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HomeMy WebLinkAbout30765-Z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-30656 Date: 12/28/04 THIS CERTIFIES that the building ACCESSORY Location of Property: 275 PRIVATE RD #8 CUTCHOGUE (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 97 Block 3 Lot 18.6 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated NOVEMBER 9, 2004 pursuant to which Building Permit No. 30765-Z dated NOVEMBER 9, 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 "AS BUILT" ACCESSORY SHED IN THE REQUIRED REAR YARD AS APPLIED FOR. The certificate is issued to ANTONIO & EILEEN MASSIMO (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. N/A PLUMBERS CERTIFICATION DATED N/A ori d Si ature Rev. 1/81 FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-30657 Date: 12/28/04 THIS CERTIFIES that the building ACCESSORY Location of Property: 275 PRIVATE RD #8 CUTCHOGUE (HOUSE NO. ) (STREET) (HAMLET) County Tax Map No_ 473889 Section 97 Block 3 Lot 18.6 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated NOVEMBER 9, 2004 pursuant to which Building Permit No. 30766-Z dated NOVEMBER 9, 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 "AS BUILT" ACCESSORY HORSE BARN IN THE REQUIRED REAR YARD AS APPLIED FOR. The certificate is issued to ANTONIO & EILEEN MASSIMO (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO_ 419786 05/13/97 PLUMBERS CERTIFICATION DATED N/A uth rized 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. 30765 Z Date NOVEMBER 9, 2004 Permission is hereby granted to: A & E MASSIMO 3155 EUGENES ROAD CUTCHOGUE,NY 11935 for "AS BUILT" ACCESSORY SHED IN THE REQUIRED REAR YARD AS APPLIED FOR at premises located at 275 PRIVATE RD #8 CUTCHOGUE County Tax Map No. 473889 Section 097 Block 0003 Lot No. 018 . 006 pursuant to application dated NOVEMBER 8, 2004 and approved by the Building Inspector to expire on MAY 9, 2006 . Fee $ 150 . 00 Authorized Signature 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. 30766 Z Date NOVEMBER 9, 2004 Permission is hereby granted to : A & E MASSIMO 3155 EUGENES ROAD CUTCHOGUE,NY 11935 for "AS BUILT" ACCESSORY HORSE BARN IN THE REQUIRED REAR YARD AS APPLIED FOR at premises located at 275 PRIVATE RD #8 CUTCHOGUE County Tax Map No. 473889 Section 097 Block 0003 Lot No. 018 . 006 pursuant to application dated NOVEMBER 9, 2004 and approved by the Building Inspector to expire on MAY 9, 2006 . Fee $ 398 .40 Authorized Signature ORIGINAL Rev. 5/8/02 Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT 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 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 1% 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: 1. 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. 1,1 //1 A y New Construction: Old or Pre-existing Building: (check one) Location of Property: 8 t► ked r House No. Street ��� Hamlet Owner or Owners of Property: �'►1�-o nl o 0 �`�i c�5 s �`rn o Suffolk County Tax Map No 1000, Section �T Block 0663 Lot U (o Subdivision Filed Map. Lot: 3 0-1 l0 5 —t Permit No. �t.,�1�aS Date of Permit. ,2 3d Applicant: x},, d ,f, ;, tl ,'/ee .l MASS.°m Health Dept. Approval: Underwriters Approval: Planning Board Approval: ` Request for: Temporary Certificate Final Certificate: t/ (check one) Fee Submitted: $ 0 6 Applicant Signature �91c 7�0 CO-& 305 Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT 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 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 1%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: 1. 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 I Date. New Construction: Old or Pre-existing Building: (check one) Location of Property: &tj k& S-1, C6,:L, h b House No. Street �� Hamlet Owner or Owners of Property: t-'hJ+o „/ � o eL �,'/��.�.J o S s ;r►, c, Suffolk County Tax Map No 1000, Section ©!_7 Block O Lot 01F. 6G6 Subdivision Filed Map. Lot: '3 o"1 to S -t Permit No. ��� t,,t„ Date of Permit. p Applicant: D Health Dept. Approval: Underwriters Approval: /� U Planning Board Approval: ` Request for: Temporary Certificate Final Certificate: t/ (check one) Fee Submitted: $ �j}. V d Applicant Signature cn � 3G�5 � 4 THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1 1185077 BUREAU OF ELECTRICITY 85 JOHN STREET, NEW YORK, NY 10038 Date MAY 13,1997 Application No.on file 13875897/97 N 419786 THIS CERTIFIES THAT only the electrical equipment as described below and introduced by the applicant named on the above opplication number in the premises of TONY MASSIMO, 3155 EUGENE RD. , CUTCHOGUE, N.Y. in thefollowinglocation; ❑ Basement ❑ Ist Fl. ❑ 2nd Fl. GAR Section Block Lot was examined on MAY 07,1997 and found to be in compliance with the National Electrical Code. FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS OUTLETS RECEPTACLES SWITCHES INCANDESCENT FLUORESCENT OTHER AMT. K.W. AMT. K.W. AMT. K.W. AMT. K.W. AMT. H.P. 2 2 1 1 DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPWALRK'PTI TIME CLOCKS "LL UNIT HEATERS MULTI-OUTLET DIMMERS dl H.P. GAS H.P. AMT. NO. - A.W.G. AMT. AMP. AMT. AMPS. TRANS. AMT. H.P. SYSTEMS AMT. WATTS NO.OF FEET SERVICE DISCONNECT NO.OF S E R V 1 C E AMT. AMP. TYPE � I X 3W 10 3W 3 Ar 3W 3.0 4W NO.OF CC.GOND. A.W.G. NO.OF HIAEG A.W.G. NO.OF NEUTRALS A.W.G. PER X OF CG C OF HI•LEG OF NEUTRAL OTHER APPARATUS: BARN-1 G.F.C.I:-1 ROSLAK ELECTRIC LIC.#3677-E P.O.BOX 164 CUTCHOGUE, NY, 11935-2453 a GENERAL MANAGER 11 a4 Per This certificate must not be altered in an manner; return to the he office of the Board if incorrect. Inspectors may be identified wy their credentials. THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE '1 8042658 BUREAU OF ELECTRICITY 85 JOHN STREET, NEW YORK, NEW YORK 10038 Date DECEMBER 07 ,1993 Application No.on file 81794293/93 H 038533 THIS CERTIFIES THAT PERMIT NO. 214142 only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of TONY MASSIMO, BANKS STREET, CUTCHOGUE , N.Y. in thefollowinglocation; 11 Basement ❑ Ist Ft. ❑ 2nd Fl. OUT flection Block • Lot' teas examined on DECEMBER 0 3,19 9 3 and found to be in compliance with the National Electrical Code. FIXTURE FIXTURES RA tOOI NCVDECKS ' OVENS DISHWASHERS EXHAUST FANS OUTLETS RECEPIACLES SWITCFIES INCANDESCENT FLUORESCENT OTHER AMT. Kw. AMT, K.W. ' AMT. K.W. AMT. K.W. AMT. H.P. DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SWJAL RECPT TIME CLUCKSgEL4 UNIT NESTERS MULTI-OUTLET D AMT. K..W. OIL H.P. GAS- M.P. AMT. NO. A.W.G. AMT. AMR.:.., AIATi :AMPS. TRANS. AMT. µ,P;: SYSTEMSOFEAMT. WATTS NO.OF FEET SERVICE DISCONNECT NO.OF S E R Y 1 C E MEM AMT. AMP. TYPE .Raw. I IN 2W 1'0 3W 3 Ar 3W 3 0 4W NO.QFERCC*COND. OFA CC. &D. NO.OF 141-LEG OA.W.G NO.OF NEUTRALS OF MEUTGA"Al OTHER APPARATUS: SUBMERSIBLE WATER PUMP-1 FSG PRESSURE SWITCH-1 FEEDERS:1-3 * 12 BASEMENT TO BASEMENT MOTORSt1-1 H.P. KREIGER WELL & PUMP CORP BOX 101 MAIN ROAD MATTITUCK, NY, 11952 QIINWRAI MANAQNt. 11 Per This certificate must not be altered in any manner;return to the office of the Board if incorrect. Inspectors may be identified by their credentials. i Applicant/ Date. Owners Name:... 'Reviewed: Architect/ Date Engineer: J. ,, Submitted: SCTM #: District: 1.000 Section: 131ock: Loi: Project Subdivision Location; - d r� - _ Name: $igle&separate Required cemfcation: (Yes f No) / Req. Rey r/ Znllillg Oistrict: (iAI SIZE: _ AgUai: �C�trLD 1 (Lot covcragc Prupo.ed 1 Req. Rey. (1'ronl Yard Proposed: I (Side Yard d`-e 6 Proposed: (Rear Yard Proiwsed=/� 1 Project Description: AGENCUE-RMITS Permit'. MUIRED FOR REVIEW N.A. NO YES 1�tumber Suffolk County Health Dept. Now York State. D. E.C. Town Trustees Town Zoning Board approval: Town Planning Board approval: 1. Flood Plane Elevation??? Flood Zone: s'�°i.`e--/� A3 765.1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ �INAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION REMARKS: O DATE /1 � INSPECTOR '� 3o�� Gt 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IN ATION [ ] FRAMING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION REMARKS: cyc DATE 67L — INSPECTOR-- "'� r FIELD INSPECTION REPORT DATE COMMENTS Q � FOUNDATION(1ST) - C, -------------------------------------- FOUNDATION -----------------------------------FOUNDATION(2ND) z 0 ulJ ROUGH FRAMING& PLUMBING INSULATION PER N.Y. -3 STATE ENERGY CODE IL 0� FINAL .� CA ADDITIONAL COMMENTS LA _U z m W � O z x H - — x e TOWN OF SOUTHOL�1 BUILDING PERMIT APPLICATI0� CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL 9 2004 Board of Health SOUTHOLD,NY 11971 1 4 sett of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502 - Survey www.northfork.net/South6ld/ PERMIT NO.y 3 0�,2w 6 Check Septic Form N.Y.S.D.E.C. Trustees Examined �� ,20 0 y Contact: Approved ,20_,0 Mail to: Disapproved a/c Phone: -7 3 cl 6 8 Expiration S ,20_a,�& Building Inspector APPLICATION FOR BUILDING PERMIT DateZZ 2 , 2� INSTRUCTIONS 1 .1 a.This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans, accurate plot plan to scale.Fee according to schedule. b.Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or 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 Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date.If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize, in writing,the extension of the permit for an addition six months.Thereafter, a new permit shall be required. 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, Suffolk County,New York,and other applicable Laws,Ordinances or Regulations, for the construction of buildings,additions, or alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,housing code,and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. (Signature of applicant or name,if a corporation) -,)(j ed t- /& P� ling address of applicant) �- J IV I State whether applicant is owner, lessee, agent, architect, engineer, n91 co ar, electrician, lumber or builder Name of owner of premises (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. Locationrof land o which,proposed work will be done: House Number Street Hamlet County Tax MNo. 1000 Section U ; D u Block 3; V 0 Lot�� z Subdivision LA9 A J C R Filed Map No.�,,� (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy b. Intended use and occupancy()i%,r P&corL Ty 2_,;,<, 3 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work 4. Estimated Cost Fee (Description) (To be paid on filing this application) 5. If dwelling, number of dwelling units Number of dwelling units on each floor If garage, number of cars 01 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories 9. Size of lot: Front Rear Depth 10. Date of Purchase el Name of Former Owner r4q..L, &[2-O_�w Z e iZ d e_(T 11. Zone or use district in which 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 NO 14.Names of Owner of premises Address Phone No. Name of Architect Address Phone No Name of Contractor Address Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO * IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C. PERMITS MAYBE QUIRED. b. Is this property within 300 feet of a tidal wetland? *YES NO * IF YES,D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey,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) S: COUNTY OF r S being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the (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. Swo o b fore me this ` ^ r1 V day of �U Y" /"21 ,,. Notary Public f Signature of Applicant PENw BtbELL Notary Public,State of Nbw`brk No.01BE6099317 Qualified in Suffolk Coin Commission Expires Sept.29, FIELD INSPECTION REPORT DATE , COMMENTS IFIF7 J FOUNDATION(1ST) H ---------------------------------- FOUNDATION(2ND) I2 V o J ROUGH FRAMING& - PLUMBING • INSULATION PER N.Y. STATZENERGY CODE r R.. . �.' • FINAL M µ1 ADDMONAL COMMENTS z m X � H O z x H x e TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CfIECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL 9 2004 Board of Health SOUTHOLD,NY11971 4 sets of Building Plans TEL: (631) 765-1802 Planning Board approval FAX: (631) 765-9502_ " .._ a Survey www. northfork.net/Southold/ PERMIT NO. 3 �� 5 Check Septic Form N.Y.S.D.E.C. Trustees Examined �/ ,20_Q� Contact: Approved ,20 Mail to: Disapproved a/c Phone: 7 3 4—Z`Z 4� 8 Expiration ,20 f Building Inspector APPLICATION FOR BUILDING PERMIT Date � � ,20.2_4INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans, accurate plot plan to scale.Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises,relationship to adjoining premises or public streets or 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 Inspector will issue a Building Permit to the applicant. Such a permit shall bq 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 what so ever until the Building Inspector issues a Certificate of Occupancy. f.Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim,the Building Inspector may authorize,in writing,the extension of the permit for an addition six months.Thereafter, a new permit shall be required. 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, Suffolk County,New York, and other applicable Laws,Ordinances or Regulations,for the construction of buildings, additions,or alterations or for removal or demolition as herein described.The applicant agrees to comply with all applicable laws,ordinances,building code,housing code,and regulations,and to admit authorized inspectors on premises and in building for necessary inspections. (Signature of applicant or name,if a corporation) (M ' ' g address of applicant) �- J Lit aJ State whether applicant is owner, lessee, agent, architect, engineer, genera contractor, electrician,Imnber or builder 600e- r, Name of owner of premises (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 bedone: House Number Street Hamlet County Tax M p No. 1000 Section G �, Block &3i 6G Lot !� Subdivision /,�•4-aJ 6,s L� z tL (Z- Filed Map No. SSU Lot (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy b. Intended use and occupancy { ut g- 3. Nature of work(check which applicable):New Building „O Addition Alteration Repair Removal Demolition Other Work 4. Estimated Cost Fee (Description) 5. If dwelling, number of dwelling units (To be paid on filing this application) If garage, number of cars Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Rear Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Rear Depth Height Number of Stories 9. Size of lot: Front Rear Depth 10. Date of Purchase 3 Name of Former Owner rL4 KI C- , 11. Zone or use district in which 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 NO 14. Names of Owner of premises Address Phone No. Name of Architect Address Phone No Name of Contractor Address Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO * IF YES, SOUTHOLD TOWN TRUSTEES &D.E.C. PERMITS MAY B QUIRED. b. Is this property within 300 feet of a tidal wetland? * YES NO * IF YES, D.E.C. PERMITS MAY BE REQUIRED. 16. Provide survey, 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) ,,q: COUNTY OF W'f -EQ 11 � OtOffl C� being duly sworn, deposes and says that(s)he is the applicant (Name of individual signing contract)above named, (S)He is the (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. Swo to before me this�/� day of /� yy• 20 Notary Nbjc 7 Signature ft Applicant PENNY BEbELL Notary Public,State of New York No.01BE6099317 Qualified in Suffolk County Commission Expires Sept.29, 4 r- > 1 a SUFfOi.K.CO. ALI* , H.S. No, t , . 45 f $tJ�Ll7 ,vG l ,• t/ 6vILD�nIG ;} _ � STATEMENT:OI:..INjLNT- ! AI ,f-i_; . �F . PiZV PE T Y THE WATER SUPPLY AND SEWAGE-vtSPpS�I, SYSTEMS FOR - THIS REsfQNCE tA1M:L . Z N �5t1f2Y� 'LC"Ddf� �� CONFORM TO T E STA T NQAR HE • 1, ;. ''; - .. 4 � SUFFOL PT. HFA 7 t�•l TCNl c� 11 A 5 15/filo cs� ion 7 R StJ1�'FOLIC Cdii'3"Y bEPT tom`. ,•G S F4R A VAU ! cumHoaucCONSTRtiCTlcILIL.Y` A2 Q� DAT V f H. S. R£R. N4.: S APPROVED. _ OCA E 40 Sp i SUFFOLK CO.-T oOJONAirl k A5 t - D 1ST. 5E1`.. BLOCK PCL. SHO wnl A e EA � '¢. 7�/ A G 2�.� to � - cs*��7 f"1•G ' : ` L07" �rcrfrtbs rS Ms " r to "Gre+� _ ,.., , ! ti, '� r✓ s • ,_ �crbdivisrarar r„cafr �b. bs��cfe� i,�r �r��c/iE ��,. ;; . __ { eD k•� x `4. w Tl�'S S�l2vEY f-fA-S F3rE-nJ A LTEjPGU Tc ln�,n/cam TiE ,E X 1 ST/�G s{CCE sSUIX/—� 7"o g �n» rYo°fn�seNEducadr A N0 P�G',O'/0O SE O /�l CW �7/ _ cob,a g* L LCA T/owl o� �CcE 55ateY tau z2,,1v6 3 / 8„ �.W. .k*Ad��''"0 _� ': .mboa.d.NJ.h�N noe b.=WdoW t A u y 9 Jr �NT� �2 E e Y�/Q lam. Q M a wNd tuf a�p�c t }. Yw tii. '• `r yam.• j! _ .. Y - . E RAYit.Y OMlE1,LNQ OlA. and an nrs w. " E� �YEARs FROM DATE OF APPROVAL 1> aer' a �oa° ►a'w ft=804i ofat war.Vimew :s • -�. addftlonal�sttuit��trarwl�nibl� K- S. OrmWa : N ENS MAYA` ROO $ICt�VAN 1fl:.h.C. * it j• S.C.-DEPT. OF .. ^ p' SERVICES LIED Lil mri 9wv4 'CR$ ° HEALTH r' Qs n,as aftz"PORT NEM YORK uwo low*p6a , �f Wi - Z0NQ_rL -,�TiCN �HA11 METHS =_'BENTS OF THE Lam- t/- -�--------- CODES Ut= Nc_uV CORK STATE. ----- --- - V' ECTIONS 1-5_/M4 ,off APPROVED AS NOTED RE: LD. T-Y,P.I: DA // 4 B.P.8 3c, 76 c FEI % { /5 BY: 1 / r NO 1 BUILDING DEPARTMENT AT N 76 1 8 AM TO 4 PM FOR THE T ,l ING INSPECTIONS: v + -- -�T 1. NDATION - TWO REQUIRED �� { —�� - ► R POURED CONCRETE a A' 2. GH - FRAMING Ili PLLUBWG I "J ULATION '�'` a C �T+nnl MUST 0. 4 HE �Lo�✓ FRE REV )'t c rte' N W STAT N: OY POR D I N R CONSTRUC110N ERRORS. ti p -O OR TrA -WITHOUT CERTIFICATE `' f _ OCCurr ANCY `;� J12 OF J ^Y LL CONSTRUCTION SHP1 [- MEET TI, REQUIREMENTS C- 'E CODES OF NEW YORK STATE. Of 1 � CERTIFICATION OF NAILING & CONNE TIONS 1 AS NOTED N �ATE- J/77,/O B.P.# FEE: O BY: ? - NOTIFY BUILDI DEPARTMENT AT _- �--G 65-1802 8 AM 4 rM FOR THE tl� _ T,ONS. N ` FOUNDATION ''WO REQUIRED ` { FOR POURE )NCRETE ROUGH - FR 14G & PLUMBING ►', U { INSULATION _ . FINAL - CON ACTION MUST BE COMPLET ,P C.O. L CONSTRUC I SHALL MEET THE �11L V EQUIREMENTS F THE CODES OF NEW �{- -- YORK STATE. N T RESPONSIBLE FOR i 5 - D IGN OR COI RUCTION ERRORS. Y UNDERnm„: ERS CERTIFICATE IFICATE i REQUIRED "_--- , --rc -Huk G E .•.LA N r,I CY n �` _ �PAN OR , UNLAWFUL TIFICATE OUT CER f'' y -CUPANCY CG74 1-4 G � L3��4�'L ovErZ do�TS 4x4sCTyre —�� r1f12v Gxb @G' o•c.47- Tv �u4 f � . I LEF`� �t12� ��v QN -- 5 � s.1 1 _ o�J — gat rTY J �r :.� ��• ! u LAz A S PHA�:T 5 H I w& LE 5 --� C S G_12 -- \ t. '-0 PEaI OPf�I ,; 9 s