the condition that there be drywells and gutters for roof run-off. 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 thesepresents to T be subscribed by a majority of the said Board as of this date. 41 FULA- o O �' � t Tmssees 'k NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION DEC PERMIT NUMBER EFFECTIVE DATE 1-4738-02950/00001 0 December 20, 2001 FACILITY/PROGRAM NUMBER(S) P ERM I T EXPIRATION DATE(S) Under the Environmental Conservation Law December 20, 2006 TYPE OF PERMIT ■ New ❑ Renewal ❑ Modification ❑ Permit to Construct ❑ Permit to Operate i ❑ Article 15, Title 5: Pro- ❑ 61JYCRR 608: Water Quality ❑ Article 27, Title 7; tection of Waters Certification 6NYCRR 360: Solid Waste Management ❑ Article 15, Title 15: ❑ Article 17, Titles 7, 8: Water Supply SPDES ❑ Article 27, Title 9; 6NYCRR 373: Hazardous Waste ❑ Article 15, Title 15: ❑ Article 19: Air Pollution Management Water Transport Control ❑ Article 34: Coastal Ero- ❑ Article 15, Title 15: ❑ Article 23, Title 27: sion Management Long Island Wells Mined Land Reclamation ❑ Article 36: Floodplain ❑ Article 15, Title 27: ❑ Article 24: Freshwater Management Wild, Wetlands Scenic and Recreational ❑ Articles 1, 3, 17, 19, Rivers ■ Article 25: Tidal Wetlands 27, 37; 6NYCRR 380: Radiation Control PERMIT ISSUED TO TELEPHONE NUMBER Edouard and Carol Beaugard (631) 477-0846 ADDRESS OF PERMITTEE P.O. Box 902, Southold NY 11971 CONTACT PERSON FOR PERMITTED WORK TELEPHONE NUMBER NAME AND ADDRESS OF PROJECT/FACILITY Beaugard Property, 830 Tarpon Drive, Southold NY LOCATION OF PROJECT/FACILITY SCTM 41000-57-1-9 COUNTY TOWN WATERCOURSE NYTM COORDINATES Suffolk Southold Canal E:719.1 11:4550.9 Description of Authorized Activity Construct a one-story addition to the existing single-family dwelling and relocate the existing septic tank. All work shall be performed in accordance with the plans prepared by Anthony W. Lewandowski last revised on 10/29/01 (sheet 1 of 2) and Carol and Edouard Beaugard on 12/9;01 (sheet 2 of 2) , and stamped NYSDEC approved on 12/20/01. By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, all applicable regulations, the General Conditions specified (see page 2 & 3) and any Special Conditions included as part of this permit. PERMIT ADMINISTRATOR: ADDRE g. 440, SUNY, Stony Brook, NY 11790-2356 John A. Wi and (MRP) AUTHORIZ SIGNATURE DATE Page 1 of 4 December 20, 2001 TOWN OF SOUTHOLD PROPERTY RECORD CARD OWNER STREET VILLAGE DIST. SUB. G'' LOT d Edocc. vi /3 esu. Ar W o nr FORMER OWNER N E ACR. r A d w F . 76 p S W TYPE OF BUILDING RES. 7- 10 SEAS. VL. FARM COMM. CB. MISC. Mkt. Value LAND IMP. TOTAL DATE REMARKS ?12clb I3La. PEf *1 DM 2 Bib fv;1 'bW. =c #15 000 ✓ L 4$ SALE �> 000, FRE - " it-/RNo, %0 W. FeANKdW P 232 L— fw- 31 00 (0300 9 OU � � _. � z �� Ilb o 0 Gwaas� CCS S�oca � 72 fr vkeju f �. 8 e A& d ArtJ2* P q69 AGE BUILDING CONDITION NEW NORMAL BELOW ABOVE FARM Acre Value Per Value Acre Tillable 1 Tillable 2 Tillable 3 Woodland Swampland FRONTAGE ON WATER ;Rol C qv Brushland FRONTAGE ON ROAD 3 d' 12o c� 0 -/ A G House Plot DEPTH BULKHEAD S Total DOCK ia► 'y .aG* 4 E■■ElICil� ■t �■■■�!■■■SEEMimp SENN ■■■■■ SSSS■■M ■■■■■e■■MM■■E■■■■■■ ■■■■■■■■■ Bldg.io ■■■e■■ ■■■■ :xtens IA`II e a BUILDING PERMIT EXAMINER CHECK LIST DATE REVIEWED: iZIZ4101 DATE SUBMITTED: iz/Z 7/Ol APPLICANT NAME: Emuap_D i 04Roc t-EWNWs3 eD — SCTM# DISTRICT: 1,000 SECTION: X57- BLOCK: / LOT:2 STREET: '6zFor o1 �21�E CITY' o�R M:��T_SUBDIV. NAME:'-- n PROJECT DESCRIPTION: wa 'mow 70 � ��F tL`l�cs � t �NC� "'���c% mss ARCHITECT /ENGINEER: 1 OT-H I I (_ oFOAST TRACK? IJa SINGLE& SEPARATE CERTIFICATION-REQUIRED? NOT - LOTS 40,000SF-100-24.Lot mcopition.(CRP.ATED before June 30,1983),UNDERSIZED LATS FR JAN.1997 0-25.Merger.(A nonconfomting at anytime atter 7/1/8 ZONING DISTRICT: ;?-(/p CONFnRMING? N" �o 00o t9/8E�-1�R SU�Cs-� Tt;C�s�+�wi 10�73.si REQ. LOT SIZE: �' ACT. LOT SIZE: REQ. LOT COV. d°y- ACT. LOT COV. REQ. FRONT 3� gD/ PROP. FRONt 40T L-REQ SIDE_ ds ACT. SIDE �s cyc.e REQ. REARz?rr _3d' PROP. REAR „io C, WATERFRONT? A10 ""W �o� 154 DESCRIPTION: .� PANEL #: 1_5`7 FLOOD ZONE: F A& �ox,J.� G 1 . r�Zo[v� �K' its E3i cosy- AGENCY PERMITS REQUIRED FOR REVIEW APPROVALS REOUIRED: SUFFOLK COUNTY HEALTH DEPT: YES or NO, (BED #) DTE:_X /,j/_/_q/ PERMIT#:RIO- ©/- D.P3X NEW YORK STATE DEC: PRE-Mc9n or NO /-ymo -0a9To- 111.12o%/ SOUTHOLD TOWN TRUSTEES: or NO �fyc{ ov. 2� 2 �•� S¢� �'+�, r,//sem..�, TOWN ZONING BOARD APPROVALrrYES 09M ~Ucr C70ire v» �W-. "r. �/or�� TOWNPLAN. BOARDAPPROVAL: YESo cif /�e..r sKrry �• T. •. TOWN HISTORICAL PRE (SPLIA): YES o NYS ENERGY:9P RNO : r EGRESS (18 H nun.?4 sq total) 7 VENT(SQ. FT. x 4%) ✓ LIGHT SQ. FT. x 8%) BUILDING PERMITS OPEN/EXPIPED: BP Z/C/O Z- I In5of N HAVE PRE CO'S : Y OR N BP6 -Z/C/0 Z-i 1 n ) c - NOTES: r r4 ✓ate- FEE STRUCTURE: FOUNDATION: 50 SF ;;;'IA 1!62_ FIRST FLOOR •oc�4 SECOND FLR : INTT OTHER TOTAL TOTAL: FEE FEE FEE OT( 14 SF)- _$SF)=��SF X$. o =$16 ,�0+$ =$'�—~��. M-1802 BUILDING DEPT. INSPECTION J FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL [ ) FIREPLACE & CHIMNEY REMARKS: /04 �. . f.:r ' � 3l/J � if�i�• Yza1 a..l � �o-.ie'+r'_ DATE INSPECTOR ��C4 dG�O M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [�CJ FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: DATE S c INSPECTOR/—/f� cd� M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ j ROUGH PLBG. [ ] F UNDATION 2ND [ ] INSULATION [ FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: A� DATE a 1/ INSPECTO M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] R GH PLBG. [ ] FOUNDATION 2ND [ INSULATION ( ] FRAMING [ ] FINAL [ ] FIREPLA & CHIMNEY REMARKS fffDATE ' I.;J 3LK^ ` 765.1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] 1 LATION [ ] FRAMING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION REMARKS: DATE ` INSPECTOR FIELD INSPECTION REPORT DATE COMMENTS FOUNDATION(IST) �4 a ! a FOUNDATION(2ND) cn Li 2 0 � o ROUGH FRAMING& -- — y PLUMBING — r m INSULATION PER N.Y. — — — STATE ENERGY"CODE -- - — ZLiLL r— FINAL -- — - / ?ADDITIONAL COMMENTS / o � m r[� 00 a a * v TOWN OF SOUTHOLD BUILDING PERMIT APPLiCA11UN Uflh &U BUILDING DEPARTMENT Do you have or need the following,before applyk TOWNHALL j c'/��,tiVY BoardofHaahh SOUTHOLD,NY 11971 3� 3 seta ofBmlding Plans TEL: 765-1802 ` Survey PERMIT NO, Z tro o g - Clueck Septic Fotm N.Y.S.D.B C. Trustees - — d ai /i . 20 O� Contact: {� Appmved CY 41-1.20 02 Mail to: L. Oea u &rcL Disapproved ake FO p>px grog D wtt1 o)eA Phone:1231 - Fin l BwTding Libe��?,SnAPPLICATION FOR BUILDING PERNIIT di bDate. �- ZVYs � .20,D,��! INSTRUCTIONS on be coag�lotely filled in by typewriter or m ink and submitted to the Building Inspector with sets of plans,accurate plot plan to scala Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets a areas,and waterways. c.The work covered by this application may not be commenced before issuance of Building Permit. d.Upon approval of this application,the Building Itispector will issue a Building Permit to the applicant. Such a perm 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 what4o-over until a Certificate of Occupw is issued by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department.for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold,Suff ft County,New York,and other applicable Laws,Ordinances or Regulations,for the construction of buildings,additions,or alterations or for removal or demolition as heraar described.The applicant agrees to comply with all applicable laws,ordinances,building code,housing cod*and regalatiow,and to admit authorized inspectors on promises and in building for necessary inspections. (Sigoatare of applk&or name.iia on) J(a 6oX clot 5Out6O NY (Mailing address of applicant) State whether applicant is owner,lessee, agent, architect; engineer, general contractor, electrician,plumber or builder Name of owner of premises eA t7 Lion:& c�( 1,(� � l a►IU I �Beaf-tm (as on the tax m latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. Phanbers License No. Electricians License No. Other Trade's License No. 1. Location of land on wl�t proposed wormwill by done: ,?-I 8o lancUr) House Number Street Hamlet County Tax Map No. 1000 Section f2 01-09 Block Subdivision Filed Map No. L tEtit a �— state existing use and oocVmcy of premises and intended use and occupancy of proposed constt edoo: a. Existing use and occupancy M�!> b. .Intended use and occupancy f`C�SI it Uf Cts Nature of work(check which applicable):New Building Addition_ Alteration Repair Removal Demolition Other Work (Description) Estimated Cost 1!5 &&-o Fee (to be paid on filing this implication) If dwelling,number of dwelling units a �i5 Number of dwelling units on each floor Ore-goer if garage, number of cars If business, commercialor mixed occupancy, specify nature and extent of each type of use. IF Dimensions of exissy'ng structures,if.any: Font_10 O Rear `f O Depth 3O Height `�(e Number of Stories a-- Dimensions of same structure with alterations or additions: Front fI(yf Rear A0.' Depth _4Zh� Height 2-V Number of Stories. 2-- Dimensions of entire new construction:Front a© Rear_,�c��l `Depth o� Height 16 Number of Stories ti Size of lot:FrontI.3 O�GG Rear I t 0 � Depth J RSI It Z" .Date of Purchase T' � fC Name of Former Owner ('t)1 I('1 am CT�"n Zone or use district in which premises are situated bt:SI,!fj Cnfi� a 1 Does proposed construction violate any zoning law, ordinance or reguilation: no Will lot be re-graded > _Will excess fill be removed from premises: NO Names of Owner ofpprmise�C b S Cl yW_Address rCb�T � Phone No.�j3 l 'E 7 7 ��1` f Name of Architect i til n Address 5 f n zunep r+— Phone No Name of Contractor Address Phone No. Is this property within 100 feet of a tidal wetland? *YES ✓ NO • IF YES, SOUTHOLD TOWN TRUSTEES PERMITS MAY BE REQUIRED Provide survey, to scale,with accurate foundation plan and distances to property lines. If elevation at any point on property is at 10 feet or below,must provide topographical data on survey. 'ATE OF NEW YORK) SS: )LINTY OF ) being duly sworn;deposes and says that(s)he is the applicant (Name of individual signing contract)above named, IHe is the (Contractor,Agent,Corporate Officer,etc.) said owner or owners,and is duly authorized to perform or have performed the said work and to make and file this application; rt all statements contained in this application are true to the best of bis knowledge and belie4 and that the work will be j *rived in the manner set forth in the application filed therewith. ,om to before me this !2_day of �•• /20.W Notary Public �Q SikAture of Applicant ELIZABETH A STATHIS NState of Now YOfk No.01 T6=PUBLIC.RY 3.Suffolk Couon Terre Expires June 8,2012 l� SU7706K( PERMIT \ SINGLE FAMILY RESIDENCE ONLY ,�G 3'3Z ,3a� /�•Qa ' L''� d I F_ 790'To .fir `a'B -- �� � n•-sl1�yL�I i�'�.�.v.-� � - 013 t IlJ O FC i..' 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