HomeMy WebLinkAbout31010-Z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-30876 Date: 04/22/05
THIS CERTIFIES that the building ALTERATION
Location of Property: 3360 KENNYS RD SOUTHOLD
(HOUSE NO. ) (STREET) (HAMLET)
County Tax Map No. 473889 Section 54 Block 5 Lot 24
Subdivision Filed Map No_ Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated MARCH 16, 2005 pursuant to which
Building Permit No. 31010-Z dated MARCH 21, 2005
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" ALTERATION OF GARAGE TO STORAGE SPACE IN AN EXISTING ONE
FAMILY DWELLING AS APPLIED FOR. CONSTRUCTION CERTIFIED BY JOSEPH FISHCETTI
PROFESSIONAL ENGINEER.
The certificate is issued to CRAIG & KIMBERLIE JOBES
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. N/A
PLUMBERS CERTIFICATION DATED N/A J
y
Auth ized Sign ture
Rev. 1/81
Form No.6
• -'�
TOWN OF r1
BUILDING DEPARTMENT
TOWN HALL t1�1
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPAN ' "2?- -! -�
This application must be filled in by typewriter or ink and submitted to the Building Department with the following:��c� f
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 I% 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. �/ -1DS-
New Construction: Old or Pre-existing Building: //JJ (check on`/e)) �/
Location of Property: �j3 (o 0 �1ny Ld 7Ut",, a` Cj
House No. Stre t Hamlet
Owner or Owners of Property:
Suffolk County Tax Map No 1000, Section Block `j Lot C) /
Subdivision r� Filed Map. Lot:
Permit No. J C) t� _Date of Permit. '/-O Applicant:
Health Dept. Appro�aL Underwriters Approval:
Planning Board Approval
Request for: Temporary Certificate Final Certificate: (check one)
Fee Submitted: 5
GO -2)C)
c
p�2 �' .applicant Signature
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. 31010 Z Date MARCH 21 , 2005
Permission is hereby granted to :
CRAIG & KIMBERLIE JOBES
3365 KENNYS ROAD
SOUTHOLD,NY 11971
for
GARAGE ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED
FOR "AS BUILT" FLOOD PMT. INCLUDED
at premises located at 3360 KENNYS RD SOUTHOLD
County Tax Map No. 473889 Section 054 Block 0005 Lot No. 024
pursuant to application dated MARCH 16, 2005 and approved by the
Building Inspector to expire on SEPTEMBER 21 , 2006 .
Fee $ 400 . 00
/ Authorized Signature
ORIGINAL
Rev. 5/8/02
317_�l0
O rJ��nrJ��nrJ�rrrJ�cnrJr�rJ�rJ��nrJ�rJcPr�rJ�cPrJr1r nr tr.Pr1rJ�rJ�rJ�r rrJ�cf�nrJrJ�c1cP�nrlrl0 VJ E rUEUEDEPr4lrAEU00EU0EUEU@P00maaprr0prr-P eo
5 5 BY THIS CERTIFICATE OF COMPLIANCE THE 5
NEW YORK BOARD OF FIRE UNDERWRITERS 5
BUREAU
40 FULTTON STREET F C
NEW YORK, NY 10038
5 CERTIFIES THAT 5
5 Upon the application of upon premises owned by
5 BEN DOROSKI CRAIG JOBES 5
5 5 42D MONSELL LN 3365 KENNYS RD �5
PO BX 781 SOUTHOLD, NY 11971 5
5 CUTCHOGUE, NY 11935 c5
5 Located at 3365 KENNYS RD SOUTHOLD, NY 11971 r5
c5 Application Number: 2045475 Certificate Number: 2045475
Section: 54 Block: 5 Lot: 24 Building Permit: BDC: nsll
5 5 Described as a occupancy, wherein the premises electrical system consisting of tj
electrical devices and wiring, described below, located in/on the premises at: 5
5 Basement, 5
5 A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed 5
5 herein, was conducted in accordance with the requirements of the applicable code and/or standard
5 promulgated by the State of New York, Department of State Code Enforcement and Administration, or other
5 5 authority having jurisdiction, and found to be in compliance therewith on the Day of
29th March,2005. 5
5 Name OTY Rate Rating Circuit Type 5
Miscellaneous
5 garage conversion to
5 living space-as built 1995 5
Wiring and Devices
Outlet 2 0 Fixture S
5 Fixture 2 0 Incandescent 5
S5 Outlet 7 0 General Purpose fj
S Receptacle 5 0 General Purpose L5J
Switch 3 0 General Purpose
55 An as built visual inspection,of the delineated electrical installation,determined that an obvious hazard is not present and the installation is
believed to be in comformance with the applicable reference standard for the estimated period of construction of the premises wiring system. L+
5 5
seal 55
5 1 of 1 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.
5 5
o �JrJ��rr nrrrJ�rr� cPrJr fo rJ rJ�rJ�rJ �nrJrJrJ�rJ�rJ�rJ�rJ�r r�n�n�n�rrI s� n���l-lr PE.PLr PLPL�3rr3P 01
F _
MAR ! 870115 1[u1
PROFESSIONAL ENGINEER
1725 HOBART ROAD/PO Boz 616, SOUTHOLD, NEW YORK 11971 _J
u DEF'
TEL631-765-2954 • FAX631-614-3516 - email: joseph@fscheto.com - 'r NN `�° THp-
J v�
Date: March 16, 2005
Reference: 3365 Kenneys Road
Southold Building Department
Main Road
Southold, NY 11971
Dear Sir,
I certify that the interior partitions and finishes for the conversion of the Garage to storage room
for the above referenced home meets the require New York State Building Code.
of
NEwr
7! R
W
Jo E.
3/16/2005 3:11 PM FROM: Fax TO: 765-9149 PAGE: 002 OF 002
MAR 1 8 ?nn� ! ,
continuous 2" x 4" Blocking
Fastening - See schedule below
Ov
•-- 16/32" ply wood minimum
1
window
Horizontal and Vertical 2" x 4" blocking
window sill
Fastener Spacing
Panel Size <2 <2<4' <4'<V <6'<8'
21/2'Woad Screws 16"oc 16"0c 1610c 12'0c
Wood Stud Wall
WINDOW SHUTTER DETAIL
FOR ALL NON-COMPLIANT WINDOWS
03-07-2005 02:07 THE FACE AND BODY SPR 6317659149 PAGE:2
a i ,
FLOOD VENT CERTIFICATIONL-6I�'
3365 Kenny's Road Southold/ Jobes House
I Joseph Fischetti, PE do herby certify that the Smart VENT Louvered Foundation Flood
Vents installed in the referenced home foundation will allow for the automatic equalizing
of t e by ros tic flood forces on the exterior walls by allowing for the automatic entry
a d it the odwaters during floods up to and including the base (100-year) flood.
April 19, 2005
Nein York State Professional Engineer License 052510
1725 Hobart Road
Southold, New York 11971 w
631-765-2954
r
�OAaxs+O
3810��~
JWI'H T. TERRY
TO%74 CLEPA L r• p T N P O. n,,< 1174
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IS ;;A vi ':1 is 1. `T:SISII,"•J �S �j �Cb � Fj. i 'i li,l 76c.IR�I
e1 p.P nl'Gf i7rnCCR �Ol SILT
RECORIIS 1APNACEMENT OITICEIt -st
rREEDC1.1 of INFVMt1T1ou onceR
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION WAS ADOPTED BY THE
SOUTHOLD TOWN BOARD AT A REGULAR MEETING HELD ON AUGUST 24, 1993 :
RESOLVED that the Town Board of the Town of Southold hereby adopts
two (2) new forms to be used under the Flood Damage Prevent regulations , s
of the Code of the Town of Southold: "Floodplain Development Permit
4pp,ication" [ FDP(93 ) 1 and "Certificate or Compliance h,r De�,elrpment in
pecial Flood Hazard Area t(-JC(93 ) ) .
TOV.,1 OF SO:PiOLD
Judith T . Terry -'
Southold Town Clerk
August 25 1993
APPLICA.Tlprr ,y
PAGE 1 0( 4 --
TOWN OF SOUTHOLD
FLOODPLAIN DEVELOPMENT PER-NIIT APPLICATION
This form is to be filled out in duplicate.
SES CTION L: GENERAL PROVISION5(.IPPLfC4NL to read and <-ienl:
L. No work may start uaW a permit is issued.
2 The permit may be revoked if any false statements are made herein.
3. If revoked, all work must cease until permit is reissued.
4. Development shall not be used or occupied until a Certifiate of Compliance is issued.
S. The permit will expire if no work is commenced within six months of issuance.
6. Applicant is hereby informed that ocher permits may be required to fulfill local, state and federal regulatory
requirements.
7. Applicant hereby gives consent to the Local Administrator or his/her representative to make reasonable
inspections required to verify compliance.
8. I,THE APPLICANT,CERTIFY THAT ALL STATEMENTS HEREIN AND IN ATTACHMENTS TO
THIS APPLICATION ARE, TO THE BEST OF MY KNOWLEDGE, TRUE AND ACCURATE.
(APPLICANTS SiGNATURFs}.1-�.. _+�—.��5^— ��--"— DATE
C
SECTION 2: PROPOAD DEVELOPN ENTi-F., is comolctcd v APPLI W
NAME ADDRESS TEI-r—PHONE
APPLICAM
P-CO Vs C � .�_i4 j I�-El.)I�� `�C,l
BUILDER
ENG If LEER
PROJECT LOCATION:
To amid delay in processing the application, please provide cuough information to easily identify the project
location_ Provide the street address, lot number or legal description (attach) and, outside urban areas, the
divance to the nearest intersrr6ng road or La cmar6_ A sketch attached to this application showing
the project location would be hclpfhd.FDP(93 )
APPLICATION
P4GF '_ OFa
DESCRIPTION OF WORE: ('Check all appbublc boxes)
A_STRUC—TURALDEVELOPMENT
ACTfVITY STRUCTURE TYPE
O New Structure �KResidtutial (1-4 Family)
❑ Addition O Residential (More Wan 4 Family)
:RtAllcration ❑ Noo-residential (Floodproofmg? ❑ Yes)
O Relocation ❑ Combined Use (Residential dz Commerdal)
❑ Demofitioo P ❑ Manufactured (Mobile) Home (in Manu-
0 Replacement factured Home Park? 0 Yes)
ESTIMATED COST OF PROJECT S
B. OTHER DEVELOPMENT ACTIVITIES:
❑ Fill O Mining ❑ Drilling 0 Grading
O Excavation (Except for Structural Development Checked Above)
❑ Watercourse Alteration (Including Dredging and Channel Modifications) ,
O Drainage Improvements (Including Culvert Work)
D Roa,,, Street or Bridge Construction
O Subdivision (New or Expansion)
❑ Irimdual Water or Sewer System
❑ Other (Please Sperify)
P.Imr compldiag SECTION I Ap PLICAI`rT should submit lorm to Local Adminisvator for rc%ic .
SECTION 3: FLOODPLAIN DETERMINATION fTo be comolctcd by LOCAL ADMIMSTRATORI
The proposed development is to-vcd on FOPM Pancl No. — Dated
The Proposed Development:
❑ Is NOT located in a Special Flood Hazard Area (Notify the applicant that the application
review is complete and NO FLOODPLAIN DEVELOPMENT PER1yQT IS REQUIRED).
❑ Is loured in a Special Flood Hazard Arca.
FTRH zone designation is
lf?)-'icU flord deviation at We site 6: Ft. rtGVD (HSL)
❑ Unavailable
❑ The proposed dcadopmcnt is locair,d ,n a 1lood,,3o
FBF?.1 Pancl rdo Dated
APPLICATION 4
PAGE ) OF 4
SECTION 4: ADDITIONAL INFORMATION REOt11RED (To hc -omnlucd b" LOC+.L ADMINIST'RATORI
The app(icanl must submit the documents checked below before the apphcauon can be processed.
O A sue plan showing lbe location of all ctasting vruclures, water bodies, adlaee❑t roads, lot
dimensions and proposed development.
❑ Development plans, drav,m to scale, and specificatipns, including where applicable: details for
anchoring structures, proposed elevation of lowest Boor(including basemew), types of water
resistant materials used below the fust Boor, detaiLs of Boodproofing of utilities located below
the first Boor and details of enclosures below the first Boor.
Also
O Subdivision or other development plans(If the subdivision or other development Cxcceds 50
lots or 5 acres,whichever is the lesser, the applicant must provide 100-year flood elevations
if they are not otherwise available).
❑ Platis showing the extent of watercourse relocation and/or landform alterations.
❑ Top of new fill elevation Ft. NGVD (MSL).
O Floodproofmg protection level (non-residcutial only) Ft. NGVD (hiSL). For
floodproofed structures, appl cant must attach certification from registered engineer or
- architect.
❑ Ccrtifimnon from a regasmred en&cer that the proposed acdv;.'y in a regulatory floodway
%till not result in any increasr in the height of the 100-year flood. A copy of all data and
c.dcmlatiom supporting this finding man also be submitted.
Cl Other -
SECTION 5: PERMIT DETERh1INATION (To be completed by WsL ADM1IINISTRATOR)
I have determined that the proposed activity. A. O Is
B. O Is not
in conformance with provisiotu of Local law d_, 19 The permit is issued subject to the conditions
attached to and made part of this permit.
SIGNED DATE
If BOx_-_chcd.c�d, the Uc.il Adminisirawr mai i:suc a Development Pcrmil upon paymcot of designated
f e. .
If BO'K B is checked, the Local Administrator w01 provnde a written summary of dcGacn-:tca. Applicant may
revise and resubmn in application in ihr Loral �dminwralor or may request a hearing Irom the Board of
pp--'J.
• �.rput:.nnor, a
P r E 1 F t --
APPE,41.; nppcalcd to Board of Appeals' U Yc% U No
Hearing date:
--- .Apps Beard-Decainv -=-�.pprovcd3. O Ycr O-Na-- ----- --- ----- ----- — _
Coaditioas
SECTION 6' AS-BUILT ELEVATIONS (To be submitted by APPLICANT before C ertificaic of Compliance
is issued)
The following information must be provided for project structures. This section must be completed by a
registered professional coginecr or a licensed land surveyor (or attach a certification to (his application).
Complete 1 or 2 below.
1. Actual (As-Built) Elevation of the top of the lowest floor, including lammeut (in Coastal Hi¢h Hazard
Areas bottom of lowest structural member of the lowest Boor, excluding piling and columns) is:
FT. NGVD (MSL).
1
L - Actual (As-Built) Elevation of Boodproofmg protection is FT. NGVD (htSL)-
NOTE: r.ny work performed prior to submittal of the above information is at the risk if the Appl-cant.
SFCCION 7: COMPLLANCE ACTION (To be completed by LOCAL ADMINISTRATOR)
The LOCAL ADMINISTRATOR will complete this seaton as apphczble based ou of the project to
ensure compliance with the community's local law for Bcod damage preventiona
INSMCIIONS: DATE BY DEFICIENCIES? U YES O NO
DATE BY DEFICIENCIES? U YES U NO
D.A'fE BY DEFICIENCIES' U 'r'ES U NO
SECTION 8• CERTIFICATE OF ONRL1AN E(To be completed by LOCAL ADMINISTRATOR)
Certificate of Compliance issued: DATE: BY:
Attachment B ,
BAMP..E
CEP.TIFIrATF :JF CGMPLIANCF.
for Development in i Spot ial Flood Hazard .Area
TOWN OF SOUTHOLD PROPERTY RECORD CARDy' 3g
-S S- 2-
W ERSTREET 33 ? VILLAGE DIST. SUB. LOT
i ''•
O S
FORM4ERN EACoL
ft Coo o
rid
rnrn I I/ lb s S^ IW TYPE OF BUILDING
RES. SEAS. VL. FARM COMM. CB. M S. Mkt. Value
LAND IMP. TOTAL DATE REMARKS
—
S"ca
,j 3 - er4Aly-1 ( " ,
7
7 `7�� • 540 �� �oG�""�. ,� -d..cyc�. �A 1Wkr
7
L zZz 60' Al l leo u f� s (�foo
AGE BUILDING CONDITION
NEW NORMAL BELOW ABOVE
FARM Acre Value Per Value
Acre _
Tillable FRONTAGE ON WATER
vVoodland FRONTAGE ON ROAD
Meadowland DEPTH 1 p
House PIS. BULKHEAD
1_
1
Total DOCK
COLOR I TRIM ✓h �� —
j
I L
M. Bldg 7S
�'�f /
Exte"1 ^ / 1
d�
Extension
Extension
Acis ?6 lgetl- 3.3C Foundation P ` Bath f Dinette
Porch S x x 2 ,/ .�15 / / Basement Floors 1,a l K.
Porch S K'r 6S Ext. Walls �� Interior Finish :i LR. /
Breezeway Fire Place Heat DR. /
Garage Type Roof Rooms 1st Floor BR. L
Patio Recreation Room Rooms 2nd Floor FIN. B
0. B. Dormer Driveway
Total
TOWN OF SOUTHOLD
CERTIFICATE OF CONfPLIANCE
FOR DEVELOPMENT IN A SPECLA-L FLOOD FL4-ZARD AREA
4OVWER-KUST-fU--WN--THIS--CERTIFICATE) _ ---
PREMISES LOCATED AT: PERMIT NO.
PERMIT DATE
OWNERS NAME AND ADDRESS: CHECK ONE:
0 NEW BUILDING
O EXISTING BUILDING
O VACANT LAND
THE LU(--'.AJ- ADNI[NIST'RATOR IS TO COMPLETE A- OR B. BELOW:
A. COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF
- LOCAL LAW #_, 19
SIGNED: DATED: --
B. COMPLIANCE IS HEREB'i CERTIFIED WITH THE pEQMRFNIENTS OF
LOCAL LAW # 19, AS MODIFIED BY VAR-LANCE #
DATED
SIGNED: _ DATED:
Cii= ( 931
ALL CONSTRUCTION SHALL
MEED THE REQUIREMENTS OF THE
CODES OF NEW YORK STATE.
EXISTING DOOR AT TOP OF STAIRS
CERTIFICAT10 I OF
NAZI Inir; R ''^"Ir 70NS
NEW STORAGE ROOM
FLOOD ZONE '�
COMPLY WITH CHAT R"46"
FLOOD DAMAGE PR N
(�SOUTHOLD TOWN E.
NEW FRAMED PARTITION & DOOR
APPROVED AS NO NEK'r
DATE E
FE. .
-,rP-RT sNT AT 9 r
%A F R THE
Sw
OL Al'
t. _ ;.GATIUh1 - '":0 F.EIED 0524��
POURED G 'jCRE7 �FE'SONP�
2. ROUGH - FRAMING. & PL ING NEW UNHEATED ROOM S►
3. INSULATION
4. FINAL - CONSTF-1- ION ST
BE COMPLETE "rOn C.O.
ALL CONFTRUCTIONMEET
REQUIREMENTS OF THE CL S OFNEW
OCUPANCY OR
YORK STATE. NOT RESPCq9BLE FOR USE IS UNLAWFUL EXISTIN DOOR
DESIGN OR CONSTRUCTI N ERRORS. WITHOUT CERTIFICATE
OF OCCUPANCY
/ EXISTING DOOR
GARAGE DOOR REMOVED AND 9'-0" SLIDER INSTALLED IN EXISTING OPEN
EXISTING CONCRETE WALLS FIRRED OUT AND SHEETROCKED UNDERWRITERS CERTIFICATE
INTERIOR FINISH OF GARAGE REQUIRED �n J
JOBES
RESIDENCE JOSEPH FISCHETTI,
3365 Kenne s Road 1725 HOBART ROAD
y SOUTHOLD, NY 11971
631-765-2954
soFFol_x co.*fEALSrI:DEFr.aPPRoiru
MAP .DT!, P20PEIZTY
SUkvEYED.'mp--�_
/ .g;. .._. !1. 1-.l ✓ STATFNIENT OF It"WNT
I roLse
AT THE;HATER SHPPL'+'AND SEWAGE 015PD5.
PE51DL-Kx ) SVS7VdS FOR THIS RESIDENCE WI:
CONFORM TO THE STANDARDS OF TI
1 Tni �w
SUFFOLK CO. DEPT. OF HEALTH SER VICI
APPLICANT
4l �i
WELL 'q7'- "� SUFFOLK COUNTY DEFT. OF HEAL'
t5 � SEiLVICES - FOR APPROVAL <
-,c` I J l .1 CONSTRUCTION ONLY
a
DATE:
F4AHO. a \� H.S.REF.NO..
HIE d
T9Sd-IS . .
M1.. j APPROVED
Lu
SUFFOLK CC).TAX MAP DESIGMRTION<
DIST. SECT BLOCK PCL
J , •i ,� ��
1000 _ a54 -
I
I jj �\ OWNERS ADDRESS:
•'� - [iLKI[tpPt T657 ilLLt .. \ 440 LtLEYAVE �
MATTTUCY,NM.1i 52'
r -
1p
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• DEED:L.'-I�'
F.
AQEA•IZ5 6 =-F r;:. TEST HOLE STAMP
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LICENSED
LICENSED LAND.SHR ORS <o Ls
GREENPORT NEW YORKO
TORN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
BUILDING IMPARTMENT Do you have or need the following,before applying?
TOWN HXL Board of Health
SOUTHOLD, NY 11971 4 sets of Building Plan
TEL: (631) 765-1802 Planning Board approval
FAN: (631) 765-9502 / Survey ✓
ww . 3 �O D w. northfork.net/Southold/ PERMIT NO. Check
Septic Form
N.Y.S.D.E.C.
Trustees
Examined 20 j) _ Contact:
Approved ,20 Mail to:
Disapproved ac
Phone:
Expiration,20 O�
i w uilding Inspector
l 11c
L I MAR 16 LICATION FOR BUILDING PERMIT
) ��.rv'. Date ^� , 20 OS
wtN_ ^t4 INSTRUCTIONS
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 pan 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)
KC NNEYS eD SNIA1141D(D N✓
(Mailing address of applicant) I I q-]/
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
DWwoe,
Name of owner of premises pCe,U C J S6bCS
(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 done:
331x5 VCNNENC eo S6 In TVl OL-C�-
House Number Street Hamlet
County Tax Map No. 1000 Section f q Block 5 Lot Z 4
Subdivision Filed Map No. Lot
(Name)
2. State existing use and occupancy of p emises and intended use and occupancy of proposed constructil
a. Existing use and occupancy AuAa
Yiz�tkt,C;;E S��G'
b. Intended use and occupancy b,)PAA `A�,on '1% WA T
3. Nature of work(check which applicable): New Building Addition Alteration
Repair Removal Demolition Other Work ZEtloJ 0L pzgL - P�,+t Ir4 SL.-WS
(Description)
4. Estimated Cost / .,Z D O , loo Fee
(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 1
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 PurchaseY b- . dSD r�.. Name of Former Owner
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 BE $SQUIRED.
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)
SS:
COUNTY OF 5,,
C (t.A r S A P s being duly swom, deposes and says that(s)he is the applicant
(Name of indfvidual signing contract)above named,
(S)He is the 0 w r-) C ti
(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
dayof r' A-Ct\ 20 v, 1
tary Public Signa4ire of Applicant
John M.Judge
NOTARY PUBLIC State of Now York
N0.01JU6059406
Qualified In Suffolk County
Commission Expires May 29,20 01