HomeMy WebLinkAbout30398-Z
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-31820
Date: 09/15/06
THIS CERTIFIES that the building
ALTERATIONS
Location of Property: 640
(HOUSE NO.)
County Tax Map No. 473889 Section 68
SOUNDVIEW AVE
(STREET)
Block 4
PECONIC
(HAMLET)
Lot 21
Subdivision
Filed Map No.
Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated
JUNE 9, 2004 pursuant to which
Building Permit No. 30398-Z
dated
JUNE 15, 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" ALTERATION (GREENHOUSE TO LIVING SPACE) IN EXISTING
SINGLE FAMILY DWELLING AS APPLIED FOR.
The certificate is issued to RICHARD & GAIL RUGGIERO
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
N/A
ELECTRICAL CERTIFICATE NO.
N/A
PLUMBERS CERTIFICATION DATED
N/A
4~~~
uthor~zed S~gnature
Rev. 1/81
.
.
Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
8 2004
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be filled in by typewriter or ink and submitted to the Building Department ~ith thefoJlowtng:_
A. For new building or new use:
I. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or
topographic features.
2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form).
3_ Approval of electrical installation from Board of Fire Underwriters.
4_ Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 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:
I. 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 /
I. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $2~00,
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 - $Ioo.oe
,
3. Copy of Certificate of Occupancy - $.25 /
4. Updated Certificate of Occupancy - $50.00 /
5 . Temporary Certificate of Occupancy - Residential $15. do, Commercial $15.00
Date. tAb. JtN
, I
New Construction:
Old or Pre-existing Building:
~"".d,II"hJ ~
Street
)(
,
(check one)
Location of Property: ~&f1J
House No.
~4!!~"/C.
Hamlet
Suffolk County Tax Map No I 000, Section &, ~
Subdivision
42ut!f9!N't'>
Block 0 .;
Filed Map.
Applicant:
Underwriters Approval:
Lot
1J/
Owner or Owners of Property:
R,,,I.A.r-A.. A..d Gi\./J
Lot:
Permit No.
Date of Permit.
Health Dept. Approval:
Planning Board Approval:
IJI ft
))/4-
,
Request for: Temporary Certificate
. jStJb
Fee SublTI1tted: $ '"
Final Certificate:
x ( check one)
.~;y
~.1~"5
Co -t: 31~(')
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.
30398 Z
Date JUNE
15, 2004
permission is hereby granted to:
KATHRYN FARRAND
725 MILLER AVE UNIT 313
FREEPORT,NY 11520
for :
AS BUILT ALTERATION (GREENHOUSE TO LIVING SPACE) AS APPLIED FOR
ADDITIONAL CERTIFICATION REQUIRED
at premises located at
640 SOUNDVIEW AVE
PECONIC
County Tax Map No. 473889 Section 068
Block 0004
Lot No. 021
pursuant to application dated JUNE 9, 2004 and approved by the
Building Inspector to expire on DECEMBER 15, 2005.
Fee $
300.00
ORIGINAL
Rev. 5/8/02
30pCf"{ :z..
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
""'"'~
[ ] FOUNDATION 1ST [] ROUGH PLBG.
[ ] FOUNDATION 2ND [] INSULATION
[ '] FRAMING I STRAPPING rM' FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS:
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DATE 9'-1 ,.-0 ~
INSPECTOR ~ ~
-
JOJ?l"Z--
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST pq ROUGH PLBG.
[ ] FOUNDATION 2ND []'1NSULATION
[ ] FRAMING I STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
;vo NJ~ floM~,-
Alv 4CCcf;:> ,
G'fs'f0
REMARKS:
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DATE
INSPECTOR ~ ~
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FIELD J}lSPECTlON REPORT DATE COMMENTS . .
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INSULATlONPERN. Y. . ~
STATE ENERGY CODE
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TOWN. OF SOUTHOLD PROPERTY RECORD CARD --
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QWNER
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I VILLAGE
COUNTY TAX MAP NO.
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LAND
IMP.
TOrAL
DATE
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REMARKS~. hi '3t e J/
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OWN~R STREET
OF . SOUTHOLDIoPER"-~' RECORD I
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CARD
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FORMER OWNER
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VILLAGE
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DISTRICT
SUB.
LOT>.#-
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FARM.
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RES. I SEAS.
LAND IMP. TOTAL:
, MISe.
DATE
REMARKS
; 3 0 0
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NEW
NORMAL
BELOW
ABOVE
Farm
Acre
Value Per Acre
Value
Tillable
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,
Tillable 2
..,
Tillable. 3
Woodland
Swompland
Brushla.,gp. _
:.c-.
House Plot
~()()
Total
Foundation
/ Basement
Ext. Walls
Fire Place
Porch
J Porch
Patio
Driveway
f
II'" ft:;
Extension 1?>tJ..-'fr:2F'1
Extension ~ l( I 0 "- .2-Cl
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Garage I~
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Rooms 1 st Floor
Rooms 2nd Floor
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TOWN OF SOUTHOLD
BUILDING DE]?ARTMENT
TOWN HALL
SOUTHOCD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
www.northfork.net/Southold/
BUILDING PERMIT APPLICATION CHECKLIST
Do you have or need the following, before applying?
Board of Health
3 sets of Building Plans
Planning Board approval
Survey
Check
Septic F oon
N.Y.S.D.E.C.
Trustees
Contact: l>Pt",d b<F~orel
Mail to: ?o Bo:l /t..64
=5..~l..o /6.& /lAfl
.
Phone: 76S-, .21/1
PERMIT NO. ~~9<6~
Examined
Approved
Disapproved ale
,20_
,20_
Expiration
--
, 20-----L
....
APPLICATION FOR BUILDING PERMIT
i ,..0
I
L_... ...._J
. This::l 1'1i911tiqtlMUST be c mpletely filled in by typewriter or in ink and submitted to the Building Inspector with 3
, ." '. . " . , ,) . . Fee according to schedule.
b. Plot plan showing location oflot 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 South old, 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. .~ 2/
(Signature of applicant or name, if a corporation)
8 2004
Date
/4/L
.
,20~
INSTRUCTIONS
sets of
i>Og"d,(,sQ. S"o{o."."cI. .J.i.'I. IVI11
. (Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
AV..ct-
Name of owner of premises fK t'-IotA..-~ It"ld (;,6,1 f( cJfj<jlb'O
(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.
I. Location of land on which proposed work will be done:
(4i10 :5..,.. ~1I1'''' A..n..
House Number Street
~UO>11 c....
Hamlet
County Tax Map No. 1000 Section
Subdivision
~~
Block t><(
Filed Map No.
Lot .2.1
Lot
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy $, n1 I, J:'A...., Ii DuI...II, ~ 1 . .
b. Intended use and occupancy ~a....J"_
3. Nature of work (check which applicable): New Building
Repair Removal Demolition
Addition
Other Work
J, 66
Fee ~;gI!>O~
(To be paid on filing this application)
5. If dwelling, number of dwelling units -L-Number of dwelling units on each floor
If garage, number of cars
I't6 BtJ, H-
Alteration X
Grun ,.1.,....... -fA '-"""1 ~f'l'",e
(Description)
4. Estimated Cost
6. Ifbusiness, commercial or mixed occupancy, specify nature and extent of each type of use.
6ee 4'H-~e.Nd.
7. Dimensions of existing structures, if any: Front Rear Depth
Height Number of Stories
fo9€, a..1I"'1~L
Dimensions of same structure with alterations or additions: Front
Depth Height Number of Stories
8 . . f' . AJI!! <::\,M\0lL. R
. DImensIOns 0 entIre new constructIon: Front J ear
Height Number of Stories
Sa A--\ttl.zl..€6
9. Size oflot: Front Rear Depth
Rear
Depth
10. Date of Purchase
Name of Former Owner
II. Zone or use district in which premises are simated <R.e~,
12. Does proposed construction violate any zoning law, ordinance or regulation? YES_NO L
13. Will lot be re-graded? YES_NO l Will excess fill be removed from premises? YES_NO_
i{ , '-.........1. rf-.. J. C:Pr,!
I{ uf/9 J.pJ,:j
Phone No. :)~-r;J.7-1./~J..
Phone No
Phone No.
Address
Address
Address
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 _ NO ~
* 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-E-
* 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 )
{)"'''I c.. t.,..t=:( 4\1 el being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
(S)He is the
A~il't+
(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 mamIer set forth in the application filed therewith.
Sworn I!- before me thi~,
day of (J/'f17 2~
~ at;.-,} ~9-OfJ.R/I)
otary Public
LINDA J COOPER k
. State of New Yo<
N~a1~2~~~3, SclfOI1<C0U~c70/,f.
TO-nnO~;~;::;\;TS DeCf;tfl[i:t.~: ~ I, -'-
- -
c; JJj)t1l0tJAt ceroF<:AnON ~aul~!
APPROVED AS NOTED
DATE:~ B.P. # -oom:c.
FEE:~BY~
NOTIFY BUILDING DEPARTMENT AT
765-1802 SAM TO 4PM FOR ~
FOLLOWING INSPECTIONS: ouse
1. FOUNDATION. TWO REQUIRED
FOR POURED CONCRET
2. ROUGH . FRAMING & PLUMBING
3. INSULATION
4. FINAL - CONSTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET THE
REQUIREMENTS OF THE CODES OF NEW
YORK STATE. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS.
o
COMPLY WITH ALL CODES oPi ii
NEW YORK STATE & TOWN CODE I
AS REQUIRED AND CONDITION
SOUTHall TOWN ZBA
SOUTHClO TOWN PLANNIt<<J
SOUTHOLD TOWN TRUSTEES
N.Y.S. DEC
,
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICATE
OF OCCUPANCY
640 Soundview Ave
Peconic, NY
1000-68-04-21
3068 3068
o
Ceiling!
Height=
7' 1 /2"
11'6
Ceiling Height=9'11"
Brick Floor
13'2
. _ _Q~lil1.9 H~ht=8' _L_
.:C". ". ~-'-:.~-~-~~--~
2832 2832 2832 2832
1/4"=1'
Al.L~' .
MEET lHEREauIREMENTS ~1HB
CODES Of NEW YORK STATe.
JfI- u./
FLOOD ZONE /J /~
CQMPl Y WITH CHAPTER "46"
FLOOD DAMAGE PREVENTION
SOUTHOlD TOWN CODE.
Shed roof - vented
Heat - none
(j)
('i)
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, ..-
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2x4 stud wall -
16"oc
;,'l~l(>itl:al of this plan bearing the seal ot tile
unaerslgnecl NYS licensed Architect is not intended
to certi(y conditions that we designed or that we
represent in compliance with applicable architeclllrai .
or engineering standards, or government codes.
Application of the Architect's seal is intended to
indicate that this is a~i' of the current
as-built conditions.
Da
UNDERWRITERS CERTIFICATE
REOUIlED
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fU::CISrnAl1 of VlTA.L ST^TlS11CS
MAnnIAGF. OFFICI.:n
nECOIl.US ~^CEMENT OFFICEI1
rnEEOOM of INfOnIMTION OfflcEn
rllwn lIall. _~.lU"~ "'1~Utl
r.o. nn. 11711
Suuthohl. Ncw.Yurk I
Fo, I> 1(" 7"'~'IR'"
Tdcflh(lnc t 51 (q 7(..\~
. " J'l:ltNTl-I T. TERRY
e tOWl'l CLERK
OFFICE OF THE TOWN CLERK
TOWN OF SOUTH OLD
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION WAS ADOPTED BY THE
SOUTHOLD TOWN BOARD AT A REGULAR MEETING HELD ON AUGUST 24, 199]:
RESOLVED that the Town Board of the Town of Southold hereby adopts
two (2) new forms to be used under tlie Flood Damage Prevent regulations .J
0; the Code of the Town of. Southold:
/IPplication" [FDP(93)). and lCertificate
Special Flood Hazard Area (CiC(9311.
"Floodplain Development Permit
i '/
of Compliance ~ir Deve?pmen t in
O i ~(0; 1 :::- . .
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BL.i>3. OC:?Y
TOW;1 OF SOUTHOLD
~~
~T.T~
Southold Town Cle,k
August 25, 1993
, "
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APPLICATION (I
P^GE I o( 4
-
.,
TOWN OF SOUTHOLD
FLOODPLAIN DEVELOPMENT PERMIT APPLICATION
This form is to be filled out in duplicate.
~
,
SECTION I: GENERAL PROVISIONS (APPLICANT to read and sirn);
1. No work may ,tart until a permit is issued. .
2. The pennit may be revoked if lUIy frue ,tatemeots are made herein.
3, If revoked, all work must cease until permit is re.issued.
4. Development ,ball not be used or occupied uDtil a Certificate o( Compliance is ls.sued.
5, Tbe permit will expire if DO work is commenced within ,U: months of is,u311ce.
6. AppUC2D1 is bereby informed that otber permilS may be required to fulfill local, state aJld federal regulatory
requiremenu,
7, Applicant bereby gives consent to tbe Local Administrator or his/her representative to make reasonable
. inspections required to verify compliance. .
6. r.. THE APPLICANT, CERTlFYzT ALL STATEMENTS HEREIN AND IN A TTACHME)'ITS TO
_ THIS APPLICATION ARE, TO TH~B OF MY OWLEDGE, TRUE AND ACCURATE. . .
. (APPLICANT'S SIGNATURE) . ~ '_- DATE r, -( f,- ()"O
I ) /
/ / /
/(SECTION 1: PROPOSED DlOYELOeltENT (T"Se comDIc'ed bv APPLlCAJ;'()
ADDRESS
r-ewftff0 () h'7 ~1'l11tJ (1J. .
p~~ V\-~
TELEPHONE
'if ~~ trf1 ~//l.{ I
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NAME
::~~~~::
ENGINEEJ\,-
. :.:j os.l?pJf
~ /.fc ~;r-I
PROJECT LOCATION:
To .void delay in pro<:essing the .pplication, please provide eDoug.h information to easily identify tbe project
location. Provide the IDeet address, lot Dumber or legal description (anach) and, outside urban areas, tbe
distance to the Deares\ intersccting road or wcU.knowo Gilldmark. A skClch attached to Lhi.s appliC>ltion sbowing
thc project location would be helpful.
FDP(93 )
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APPLlCA TION ~
PAGE10F'
DESCRIPTION OF WORK (Check all appGqblc boxcs)
A STRUCTURAL DEVELOPMENT
ACTIVITY
STRUCTURE TY1'E
o Ne.w Structure
o Additioo
~cratioo
o Relocatioo
o Demalitioe
o Replacement
o Re.idential (1-4 Family)
o Residential (More thOll 4 Family)
o Noo.residential (FloodproorlDg? 0 Yes)
o Combined U.e (ResideDtiaJ & CommercUJ)
p. 0 Manufactured (Mobile) Home (10 Manu.
factured Horne Park? 0 Yes)
ESTIMATED COST OF PROJECT S / ()D, IJ6i)
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B. OTHER DEVELOPMENT ACOVlTIES:
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o Fill 0 Mining 0 Drilling 0 Grading
o Excavation (Except for Structural Development Checked Above)
o Watercourse AJteration (lDeluding Dredging aod Channel t,{odiJiC<ltions)
o Drainage Improvemeots (Iocluding Culvert Work)
o Ro.;~ Street or Bridge Construction
o Su~visioo (New or Expansioo)
o ~ilividuaJ Water or Sewer System
o Otber (Please Specify)
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After completing SECTION 2, APPUCA..NT shouJd s:ubmit Corm to Local Admi.n.islrator for review.
SECTION); fLOODPLAIN DETERMIN,1"TION lTo be comulcted bv LOCAL ADMINISTRATOR)
The proposed developmeDt ls located on FIRM Pand No.
. Dated
The Proposed Development:
o u l!!QI located in a Special Flood Hazard Area (Notify the applicant that the applkatioD
review is ""mplo'e IUld NO FLOODPLAIN DEVELOPMEl'fT PERMIT [S REQUIRED).
o U 10000tcd io a Special Flood H aurd Area.
FTRN 'tOne de..'>igDation is
100- Year Rood elevatioo at the sile is;' Fl. NOVO (MSL)
o UoavalJable
o The proposed developmenl is locnlcd LO a Ooodway.
FBFM Pwd No. Datcd
o See Section ~ (or .Hloilional 'IOSlrlJctioos
SIGNED
DATE
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A1'PLlCATION >'I
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SECTION ., ADDITIONAL INFOIlMATION REOUIRED (To he comnlcted bv LOCAL ADMINISTRATORJ
The applicant must submit the documents checked below belo<< tbe applicauon can be processed:
o A sile plan sbowing tue local ion 01 all existing S(fUClures, waler bodies, adjacent roads, 101
dimeosioD5 and proposed development.
o Development plans, drawn 10scaJc, and speciOcaliflns, induding wbere applicable: details lor
ancboring structures, proposed elevalion 01 lowest Ooor (including basemenl), Iypes ofwster
resistant materials used below the rust noorl detall..s of noodproofwg of ulilities located below
!.he orsl Ooor and detalls 01 enclosures below tbe flfst Ooor.
ALso.
o Subdivision or nlber developmenl plms (Iltbe subdivision or otber developmenl exceeds 50
lots or 5 acres. wbicbever is tbe lesser, the applicant !!!Jill provide lOO-yeu flood elevations
if they ue nol otberwise available).
o PI3\l.S showing the extent of watercourse relocation ad/or landform alterations.
o Top of new fill elevation
FL NGVD (MSL).
o Floodproofmg protection level (non-residential only) Ft: NOVO (MSL). For
Ooodproofed structures, ';,ppliGlnt musl allacb certification from r-.gistered engineer or
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o Certification from i1i,r:gistcred eogineer lhat tbe proposed acti<.:l{~ in a regulatory fioodway
will Dol result in -!illY increase in the height of Lhe loo-year (load. A copy of all data and
caloUations supporting ttill Hnding must also be. submitted.
o Otber.
SECTION 5: PERMIT DETERMINJ.TI()/'l ITo be comnlcled bv LO,:AL ADMINISTRATOR)
I have determined tbat tbe proposed activity. A. 0 Ls
B.O Is nol
in conlormance wi!.h provisions of Local Law , . 19 The permit is issued subject to lbe conditions
attached to aod made part of this pennil. -
SIGNED
,DATE
If BOX A is checked, Ibe Local Admin.i.slralOr m,y "sue a Dcvclopmeol Permil upon payment of &signaled
fee.
If ~OX B is checked, tbe Local Admiruslrator wtIl provide a .....,.-ilteo summary o( dcClciencic.s. Applicanl may
fLVlSC and rtsubmit an application lo lhe Loc.al Administrlllor or may request a. bearing (rom lb~ Board or
Appeals
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APrLlCA TION H
PAGE 4 OF 4
APPEALS: Appealed to Board o( Appeals' 0 Yos 0 No
Hearing date:
Appeah BUilld D(....~;vLt _u AppIVH..d'! 0 '/d 0 ~r6
Coodilions
SE:CfJON 6: "''s.oOlLT ELE:VATIONS (To be submilled bv APPLICANT before Certif,cate o( Comolianee
is issued\
The roUowiag informatioD must be provided for project structures. This sectioD must be completed qy a
registered professioDal eDgineer or a lieeosed land surveyor (or atlaeb a cutification to this application).
Complete 1 or 1 below.
L Actual (As-Built) E1evatioD of the top of ihe lowest Ooor, including basemeDt (in Coastnl Hi<<h Hau'rd
Areas. bollom of lowest structural member of the lowest Ooor, excludlog piIlog and columns) is;
Fr. NGVO (MSL).
2. . . Actual (As.Bu~t) ElevatioD of Ooodproofrng protectioD is ,', Fr. NO VD (MSL).
Noj: Any work performed prior to ,"bmiltal/~f the above inIormatioD is at tbe risk /~( the A~pli;~l.
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SE:CfION 7: COMPLIANCE ACTION fro be eomDle(ed bv LOC.u: ADMINISTRATOR)
The LOCAL ADMlNISTRATOR will complete this section as applicable based 00 in.spedioo o( Lhc project to
ensure compliance 'Hith the community's local law for noed damage prevention.
[/'1SPECTlONS: DATE
DATE
DATE
DEFlCfENCIES? 0 YES 0 NO
DEFlCIENCfES? 0 YES 0 NO
DEFICIENCIES? 0 YES ' 0 NO
BY
BY
BY
SE:CfION 8: CERTIFICATE OF COMPLIA/'1CE:ffo be comn[eted bv LOCAL ADMINlSTRATOR\
Cutifieate of CompUaoce issued: DATE:
BY:
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Attach:ment B
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) 8AHP;LE
CERTI.r'iCATEj5F COMPLIANCE
for Developm~nt in a special Flood Hazard Area
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TOWN OF SOUTHOLD
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CERTIFICATE OF COMPLIANCE
Fon DEVELOPMENT IN A SPECIAL FLOOD H.AZ.ARD AREA
(OWNER MOST REH TN THIS C:F.RTIFICATE)
PERMIT NO.
PERMIT DATE
PREMISES LOCATED AT:
CHECK ONE:
o NEW BUILDING
o EXISTING BUILDING
o VACANT LAND
OWNERS NAME AND ADDRESS:
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THE LOCAl.. ADM[NISTRATOR [S TO COMPLETE A, OR B. BELOW:
A. COMPLI.A1'lCE IS HEREBY CERTIFIED WlTIl THE REQillREMENTS OF
LOCAl.. LAW # _, 19
SIGNED: DATED:
B. COMPLI.A1'lCE IS HEREBY CERTIFIED WlTIl TIiE REQillREMENTS OF
LOCAL LAW # .19_. AS MOD[FIED BY VARIANCE #
DATED
S[GNED: DATED:
C I C (93)