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Home My WebLink About30872-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPA/~CY No: Z-31390 Date: 01/12/06 THIS CERTIFIES that the buildln~ ADDITIONS & ALTERATION Location of Property: 425 DIAMOND LA PECONIC (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 68 Block 2 Lot 13.2 Subdivision Filed Map No. __ Lot No. __ conforms substantially to the Application for Building Permit heretofore filed in this office dated DECEMBER 27, 2004 pursuant to which Building Permit No. 30872-Z dated DECEMBER 29, 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 ADDITIONS & ALTERATIONS TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR & AS PER CONDITIONS OF ZBA #5600 DATED 11/4/04. Tg~e certificate is issued to MARION B GOTBETTER & CARMEN RAMIS (OWNER) of the aforesaid building. SUFFOLK COUNTYDEPARTMENT OFHF~LTHAPPROVAL HLEt-rKICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DA'r~u 01/04/06 N/A 101580C 11/21/05 CUTCHOGUE EAST PLUMBING Rev. 1/81 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. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form). Approval of electrical installation from Board of Fire Underwriters. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 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~_Altemtions to dwelling $25.00, Swimming pool $25.00, Accessory building $25.00, Additions to accessory building $25.00, Businesses $50.00. 2. Certificate ofOccupancy 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 Property: House No. Owner or Owners of Property: Suffolk County Tax Map No 1000, Section Old or Pre-existing Building: (check one) Street Hamlet Block Lot Subdivision Pen~tNo. ~o~'~ Health Dept. Approval: Filed Map. Lot: DateofPermit. /o2/o2~///0~/ Applicant: ~oTt~JOt4'~/~- Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ Final Certificate: ~/(check one) Town Hall, 53095 Main Road P. O. Box 1179 Southold, New Yom 11971 Fax (516) 755-t823 Telephone (516) 765-1802 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLO CERTIFICATION DATE: Owner: (please pr/iht) (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. l~umbers ~ignature ) Sworn to before me this Notary Public, ~. County B.IZAB~-rH H. BtJF'~I~ 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. 30872 Z Date DECEMBER 29, 2004 Permission is hereby granted to: MARION B GOTBETTER 205 WEST END AVE APT llH NEW YORK,NY 10023 for : ADDITIONS & ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR PER ZBA DECISION #5600 at premises located at County Tax Map No. 473889 Section 068 pursuant to application dated DECEMBER Building Inspector to expire on JUNE 425 DIAMOND LA PECONIC Block 0002 Lot No. 013.002 27, 2004 and approved by the 29, 2006. Fee $ 651.90 Authorized Signature ORIGINAL Rev. 5/8/02 Issue Date 11/21/2005 Electrical Inspection Certificate Electrical Inspection Service, Inc. Application 375 Dunton Avenue 101580C East Patchogue, NewYork 11772 (631) 286-6642 Issued To: Ms. Better Street: 425 Diamond Lane Village: Peconic Zip: Section: Block: Lot: 11958 Town: Southold Contractor: Shore Power Electric Contracting Lic.# 31697-ME Was examined and found to be in compliance with the National Electrical Code. [] Commercial [] NVDefects [] Pool [] lstFIoor [] Indoor [] Basement [] HotTub [] Residential [] Det. Garage [] Attic [] 2nd Floor [] Outdoor [] Addition [] Survey Switches Receptacles Fixtures GFI Heaters A/C Fans 25 29 31 4 1/30 4 Dishwasher Washer/Amps Dryer/Amps Oven Range/Amps Microwaves 30 1 Com Furnace Oil Gas Circulators Smoke Detector Bell Transformer 4 Meter Amps Phase UG/OH Jacuzzi Television CO Detector 1 200 1 [] / 2 Bldg. Permit: Other Equipment 1- 200 Amp Main Breaker Panel / 1- Garage Door Opener Receptacle / 1- 15 Amp Air Handler Disconnect Hugo S. Sl~rdi President Rough Inspection: 08/12/2005 Inspector: John Mc Mahon III Final Inspection: 11/17/2005 Inspector: John Mc Mahon III This certificate must not be altered in any manner. Inspectors may be identified by their credentials, APPEALS BOARD MEMBERS Ruth D. Oliva, Chairwoman Gerard E Goehringer Lydia A. Tortora Vincent Orlando James Dinizio, Jr. http:#southoldtown.northfork.net BOARD OF APPEALS TOWN OF SOUTHOLD Southold Town Hall 53095 Main Road P.O. Box 1179 Southold, NY 11971-0959 Tel. (631) 765-1809 Fax (631) 765-9064 FINDINGS, DELIBERATIONS AND DETERMINATION MEETING OF NOVEMBER 4, 2004 ZBA Ref. 5600 - MARION GOTBETTER and CARMEN RAMIS Property Location: 425 Diamond Lane and Private Road, Peconic; CTM 68-2-13.1. SEQRA DETERMINATION: The Zoning Board of Appeals has visited the property under consideration in this application and determines that this review falls under the Type II category of the State's List of Actions, without an adverse effect on the environment if the project is implemented as planned. PROPERTY FACTS/DESCRIPTION: The applicants' 22,533 sq. ft. parcel has 199.39 feet along a private road known as Diamond Lane, 122.92 feet along the southerly lot line bordering a 15' wide private road, 195.77 feet along the westerly lot line and 92.10 feet along the northerly lot line. The property is improved with a 1-¼ story frame dwelling with garage and porch, as shown on the March 22, 1995 survey, amended March 23, 1995, prepared by Roderick VanTuyl, P.C. BASIS OF APPLICATION: Building Department's August 12, 2004 Notice of Disapproval, amended September 3, 2004, citing Sections 100-242A and 100-244, in its denial of a building permit to construct second-story and garage additions to the existing single-family dwelling, with an increase in the degree of nonconformity with a front yard setback at less than 40 feet, FINDINGS OF FACT The Zoning Board of Appeals held a public hearing on this application on October 21, 2004 at which time written and oral evidence were presented. Based upon all testimony, documentation, personal inspection of the properly, and other evidence, the Zoning Board finds the following facts to be true and relevant: AREA VARIANCE RELIEF REQUESTED: Applicants wish to construct second story and mud room/garage additions as shown on the 8/31/2004 site plan prepared by Frank Uellendahl, Architect. The second-story addition is proposed at 21 feet, and the garage/mud room additions at 20 feet, measured at the closest points to the southerly front yard near Diamond Lane. REASONS FOR BOARD ACTION: On the basis of testimony presented, materials submitted and personal inspections, the Board makes the following findings: 1. Grant of the relief requested will not produce an undesirable change in the character of the neighborhood or a detriment to nearby properties. The yard line adjacent to the proposed additions is a dead end/private road, used by the applicants for access to their driveway and by Suffolk Frank W. Uellendahl Architect PO Box 316, Greenport, NY 11944, tel 631-477-8624, fax 631-477-2997 e-moil: fuellead@optanline, net August 8, 2005 Clients: Marion Gotbetter Carmen Aamis 425 Diamond Lane Peconic, NY 11958 Project: 2"d Floor Addition to the Gotbetter Ramis Residence in Peconic, NY BUILDING PEPNIT # 30872-Z FRAMING INSPECTION 07/28/2005 LETTER OF C~ATIFICATION Attached please find the revised floor plans of the first and second floors as per the Building Inspector's request. The construction hc~ been executed according to the design standards of the American Forest Products Wood Frame Construction Manual or better. There isno post required at the 1" floor foyer between the two 8' sliders. The 3.5"x14" laminated beam for the 16' opening e~cceeds the required 3"x12.375" girder for a 17'-5" wide span. The h~ader assembly over the sliding doors at the 2~ floor have been transformed into a truss (rafter / header truss). The triple 2x6 plate above the sliding door was tied back into the header and rafter using coil strapping, There is no load coming down onto the triple plate. The triple plate is suspended from the truss. TICO's were installed at the 3-quad (reverse header) at the dormer, ~ereb¥ state that the information provided above is true to the best of mV knowledge. [/ ' TOWN OF SOUTHOLD BUILDING DEPT. 765-1602 INSPECTION FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND [ ] INSULATION FRAMING/STRAPPING [~ FINAL ~ I FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION REMARKS: DATE TOWN OF SOUTHOLD BUILDING DEPT, 765-1802 INSPECTION FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND [~ ] INSULATION FRAMING / STRAPPING [~/FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION REMARKS: b,-~~..~~ ~ DATE INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND ,~]/INSULATION [ ] FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY I ] FIRE SAFETY INSPECTION REMARKS: ~ INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION ]FOUNDATION 1ST ~*~ROUGN PLBG. FOUNDATION 2ND [ ]INSULATION FRAMING/STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION 3o 7 -7., 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ]ROUGH PLBG, [ ] FOUNDATION 2ND [ ]INSULATION ~.~FRAMING [ ]FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION DATE 765-1802 BUILDING DEPT. INSPECTION ~.~FOUNDATION 1ST [ [ ] FOUNDATION 2ND [ [ ] FRAMING [ [ ] FIREPLACE & CHIMNEY [ REMARKS: /'~~.~~ ] ROUGH PLBG. ] INSULATION ] FINAL ] FIRE SAFETY INSPECTION DATE INSPECTOR ~ ~-~-.~ AlBert J. Krupski, President James King, Vice-President Artie Fester Ken Poliwoda Peggy A. Dickerson Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-1366 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD October 6, 2004 Mr. Frank Uellendahl P.O. Box 316 Greenpor[, NY 11944 RE: MARION GOTBETTER/CARMEN RAMIS 425 DIAMOND LANE, PECONIC SCTM #68-2-13.1 Dear Mr. Ueliendahh The Southold Town Board of Trustees reviewed the survey prepared by Van Tuyl dated March 23, 1995 and the site plan prepared by Frank Uellendahl dated August 31, 2001 and determined the proposed additions to the existing dwelling and proposed garage to be out of the Wetland jurisdiction under Chapter 97 of the Town Wetland Code and Chapter 37 of the Town Code. Therefore, in accordance with the current Tidal Wetlands Code (Chapter 97) and the Coastal Erosion Hazard Area (Chapter 37) no permit is required. Please be advised, however, that no construction, sedimentation, or disturbance of any kind may take place seaward of the tidal wetlands jurisdictional boundary or seaward of the coastal erosion hazard area as indicated above, or within 100' of a freshwater wetland without a permit. It is your responsibility to ensure that all necessary precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Tidal Wetlands jurisdiction and Coastal Erosion Hazard Area, which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundary and the coastal erosion hazard area and your project or erecting a temporary fence, barrier, or hay bale berm. However, any activity within 100' of a Wetland line or seaward of the Coastal Erosion Hazard Area would require permits from this office. This determination is not a determination from any other agency. If you have any further questions, please do not hesitate to call. Sincerely, Albert J. Krupski, Jr., Board of Trustees AJk:hct Generated by Package REScheck Generator Compliance Certificate Permit Number Checked By/Date Energy Code: Location: Construction Type; Heating Type: Window-to-Wall Ratio: Heating Degree Days: Report Date: Date of Plans: New York State Energy Conservation Construction Code Suffolk County, New York Detached 1 or 2 Farcily Non-Electric 0.15 5750 Project Information: 425 Diamond Lane, Peconic. NY 11958 Builder Information: Frank W. Uellendahl, Architect Sid Beebe and Sons Builders, Inc. POB 979, Cutchogue, NY 11935 631.477.8624 Ceiling: 38.0 0.0 Wall: 17.0 0.0 Window: 0,400 Dooc 0,350 Ftoor: 21,0 0,0 Statement of Compliance: The proposed building repmeented in this document Is consistent with the building plans, specifications, and other calculations submtited with this permit application, The propceed systems have been designed to meet the New York State,Energy Conservation Construction Code requirements. When a Registered Design Professional has stamped and signed this p~eg~ta? ere attesting that to the best of his/her knowledge, beliof, and professional Judgment, such place or specifications am In Company Name / Date Generated by REScheck Package Generator REScheck Inspection Checklist Ceilings: Ceiling 1:, R-38.0 cavity insulation Comments: Above-Grade Wells: [] Wall 1:, R-17.0 cavity insulation Comments: upgraded to R -21 Windows: Window 1:, U-factor: 0.400 For windows without labeled U-fact.s, deac~ibe features: #Panes Frame Type Thermal Break? Comments: Yes __ No F-I Dear 1:, U-factor. 0.350 Comments: Front door exempt FIOo~ 1:, R-21.0 cavity Insulation Comments: R-38 in entry area Air Leakage: [] Joints, penetrations, and ail other such openings in the bul~dthg envelope that are scurces of air leakage must be sealed. [] Recessed tights must be 1) Type lC rated, or 2) irmtsl~ed inside an appropriate air-tight assembly with a 0.5" cioaranca from combusgble materials. If non-lC rated, the fixture must be installed w~th a 3" clearance from insulation. Vapor Retarder: Required on the warm-in.winter side of all non.vented framed ceilings, walls, and floors. Materiels Identification: [] Materials and equipment must be Installed \plain\f2\fs20 in accordance with the manufacturer's installation Instructions. ~1 Matahals and equipment must be Identified so that compllanca can be determined. [] Manufacturer manuals for all Installed heating and cooling equipment and service water beating equipment must be provided. [] Insulation R-values and glazing U-factors must be dearly marked on the building plans or specifications. Duct Insulation: Supply ducts in unconditioned attics or outside the building must be Insulated to R-8. Retom ducts Jn unconditioned attics er outside the building must be insulated to R-4. Supply ducts in unconditioned spaces must be Insu~ated to R-8. Retum ducts In unconditioned spaces (except basements) must be insulated to R- I-t Return ducts in unconditioned spaces (except basements) must be insulated to R-2. , Insulation is not requlrad on return ducts in basements. Duct Construction: All Joints, seams, and connecttons must be securely fastened with welds, gaskets, mastics (adhesives), Page2 mastic-pica-embedded.fabric, or tapes. Duct tape Is not permitted. Exception: Continuously welded and locking-type longitudinal joints and seams on ducts operetleg at less than 2 in. w,g. (500 Pa). Ducts shall be supported evmy 10 feet or in accordance with the manufacturer's Instructions. Cooling ducts with exterior insulation must be covered with a vapor retarder. Air filters are required in the tatum air system. The HVAC system must provide a means for balancing air and water systems. Temperature Controls: FI Each dwelling u~lt has at idset one therm~hat capable of automatio~lly edjustir,~l the spaca temperetum sot point of ~he I~est Etectdc Systems: r~ Sepemte electric meters are required for each dwelling unit. Ftreplacae: Fireplaces must be Installed with tight fitting non-combustible fireplace doors. Fireplaces must be provided with a source of combustion air, es required by the Fireplace construction provisk~s of the Building Code of New Yo~ ~tate, the Residential Code of New York State or the New York City BuiEIIng Code, as applicable. Service Water Heating: Water heaters with vertical pipe rleam must have a heat trap on both the inlet and outlet unless the water heater has an integral heat trap or is port of a clrculsting systers. Insulate circulating hot water pipes to the levels in Table 1. Circulating Hot Water Systems: I-I Insolate circulating hot water pipes to the levels in Table t. Swimming Pools: All heated swimming pools must have an on/off heater switch and require a cover unless over 20% of the heating enen3y Is from non-depletabte sources. Poul pumps require a time Heating and Cooling Piping insulation: HVAC piping conveying fluids above 105°F or chilled fluids below 55°F must be Insulted to the levels in Table 2. Page 3 Table 1: Minimum Insulation Thickness for Circulating Hot Water Pipes Heatsd Water Tempam~m (°F) 170-180 140-160 100-130 Ineulaflon Thickness in Inches ~ Pipe S~a NomClrcu~ting Runou~ Clmu~tlng Mains and Runoute Up to 1" Up to 1.25" 1.5" to 2.0" ~er 2" 0.5 1.0 1.5 2.0 0.5 0.5 1.0 1.5 0,5 0.5 0.5 1.0 Table 2: Minimum Insulation Thickness for HVAC Pipes. Hot Water Pipes Fluid Temp. Piping System Types Range(°F) Heating Systems Low Pr essu re/'i'em par at um 201-250 1.0 Low Temparatum 120-200 0.5 Steam Condensate (for feed water) Any 1.0 Cooling Systems Chilled Water, Refrigerant and 40-55 0.5 Brine Below 40 1.0 Insulation Thickness In inches by Pipe Sizes 2" Run(uts 1" and Less 1.25" to 2.0" 2.5" to 4" 1.5 1,5 2.0 1.0 1.0 1.5 1.0 1.5 2,0 0.5 0.75 1.0 1.0 1.5 1.5 NOTES TO FIELD: (Building Department Use Only) Page 4 r~LV ~NSPrC~ON R~rORT.. FOUNDATION (1ST) FOUNDATION (2ND) CO~s.M. ENTS ROUGH FRAMING & PLUM~ING INSULATION PER N. Y. STATE ENERGY CODE FINAL ADDITIONAL COMMENTS TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 www. northfork.net/Southold/ Examined_ Approw~d Disapproved a/c Expiration PERMIT NO. Building Inspector BUILDING PERMIT APPLICATION CHEf Do you have or need the following, before app.. Board of Health 4 sets of Building Plans Planning B.~d approval Survey Check~/ Septic Form N.Y.S.D.E.C. Trustees Contact: Mail to: ~.. APPLICATION FOR BUILDING PERMIT Date INSTRUCTIONS 2004- a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on prenfises, 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 th/s 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 Conunenced 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 perrmt for an addition six months. Thereafter, a new penuit shall be required. .APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to thc 'Building Zone Ordinance of the Town of Southold, Suffolk County, New York, an Regulations, for the construction of buildings, additions or alterations or for rem~ ~PutP~ioCrizar te~ i~n: ;;; t°o; s° omnP lpYr eWn~hs eals ~ (~[~cba buill~tli~; ~'o r° ~ldeicne s~sC~r~ ibn~Uipl edic tnigo nC s°.d e' ~ other applicable Laws, Ordinances or r:g~ demolition as herein described. The code, aD~regulations, and to admit ~icant or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plmnber or builder Name of owner of premises (As on the flax 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. Location of land on which proposed work will be done: House Number Street County Tax Map No. 1000 Subdivision (Name) Section ~:~'~ Hamlet Filed Map No. L°tLot/~ '-'''; State existing use and occupancy of premises and inteL ded use and occupancy of proposed construction: a. Existing use and occupancy b. Intended use and occupancy 3. Nature of work (check which applicable): New Building Repair Removal Demolition Estimated Cost ~/70. ~ Addition V'/ Alteration v/' Other Work (Description) If dwelling, number of dwelling units if garage, number of cars / Fee Number of dwelling units on each floor (To be paid on filing this application) If business, commercial or mixed occupancy, specify nature and extent of each type of use. Dimensions of existing structures, if any: Front Bi/ Rear Height -~, 2~0 ~ Number of Stories /~,~ Dimensions of same structure with alterations or additions: Front Depth ~' 4'Z' Height "' 2,~. ~ t 8. Dimensions of entire new construction: Front -." ge~..q~ Height ,~ 2~.'~~ Number of Stories ,~ 9. Size of lot: Front /;7.2 ,~. Rear etd2, ! Number of Stories ,~ ' Rear ~'Z~" Depth ~.~,! t Depth 1'~7 7! 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated ,~v 12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO v/ 13. Will lot be re-graded? YES ~No Will excess fill be removed from premises? YES v/NO · 14. Names of Owner of premises ~Off~t~ ,/2~//nt~ Address 42~lT~d~t~l/t~s~.. ~¢. Phone No. ~/. '7~, NameofArchitect tu'~,O/~at( L.~'L~.~'d.2/",~,,~/~ Address~/3,~/~./_~/t~/- PhoneNo ~;.~1. Name of Contractor ~/~.//~'t:~ ~ .,ff~/~ Address,/~d~/~~one No. ~,3t'. 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 ~REQUIRED. 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 ~"~t~"/<' ~;ff~'~..l.~-/.J Z2>.,z¢ ~/~[.~ keing 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. Sworn to before me thi~ ~['~ day of k.~-~.. - otary Public LYNOA M ~HN ~ ~BLIC, 8tare of N~w York NO. 01BO~9~2, Suffolk County Term Expires March 8 ~0 ~ 20 Ocr Signature of Applicant