HomeMy WebLinkAbout30799-ZFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
NO: Z-30642 Date: 12/05/04
T~IS CERTIFIES that the building ADDITION
Location of Property: 1450 MILL CREEK DR SOUTHOLD
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 51 Block 6 Lot 27
Subdivision Filed Map No. Lot NO.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated NOVEMBER 24, 2004 pursuant to which
Building Permit No. 30799-Z dated NOVEMBER 24, 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 INSTALLATION OF CENTRAL AIR CONDITIONING SYSTEM IN EXISTING SINGLE
FAMILY DWELLING AS APPLIED FOR "AS BUILT".
The certificate is issued to MARGARET R PAWLIK
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEP~TMENT OF H~J~T~
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION D;~rmu
APPROV~J~
N/A
2034910 12/02/04
N/A
Authorized 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. 30799 Z Date NOVEMBER 24, 2004
Permission is hereby granted to:
MARGARET R PAWLIK
PO BOX 307
SOUTHOLD,NY 11971
for :
INSTALLATION OF AN AIR CONDITIONING SYSTEM IN AN EXISTING ONE
FAMILY DWELLING AS APPLIED FOR. AS BUILT.
at premises located at
County Tax Map No. 473889 Section 051
pursuant to application dated NOVEMBER
Building Inspector to expire on MAY
1450 MILL CREEK DR
SOUTHOLD
Fee $ 150.00
Block 0006 Lot No. 027
24, 2004 and approved by the
24, 2006.
ORIGINAL
Rev. 5/8/02
Form No. 6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Thts application must be filled in by ts,pe'aTiter or ink and submitted to the Building Department with the following:
For new building or new use:
1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or
topographic features.
2. Final Approval t¥om Health Dept. of water supply and sewerage-disposal (S-9 form).
3. Approval of electrical installation from Board of Fire Under~mters.
4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead.
5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate
of Code Compliance from architect or engineer respousible tbr the building.
6. Submit Planning Board Approval of completed site plan reqmrements.
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 xwiting to the applicant.
Co
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
New Construction:
Location of ProperD,:
Owner or O~vners of Property: /V~ a, r~
Suffolk Count5, Tax Map No 1000, Section
Subdivision
Permit No.
Health DepL Approval:
Planning Board Approval:
Old or Pre-existing Building:
/ r rl(
House No.
Date of Permit.
Date. ~,/' 't'~rf ' ~
(check one)
Street
Hamlet
cfi-/' Block ,~ Lot
Filed Map. Lot:
Applicant:
Underwriters Approx al:
Request for: Temporary Certificate
Fee Submitted: $
Final Certificate: (check one)
A~,plicant Signature
INSTALLER'S
GUIDE'
18-AC34D 1-1'
Library Service Literature
Product Section Unitary
Product Sprit System Cooling
Model TTP
Literature Type Installer's Guide
Date February 1993
File No. SV-UN-S/S-'I=rP-IN-1 2/93
Supersedes New
Model:
TTP018-060C
Condensing Units
IMPORTANT~ThisDocumentis customer proper ty andis to remainwith this unit.
Pleasereturnto servicein formation packuponcorapletiono fwork.
These instructions do not cover all variations In systems nor provide
for every possible contingency to be met in connection with installa-
tion. All phases of this installation must comply with NATIONAL,
STATE AND LOCAL CODES. Should further information be desired
or should particular problems arise which are not covered sufficiently for
the purchaser's purposes, the matter should be referred to your installing
deal or local distributor.
A. GENERAL
The following instructions cover TTP018-060C Condensing Units.
CAUTION: These outdoor, units may be used with indoor units
equipped with Capillary Tube, Thermostatic Expansion Valve or the
AecutronTM Flow Control Check Valve (F.C.C.V.) assembly for refrig-
erant flow control.
Check for transportation damage after unit is uncrated. Report promptly,
to the carrier, any damage found to the unit.
To determine the electrical power requirements of the unit, refer to the
nameplate of the unit. The electrical power available must agree with that
listed on the nameplate.
B. LOCATION & PREPARATION OF THE UNIT
1. The unit should be set on a level, support pad at least as large as the unit
base pan.
2. The support pad must NOT be in direct contact with any structure. Unit
must be positioned a minimum of 12" from any wall or surrounding
shrubbery to insure adequate airflow. Clearance must be provided in front
of control box (access panels) & any other side requiring'service access to
meet National Electrical Code. Also, the unit location mast be far enough
away from any structure to prevent excess roofrun-offwater from pouring
directly on the unit.
3. Vibration isolators (shipped v, ith unit) should be used if unit location
is damp or requires vibration isolation. Place supplied mounting pads
under unit comers as illustrated in Figure 2.
VIBRATION ISOLATOR LOCATION
SOLATOR
TYPICAL 4 CORNERS
From Dwi. No. 21B 139052 Rev 0
~ Arr~rlcan Standard Inc. 1993
Dwg. No.21X149036P01
INSTALLER'S GUIDE
4. When the outdoor unit is mounted on a roof, be sure the roof will support
the unit's weight. Properly selected isolation is recommended to prevent
transmission to the building structure.
5. The maximum length of refrigerant lines from outdoor to indoor unit
should NOT exceed eighty (80) feet.
6. If outdoor unit is mounted above the air handler, maximum lift should
not exceed eighty (80) feet (suction line). If air handler is moonted above
condensing unit, maximum lift should not exceed sixty (60) feet (liquid
line).
NOTE: Refer to "Refrigerant Piping Guide' Pub. No. 32.3009.1, Tab l 8
in "APPLICATION MANUAL."
7. Locate and install indoor coil or air handler in accordance with
instruction included with that unit.
C. ACCUTRONTMFLOW CONTROLVALVE
If the indoor unit System Refrigerant Flow control is an AccutronTM
oririce and check valve assembly, an orifice size change will be necessary.
The outdoor model determines the required orifice size. Check the listed
orifice size on nameplate of the selected outdoor model. If the indoor un it
is factory shipped with adifferent orifice size, the orifice must be changed
to obtain system rated performance.
IMPORTANT: The outdoor u~it is shipped with the proper size orifice
and a stick-on orifice size label in an envelope attached to the outdoor
unit. Outdoor unit nameplate will have correct orifice size specified as
BAYFCCV - - - A for rated performance.
D. INSTALLING REFRIGERANT LINES
Condensing units have provisions for braze connections.
Pressure taps are provided on the service valves of outdoor unit for
compressor suction and liquid pressures.
The indoor end of recommended refrigerant line sets may be straight or
with a 90 degree bend, depending upon situation requirements. This
should be thoroughly checked out before ordering refrigerant line sets.
The gas line must always be insulated.
The units are factory charged with the system charge required when using
twenty-five (25) feet ofcoonecting line. Unit nameplate charge is the same.
Final refrigerant charge adjustment is necessary. Use the Charging Charts
in the outdoor unit Service Facts.
I. Determine the most practical way to run the lines.
2. Consider types of bends to be made and space limitations.
BRAZE TYPE INDOOR END
ACCUTRON SEALING CAP
COMPO~~
('X,",._~ FLOWCONTROL
~ ~ CHECKVALVE
/ i_~C.V.)ORIFICE
BODY ~
AS SHIPPED
,.,..FIELD SUPPLIED
LIQUID LINE
NOTE: Large diameter tubing will be very di~cult to rebet~l once it has
been shaped.
3. Determine the best starting point for routing the refrigerant tubing- -
INSIDE OR OUTSIDE THE STRUCTURE.
4. Provide a pull-thru hole of sufficient size to allow both liquid and gas
lines. The location of this hole (if practical) should be just above the wall
plate which is resting on the foundation.
5. Be sure the tubing is of sufficient length.
6. Uncoil the tubing --. do not kink or dent.
7. Route the tubing making all required bends and properly secure the
tubing before making connections.
8. To prevent a noise within the building structure due to vibration
transmission ~omtherefrigerantlines, the followingprecautions should
betaken:
a. When the refrigerant lines have to be fastened to floor joists or other
framing in a structure, use isolation type hangers.
b. Isolation hangers should also be used when refrigerant lines are run
in stud spaces or enclosed ceilings.
c. Where the refrigerant lines run through a wall or sill, they should be
insulated and isolated.
d. Isolate the lines from all ductwork.
page 2 Dwg. No. 21X149036P01
INSTALLER'S GUIDE
E. SERVICE VALVE OPERATION
BRASS LIQUID LINE SERVICE VALVE
The Brass Liquid Line Service Valve is factory shipped in the mated
position to hold factory charge. The pressure tap service port (when
depressed) opens only to the field brazing side of the valve when the valve
is in the seated position. The liquid line valve is not a back seating valve
(see WARNINGbelow).
WARNING: Extreme caution should be exercised so the internal steel
stem retaining ring is not damaged by backing out the valve stem when
opening the valve. If the valve stem is forced out past the retaining
ring, system pressure could force the valve stem out of the valve body.
Iftbo retaining ring is missing, do not attempt to open the valve. See
Figure 5.
UNIT SIDE OF
SERVICE VALVE
VALVE SYSTEM ~/
CAP ' G ~
RETAINING RING
GAS LINE BALL SERVICE VALVE
1/4 TURN ONLY
COUNTERCLOCKWISE
CAP
~'f~ FOR FULL OPEN
UNIT SIDE V/~~V~.VE STEM
OF VALVE
GAS LINE CONNEC~TION (-11)
CAP ~ BODY
COOUN%~
CORE
BRASS GAS LINE SERVICE VALVE
The Brass Gas Line Service Valve is shipped in the closed position to hold
the factory refrigerant charge. The pressure tap service port (when
depressed) opens only to the field brazing side when the valve is in thc
closed position.
The Gas Line Service Valve is full open with a 1/4 turn. See Figure 5.
BRAZING REFRIGERANT LINES
1. Before brazing, remove plugs from external copper stub tubes. Clean
internal and external surfaces of stub tubes prior to brazing.
2. Cut and fit tubing minimizing the use of sharp 90° bends.
3. Insulate the entire gas line and its fittings.
4. Do NOT allow uninsulated liquid line to come in direct contact with bare
gas line.
5. Precautions should be taken to avoid heat damage to the pressure tap
valve core during brazing. It is recommended that the pressure tap port
valve core be removed and a wet rag wrapped around the valve body.
CAUTION: Use care to make sure that no moisture enters pressure
tap port, while wet rag is being used.
6. Use aDeft Nitrogen Purge and Brazing Alloy without flux when brazing
the field line to the copper factory connection. Flow dry nitrogen into either
valve pressure tap port, thru the tubing and out the otherport while brazing.
Dwg. No. 21X149036P01 page 3
INSTALLER'S GUIDE
7. Braze using accepted good brazing techniques.
8, Leave heat shield in place while brazing to pre vent dam aging the paint
finish with torch, See Figure 6. Discard the heat shield when finished with
brazing, See Figure 6.
LEAK CHECK
IMPORTANT: Replace pressure tap port valve core before attaching
hoses for evacuation.
After the brazing operation of refrigerant lines to both the outdoor and
indoor unit is completed, the field brazed connections must be checked for
leaks. Pressurize through the service valve ports, the indoor unit and fie Id
refrigerant lines with dry nitrogen to 200 psi. Use soap bubbles or other
leak-checking methods to see that all field joints are leak-free! If not,
release pressure; then repair!
SYSTEM EVACUATION
NOTE: Since the outdoor unit has a refrigerant charge, the gas and liquid
line valves must remain closed.
1. Upon completion of leak check, evacuate the refrigerant lines and indoor
coil before opening the gas and liquid line valves.
2. Attach appropriate hoses from manifold gauge to gas and liquid line
pressure taps. See Figure 7 for suggested hook-up.
NOTE: Unnecessary switching of*hoses can be avoided and complete
evacuation o fall lines leading to sealed system can be accomplished with
t?tanifold center hose and connecting branch hose to a cylinder of
HCFC-22 and vacuum pump.
3. Attach center hose of manifold gauges to vacuum pump.
4. Evacuate until the micron gauge reads no higher than 350 microns.
5. Close offvalve to vacuum pump and observe the micron guage. I fgauge
pressure rises above 500 microns in one (1) minute, then evacuation is
incomplete or system has a leak.
6. I f vacuum gauge does not rise above 500 microns in one ( 1 ) min ute, the
evacuation should be complete.
7. With vacuum pgmp and micron gauge blanked off, open valve on
HCFC-22 cylinder and charge refrigerant lines and indoor coil with vapor
to tank pressure of HCFC-22 supply.
WARNING: UNIT CONTAINS AN HCF¢ (R.22) R~FRIG-
ERANT. Section 608paragraph C of the 1990 Clean Air Act states:
"Effective July 1,1992, it shall be unlawful for any person, in the
course of malntainlng, serviolng, repaln'ng, or disposing of an air
conditioning system, to knowingly vent or release any CFC or HCFC
refrigerant. Minimal releases (air purges or refrigerant hoses)
associated with good faith attempts to recapture or recycle are exempt
from the ban on venting."
8. Close valve on HCFC-22 supply cylinder. Close valves on manifold
gauge set and remove refrigerant charging hoses from liquid and gas
pressure tap ports.
NOTE: A 3/l 6" Allen wrench is required to open liquid line service vah,e.
A I/4" Open Endor Adjustable wrench is required to open gas line vah'e.
A 3/4" Open End wrench is required to take offthe vah,e stem cap.
9. The liquid line shut-off valve can now be opened. Remove shut-off
valve cap. Fully insert hex wrench into the stem and backout counterclock-
wise until valve stem just touches retainer ring (approximately five (5)
turns) observing WARNING statement on page 3. See Figure 4.
10. Replace liquid service pressure tap port cap and valve stem cap. The se
caps MUST BE REPLACED to prevent leaks. Replace valve stem and
pressure tap cap finger tight, then tighten an additional 1/6 turn.
11. The gas valve can now be opened. Open the gas valve by removing
the shut-off valve cap and turning the valve stem 1/4 turn counterclock-
wise, using 1/4" Open End or Adjustable wrench. See Figure 5.
12. The gas valve is now open for refrigerant flow. Replace valve stent
cap to prevent leaks. See Figure 5.
Final check requires operational and refrigerant charge adjustments to
obtain proper per forniance. Refer to the Charging Charts contained in the
Service Facts shipped with the outdoor unit.
TYPICAL REFRIGERANT & VACUUM
PUMP CONNECTION
MICR~J
EE GAUGE
V^CUUM PUMP
page4 Dwg. No.21X149036P01
INSTALLER'S GUIDE
F. ELECTRICAL CONNECTIONS
WARNING: When installingor servicing this equipment, ALWAYS
exercise basic safety precautions to avoid the possibility of electric
shock.
1. Power wiring and grounding of equipment must comply with local
codes.
2. Power supply must agree with equipment nameplate.
3. Install a separate disconnect switch at the outdoor unit.
4. Ground the outdoor unit per local code requirements.
5. Provide flexible electrical conduit whenever vibration transmission may
create a noise problem within the structure.
6. The use of color coded low voltage wire is recommended to simplify
connections between the outdoor unit, the thermostat and the indoor unit.
Table 1 --- NEC Class II Control Wiring
24 Volts
Wire Size Max. Wire Lentoh
*22 AWG 30 Ft.
20 AWG 100 Ft.
18 AWG 150 Ft.
16 AWG 225 Ft.
14 AWG 300 Ft.
*If22 AWG is used, make sure it is high quality wire.
7. Table 1 defines maximum total length of low voltage wiring from
outdoor unit, to indoor unit, and to thermostat.
8. Mount the indoor thermostat in accordance with instruction included
with the thermostat. Wire per appropriate hook-up diagram (included in
these instructions).
G. COMPRESSOR SUMP HEAT
After all electrical wiring is complete, SET THE THERMOSTAT SYS-
TEM SWITCH IN THE OFF POSITION SO COMPRESSOR WILL NOT
RUN, and apply power by closing the system main disconnect
switch. This will activate the compressor sump heat. Do not change the
Thermostat System Switch until power has been applied long enough to
evaporate any liquid HCFC-22 in the compressor (30 minutes for each
pound of HCFC-22 in the system as shown on the nameplata). Following
this procedure will prevent compressor damage at the initial startap.
Record the "POWER APPLIED DATE" on the designated lines below:
Time A.M./P.M. Date
By.
(Electrician)
H. OPERATIONAL AND CHECKOUT PROCEDURES
Final phases of this installation are the unit Operational and Checkout
Procedures which are found in this instruction. To obtain proper perfor-
mance, all units must be operated and charge adjustments made in
accordance with procedures found in the Service Facts.
L ELECTRIC HEATERS
Electric heaters, if used, are to be installed in the air handling device
according to the instructions accompanying the air handler and the heaters.
J. START CONTROL
These units have quick start components which are factory installed.
K. OUTDOOR THERMOSTAT
An outdoor thermostat BAYSTAT250 may be field installed. For data, see
wiring diagram attached to unit and instruction sheet packaged with
outdoor thermostat.
Dwg. No. 21X149036P01 Page5
INSTALLER'S GUIDE*
A TYPICAL FIELD WIRING DIAGRAM FOR TTP018-060A WITH FURNACE
ou~ooo~ SEC ~mo. J From Dwg. 21B3~297 Rev 0
#ORES:
A TYPICAL FIELD WIRING DIAGRAM FOR
TTP018-060A WITH AIR HANDLER
ROO)d THERfdOSTAT
2-STA~ HEAT/I STARE COOL
COOL [NO UNIT
O. O. SECTION
IS[N aLE S~EEDI
ODT --
....... Z4V.~ FACTORY
....... LiNE v~ WIRING
PER LOCAL CODES
AIR HANOLER
From Dwg. No 21 B800254 Rev I
page 6 Dwg. No. 21X149036P01
INSTALLER'S GUIDE
TTP018-060C OUTLINE DRAWING
B
GAS L[NE SER¥]CE VALVE,
"D"O.D. FEMALE BRAZED
LIQUID LiNE SERe[CE VALVE.
"E" O.D. FE MALE BRAZED
CONNECTION WITH I/4" SAE FLARE
PRESSURE TAP FITTING.
, FIG_.__:. _1
GAS LINE ~ALL SERVICE VALVE, BALL I/4 TURN
"D"O.D. FE MALE BRAZED CONNECTION WITH
FIG. E
MODELS A B C D E
~IT01$C-A 28-5/8 32-7/8 28-3/4 518 I/4
TI'P024C-A' 32-3/4 32-7/8 28-3/4 3/4 5/16
TITO30C-A 40-5/8 32-7/8 28-3/4 3/4 5/16
From Dwg, No. 21DI47561 Rev 6
page 7 Dwg. No. 21X149036P01
INSTALLER'S GUIDE
CHECKOUT PROCEDURE
After installation has bee~.completed, it is recommended that the entire system be checked
against the followir~g list;-
1. Refrigerant Line, Leak checked ...................................... [ ]
2. Suction Lines and Fittings properly insulated ............................ [ ]
3. Have all Refrigerant Lines been secured and isolated properly? ................ [ ]
4. Have passages through masonry been sealed? If mortar is used, prevent
mortar from coming into direct contact with copper tubing .................. [ ]
5. Indoor coil drain line drains freely. Pour water into drain pan ................. [ ]
6. Supply registers and return grilles open and unobstructed ................... [ ]
7. Return air filter installed ........................................... [ ]
8. Thermostat thermometer is accurate. Check against a reliable thermometer.
Adjust per instructions with thermostat ................................ [ ]
9. Is correct speed tap being used? (Indoor blower motor) .................... [ ]
SYSTEM OPERATIONAL CHECK
IMPORTANT: TO prevent compressor damage which may result from the presence of LIGUID
refrigerant in the (~rankcase, these procedures should be followed at initial Start-Up and at
anytime the power has been off for 12 hours or more.
1. Before proceeding with this "Operational Check," go to "Compressor Sump Heat Sec-
tion'' of this instruction to determine the time compressor heat has been 'ON," and make
entry on the designated lines, in Step 2.
2. Start-Up Time A.M./P.M. Power Applied Time A.M./P.M.
Time Lapse Hours Minutes.
3. If Steps 1 and 2 cannot be used, then place thermostat's system switch in the "OFF"
position and apply power by closing system disconnect switch. This energizes com-
pressor heat and evaporates the liquid in the crankcase. TO EVAPORATE LIQUID ALLOW
AT LEAST ONE-HALF HOUR PER POUND (R-22), AS SHOWN ON UNIT NAMEPLATE.
4. Except as required for safety while servicing: DO NOT OPEN SYSTEM DISCONNECT
SWITCH.
5. After completing above proce~lures, turn to reverse side of page for Operational check-
out of system(s).
page 8 Dwg. No.21X149036P01
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
KOLB MECHANICAL CORP.
P.O. BOX 106
MA'I-I'ITUCK, NY 11952
MARGARET PAWLIK
1450 MILLCREEK DR.
SOUTHOLD, NY 11971
Located at 1450 MILLCREEK DR. SOUTHOLD, NY 11971
Application Number: 2034910
Certificate Number: 2034910
Section: Block: Lot: Building Permit: BDC: ns11
Described as a occupancy, wherein the premises electrical system consisting of
electrical devices and wiring, described below, located in/on the premises at:
Basement, Outside,
A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed
herein, was conducted in accordance with the requirements of the applicable code and/or standard
promulgated by the State of New York, Department of State Code Enforcement and Administration, or ether
authority having jurisdiction, and found to be in compliance therewith on the 2ad Day of
Name 0'~' Rathe Rating Circuit.~ Type
Appliances and Accessories
Air Conditioner 1 0 40 Amps
Air Handler 1 0
Wiring and Devices
Disconnect I 0 60 amp
December, 2004.
Amount
$0.00
$0.00
AQ' Conditioner $0.00
Invoice Total $85.00
seal
I of 1
This ce~ificatemay not be altered in any way and is validated only by the presence of a raisedsealatthe location indicated.
TOWN OF SOUTHOLD
BUILDING D~PARTMENT
TOWN HA!~L
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
W~WV. nor thfork, ne~/Southold/
~¢( ,20
Disapproved wc
Expiation
PERMIT NO. ~O"~iq ~-"
BUILDING PERMIT APPLICATION CHECKLIST
Do you have or need the following, before applying?
Board of Health
4 sets of Building Plans
Planning Board approval
Survey
Check
Septic Form
N.Y.S.D.E.C.
Trustees
Contact:
~_ b, ~, APPLICATION FOR BUILDING PERMIT
":~ .... ~STRUCTIONS
a. ~is application MUST be completely filled h by ~ewfiter or m i~ ~d sub~tted to the Building hsp~tor with 4
sets of plans, accurate plot pl~ to scale. Fee accor~ng to sched~e.
b. Plot plan showing location ot lot and ofb~ldings on pre~ses, relatio~p to adjo~g pre~ses or public sweets or
~eas, and wate~'ays.
c. ~e work covered by t~s application may not be co~enced before issu~ce of Bulldog Pemt.
d. Upon approval of t~s application, the Building ~spector will issue a Building P~t to the applic~t. Such a pe~t
shall be kept on the pre~ses available for ~spection t~oughout the work.
e. No building shall be occupied or used in whole or ~ p~ for ~y p~ose what so ever ~til the Buil~ng ~spector
issues a Ce~ificate of Occupancy.
f. EveD, b~lding pe~t shall expire if ~e work authodzed has not co~enced witch 12 momhs after ~e dine of
iss~nce or has not been completed wit~ 18 months from such date. If no zoning amendments or other re~latiom affect~g the
property have been enacted in the ~t~m, the Build~g ~spector may authodze, ~ whfing, the extension of ~e p~t for ~
addition six months. Th~fler, a new pe~t s~ll be requked.
.~PLICATION IS HE,BY M~E to the Building Department for the issu~ce of a Building Pemt pursuant to the
Building Zone Ordin~ce of the Town of Southold, Suffo~ Cowry, New York, ~d other applicable Laws, Ord~ces or
Re~lations, for the construction of buildings, additions, or alterations or for removal or demolition as herein descdbed. The
applicant a~ees to comply with all applicable laws, ordinances, bulldog code, housing code, ~d re~lations, ~d to ad~t
authorized inspectors on pre~ses ~d in building for necess~ inspections.
(Signa~e of applic~t or n~e, if a co~oration)
(Mailhg ad&ess of applic~t~ '
State whether applicant i~ owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Nameofownerofpremises Hc~*,~a.~c. ff/- ~ c,J [ ;1<
(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.
Electricians License No.
Other Trade's License No.
1. Location of land on which proposed work will be donezT~'
House Number Street Hamlet
County Tax Map No. 1000 Section
Subdivision
Block ~ Lot o7 "7
Filed Map No. ~ Lot
(Name) .... :~
2. State existing use and occupancy of premises and intended use and occupancy of proposed co.~,~traction:
a. Existing use and occupancy
b. Intended use and occupancy.
Nature of work (check which applicable): New Building
Repair Removal Demolition
Estimated Cost ~-(~v C)
If dwelling, number of dwelling units
If garage, number of cars
Addition
Other Work
Fee ~ F~) ~)
Alteration
(Description)
(To be paid on filing this application)
Number of dwelling units on each floor
If business, commercial or mixed occupancy, specify nature and extent of each t.vpe of use.
Dimensions of existing structures, if any: Front
Height Number of Stories
Rear
Dimensions of same structure with alterations or additions: Front
Depth Height Number of Stories
8. Dimensions of entire new construction: Front
Height Number of Stories
Rear Depth
9. Sizeoflot: Front Rear Depth
l 0. Date of Purchase
Name of Former Owner
11. Zone or use district in xvhich premises are situated
12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO
13. Will lot be re-graded? YES __ NO__ Will excess fill be removed from premises? YES
Address Phone No.
Address Phone No
Address Phone No.
14. Names of Owner of premises
Name of Architect
Name of Contractor
15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES
* IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED.
b. Is this property within 300 feet of a tidal wetland? * YES NO
* IF YES, D.E.C. PERMITS MAY BE REQUIRED.
NO
16. Provide survey, to scale, with accurate foundation plan and distances to property lines.
_Depth
Rear
NO
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 $off, lk )
~ .~, t~5~,e 4 PA,,, I ~: 1: being duly swom, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named.
(S)He is the 0 co,a*..
(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 this application are true to the best of his knowledge and belief; and that the work will be
performed in the manner set forth in the application filed therewith.
Sworn to before me this
24~'~' dayof ~ ~,a e~-, {>~-. 200q~
~ NotaD' Public~'D ~ -
/ Sign~ature of Applicant
John M. Judge
NOTARY PUBLIC Stateof NewYork
No. 01JU605940(5
Ouc' '- ~ In Suffolk County
C *, .... on Expires May 29, 20 0-7