HomeMy WebLinkAbout27262-Z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-32078 Date: 12/15/06
THIS CERTIFIES that the building ALTERATION
Location of Property: 60 RAMBLER RD SOUTHOLD
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 88 Block 5 Lot 36
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JUNE 20, 2000 pursuant to which
Building Permit No. 27262-Z dated APRIL 23, 2001
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 ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR &
AS PER CONDITIONS OF ZBA #4907 DATED 1/4/01.
The certificate is issued to MARSHALL S HURWITZ
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. 2030217 11/19/04
PLUMBERS CERTIFICATION DATED 04/02/06
t ori ed gnature
Rev. 1/81
Form No.6AA0A.?J"4
�. TOWN OFUTHOiLD �D 6 7M
BUILDING DEPARTMENT �^
TOWN IIALL
7654802 DEC 1 3 0
APPLICATION FOR CERTIFICATE OF OCCUPANCY-]
This application must be filled in by typewriter or ink and submirited 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 td 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. I I —Zt
New Construction: ✓ Old or Pre-existing Building: ��(check one)
Location of Property: ��{� R d4 M PJ l.(3� C-4- Isu LTI,l O�—t�
House No. Street ' Hamlet
Owner or Owners of Property: JaN NZ:- ' wyam kS`Z
Suffolk County Talc Map No 1000, Section V2 kBlock Lot 3 6
Subdivision Filed Map. Lot:
Permit No.2Cl Z(OZZ Date of Permit. Applicant:
Health Dept. Approval: Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate Final Certificate: ✓ (check one)
Fee Submitted: $ 25
Applicant Signature
��- •"115��
r^0�
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. 27262 Z Date APRIL 23 , 2001
Permission is hereby granted to:
MARSHALL S HURWITZ
160 CRESCENT AVENUE
LEONIA,NJ 07605
for
ALTERATION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR
WITH TOWN ZBA 4907, TRUSTEE ' S AND NYS DEC APPROVALS . INCLUDES FLOOD PERMIT.
at premises located at 60 RAMBLER RD SOUTHOLD
County Tax Map No. 473889 Section 088 Block 0005 Lot No. 036
pursuant to application dated JUNE 20, 2000 and approved by the
Building Inspector.
Fee $ 175 . 00
Authorized Signature
ORIGINAL
Rev. 2/19/98
ALS BOARD MEMBERS �gUFFO(,(
p� OG Southold Town Hall
Gerard P. Goehringer, Chairman �� y� 53095 Main Road
James Dinizio,Jr. y P.O. Box 1179
Lydia A.Tortora ip
- • Southold, New York 11971
Lora S. Collins p! ZBA Fax(631)765-9064
George Homing l �a Telephone(631)765-1809
BOARD OF APPEALS
TOWN OF SOUTHOLD
FINDINGS, DELIBERATIONS AND DETERMINATION
MEETING OF JANUARY 4, 2001
Appl. No. 4907—ANN HURWITZ
STREET& LOCATION: 60 Rambler Court, Southold 1000-88-5-36
DATE OF PUBLIC HEARING: January 4, 2001
FINDINGS OF FACT
PROPERTY FACTS/DESCRIPTION: The applicant's property contains 13,090 sq. ft. of land
area and fronts along the south side of Rambler Road Extension, Southold. The lot is
improved with a single-family 1-1/2 story dwelling situated at 39+- feet from the front
property line, 75 feet from the rear property line. The rear screen porch at the southeast
comer of the house has combined side yards at 18 feet from the west side line and 9.3+-
feet from the east side line.
BASIS OF APPLICATION: Building Department's November 30, 2000 Notice of Disapproval
for the reason that the permit application for an addition to one-family dwelling does not
meet the minimum side yard of ten (10)feet, pursuant to Article XXIV, Section 100-244B.
AREA VARIANCE RELIEF REQUESTED: A 9.5 x 11+- screened porch at the rear of the
dwelling, having a setback of 9.3 feet from the east side property line at its closest point.
REASONS FOR BOARD ACTION: Based on the testimony and record before the Board and
personal inspection, the Board makes the following findings:
(1) The grant of the area variance will not produce an undesirable change in character
of neighborhood or a detriment to nearby properties. This 8" reduction will not be visually
noticeable, and the new construction will replace an existing structure within the same
footprint.
(2) The benefit sought by the applicant cannot be achieved by some method, feasible for
applicant to pursue, other than an area variance. A structure existed in this same location
for approximately 10 years, and the applicant only wants to reconstruct a new porch in the
same footprint.
(3) The requested area variance is not substantial, representing less than nine inches.
(4) The screened porch will not have an adverse effect or impact on the physical or
environmental conditions in the neighborhood or district.
In considering this application, the Board deems the grant of an increased lot coverage for
a screened porch, as the minimum necessary and adequate, and at the same time preserves
and,protects the character of the neighborhood, and the health, safety, welfare of the
Page 2—January 4, 2001
ZBA Appl. No. 4907—A. Hurwitz 41
Parcel 1000-88-5-36 at Southold
community.
RESOLUTION/ACTION: On motion by Member Dinizio, seconded by Chairman Goehringer,
it was
RESOLVED, to GRANT the variance, as applied for, provided the easterly side yard setback
not be reduced to less than the requested 9.3 ft.
VOTE OF THE BOARD: AYES: MEM GOEHRI R IZIO, T RA, COLLINS,
AND HORNING. This Resolution w duly ADOP (5-
GERARD P. GOEHRINGER, CHAIRMAN
Approved
Albert J. Krupski, President Town Hall
James King,Vice-President � 53095 Route 25
Henry Smith o P.O.Box 1179
Artie Foster di Z Southold,New York 11971-0959
Ken Poliwoda Dy �'� Telephone(631) 765-1892
Fax(631) 765-1366
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
December 22, 2000
Mr. Albert T. Fickeissen
P.O. Box 1451
Southold, NY 11971
RE: ANN& MARSHALL HURWITZ
60 Rambler Rd., Southold
SCTM488-5-36
Dear Mr. Fickeissem
The following action was taken by the Southold Town Board of Trustees at their Regular
Meeting held on December 20, 2000:
RESOLVED, that the Southold Town Board of Trustees grant the request for a Waiver to
remove the existing structure on the deck and rebuilt as per plans, new concrete piers to be
installed and drywells.
This approval does not constitute approvals from any other agency.
If you have any questions, please call our office at (631) 765-1892.
Sincerely,
Albert J. Krupski, Jr.
President, Board of Trustees
AJK:Ims
DEC
New York State Department of Environmental Conservation A&Building 40 -SUNY,Stony Brook, New York 11790-2356
Telephone (516)444-0365 Facsimile (516) 444-0373 ahme
John P. Cal
Commissioner
NO PERMIT NECESSARY - TIDAL WETLANDS ACT
Ann & Marshall Hurwitz
160 Crescent Ave .
Leonia, NJ 07605 November 15, 2000
Application No: 1-4738-02764/00001
Location: 60 Rambler Rd. , Southold, Suffolk County
Dear Applicant :
A review has been made of your proposal to :
Replace a 10 ' x 121 , screened in porch with a permanent year-
round structure of the same size and in the same place .
Based on the information you have submitted, the New York State
Department of Environmental Conservation has determined that the
project is listed in Part 661 . 5 of 6NYCRR (Tidal Wetlands Land
Use Regulations) as a use not requiring a permit or notification
letter of approval . Therefore, no permit is required under the
Tidal Wetlands Act (Article 25 of the Environmental Conservation
Law) .
Please note that any additional work, or modification to the
project as described, may require authorization by this
Department . Please contact this office if such are contemplated.
Please be further advised that this letter does not relieve ;rou
of the responsibility of obtaining any necessary permits or
approvals from other agencies .
JeDly yours,
r Evans
ty Regio
nal
Permit Administrator
cc : file
LSJ BY THIS CERTIFICATE OF COMPLIANCE THE 5
5 NEW YORK BOARD OF FIRE UNDERWRITERSBUREAU C5
5 TY
40 FULTTON STREET C
NEW YORK, NY 10038 5
CERTIFIES THAT S
5 Upon the application of upon premises awned by
5 BRIAN BROOKS ELEC. INC. ANN HURWITZBOX 1001, 455 5
�S CUTCHOGUE, NY 11935,19355, SOUTHOLDR YCOURT1971
5 Located at 60 RAMBLER COURT SOUTHOLD, NY 11971 5
C 5
C� Application Number: 2030217 Certificate Number: 2030217 5
Section: Block: Lot: Building Permit: BDC: nsl1
5 Described as a Residential 0-599 square ft. occupancy, wherein the premises electrical system consisting of 5
5 electrical devices and wiring, described below, located in/on the premises at: 5
55� Second Floor,Outside, �5
cl A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed Pj
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
authority having jurisdiction, and found to be in compliance therewith on theDay of 5
19th November,2004.
Name OTY Rate Racine Circuit Type 5
5 Wiring and Devices 5
5 Outlet 1 0 Fixture S
5 Fixture 1 0 Incandescent 5
5 Outlet 10 0 General Purpose 5
5 Receptacle 8 0 General Purpose 5
5 Switch 4 0 General Purpose 5
5 Paddle Fan 1 0
5 5
5 5
5 5
5 5
5 seal
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. S
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2, -
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION IST [ ] ROU PLBG.
[ ] FOUNDATION 2ND [ SOLATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLACE & CHIMNEY/
REMARKS: !
c
DATE Q 1 INSPECTOR
c)-
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUND IST [ ] ROUGH PLBG.
[ ] F DATION 2ND [ ] INSULATION
[ FRAMING [ ] FINAL
[ ] FIREPLACE A C IMNEY
REMARKS:
DATE /D//40/ INSPECT
M-1802
BUILDING DEPT.
NSPECTION
[ UNDATION IST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLACE & CHIIMMNEY
REMARKS: D<
DATE ( a/ INSPECT
FIELD INSPECTION REPORT DATE COMMENTS
X jn
II IID � A
Com/ H
FOUNDATION OST)
H
FOUNDATION (2ND) II pq
----=---------------------
----------- ----�_ ___ = ___- _______--- ----- -_ -__-___ -=___
Ao 11;7,61-
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ROUGH FRAME
PLUMBING r
INSULATION PER N. Y. i (�
STATE ENERGY
CODE
I
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FINAL q N
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- ADDITIONAL COMMENTS:
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4
BOARD OF HEALTH . . . . . . . . . . . . . . .
FORM NO. 1 3 SETS OF PLANS . . . . . . . . . . . . . . .
TOWN OF SOUTHOLD SURVEY . . . . . . . . . . . . . . . . . . . . . . . .
BUILDING DEPARTMENT CHECK . . . . . . . . . . . . . . . . . . . . . . . . .
TOWN HALL SEPTIC FORM . . . . . . . . . . . . . . . . . . .
SOUTHOLD, N.Y. 11971
TEL: 765-1802 NOTIFY:
CALL . . . . . . . . . . . . . . . . . .
Examined... �e? ....... 39]4.! MAIL TO: . . . . . . . . . . . . . . . . . . . .
Approved.....f/e J�........ Permit No. ./L..���� ....................................
.A Disapproved a/c � [04. ................... ....................................
............................................. `J6S-/ 'o
r1� h .... ..... .. ........
_. ...__. ' __.'�..�. r !1 (Building Inspector)
i
APPLICATION FOR BUILDING PERMIT cg?D ,Z'09V
-� Date. . . . . . . . . . . . . . 19
INSTRUCTIONS
a. 'Ibis application mist be completely filled in by typewriter or in ink and submitted to the Building Inspector wit
3 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 giving a detailed description of layout of property mist be drawn on the diagram which is part of
this application.
c. The cork covered by this application may not be camenced before issuance of Building Penmit.
d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such
permit shall be kept on the premises available for inspection throughout time work.
e. N building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of
Occupancy 11 have been granted by time Building Inspector.
APPI CATION IS lEEEBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Tam 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 build�ingg for necessary in tions.
......................
(Signature of applicant, or name, if a corporation)
57S.Tarc„p��2c1 N.',.IIFY
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
..........9.ene-A(..C.on7�rac os�/.........................•---....................................................
Nam of owner of premises /1.R9Kt�4�..tyYRf(�t.rZ_.................................
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
.........................................................
(Nave aid title of corporate officer)
Builders License No.Plumbers License No. ..... ..
Electricians License No. ............
Other Trade's License No. ....................
I. location of lard on which proposed work will be
done................................................................
Sf!6..................!.lQ 11/ l COU/ /,-,..........................SOAPW.........................
House Number Street Hamlet
County Tax Map No. 1000 Section ...0 B.8 ....... Block ...X ......... Lot ..36,_,,,,,,,,
Subdivision .l�rC .U10. ................. Filed Map No. ....... lot /�..........
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ...�' !hgle..�A Nf.�� .J,oe;Sir(vc*........................................
b. Intended use and occupancy ..S�:'.,`1/r.. _'rr."�.'.�/l.../r`S i en��-
.............................................
1. Nature of work (check which applicable): Neu Building ......... AQ\ir--- Alteration X.......
.
Repair ............ Removal ............. Demolition ............ uitl_ ...— r..................... ...........
(Description)
Estimated Cost ............ fee ......
Tao.•:.. ..............................................
(to be paid on filing this application)
If dwelling, number of dwelling units ...1....... limber of dwelling units on each floor ................
Ifgarage, ember of cars ......................................
If business, commercial or mixed occupancy, specify nature and extent of each type of use......................
Dimensions of existing structures, if any: Front....(07....... Rear ......... Depth .!S.�o............
Ileiglht *Pzag•.a�re ............ Nnber of Stories ...Z.z.............
Dimensions of sestructurewith alterations or additions: Front ...b3........ Rear ...6.3.........
Depth ...:34............. Height ............ Number of Stories ./.y2.-.........
Dinnensions of entire new construction: Front ................ Rear ............... Depth ..............
Height ......................... Nmber of Stories .....................
�. Size of lot: Front ../! :yS........ Rear ....�0.!:A.2........ Depth .15-0..............
?
0. Dace of Purchase ..1011p7....... Name of Former Owner .�!V.CE.4.�4'C.h.(!Q.. 0!lek4
1. Zone or use district in which premises are situated ..............................................................
12. Does proposed construction violate any zoning law, ordinance or regulation: !VO....................
13. Will lot be regraded ...NO.............. Will excess fill be removed from premjse$: YES
/60 C,reSC n ve .i?O/-Y6/-5663
14. Names of owner of premises/N'OJVAJY.IY.h... ......... Address AAen.!¢., .T..O.Z.GOS... Phone No. .............
Name of Architect .................................... Address ............. .. Phone No. .............
.�..... q . .....
Name of Contractor ,c7!QH.'a`:T. S�'�f(SSf:�........ Address ..Jvey�ml[lrX:Yr.<!y.7l......Plhone No.
15. Is this property within 300 feet of a tidal wetland? * ITS .......... NO ..........
*IF YES, SOL]THO D IUM TRUSTEES PM4rT MAY BE REQUIRP.D.
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dime. e?ns
from property lines. Give street and block number or description according to deed, and show street names and Iicate
another interior or corner lot.
SfAlli (F Nld Y0121C,
SS
M
awry OF 5'jq?gel(e...........
... ��<r.2`.../.,..C.t.CffP.6S4c:!1........................being duly sworn, deposes and says Lhat he is the applicant
(Name of individual signing contract)
above named,
ed,
Ile is Che ...CO nb71,
za. ;1(or................................................................................
(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
Lhat the work will be perfonmed in the manner set forth in the application filed therewith.
Sworn to before me this A
...day of /�.a....��!nn9.
Notary Public L✓ 4�:. .1V/ % ly�'�
.. ..................
HELENE D.HORNE (Signature of Applicant)
Notary Public,State of Now York
No.4951354
Qualified in Suffolk Coun
Commission Expires May 22, a0�
BUILDING PERMIT REVIEW CHECK LIST Z7
DATE REVIEWED: 11/,2-3/o ff
APPLICANT NAME: W i�z DATE SUBMITTED: 6/Ao/cap
SCTM# --- DISTRICT: 1,000 SECTION: BLOCK: S LOT: 3.6'
PROJECT LOCATION /
STREET:6,o 1�o ads CITY: SUBDIV. NAME:
ARCHITECT/ENGINEER: /"0—C FAST TRACK: YES o
-d
SINGLE & SEPARATE CERTIFICATION-REQUIRED: YES oNO OTES:
ZONING: PERMIT E,PAMATE AMOUNT:_$ 2/< 00
ZONING DISTRICT: (Z401, R80 AC CONFORMING: YES oN REQUIRED LOT SIZE: SQ]
WHERE ACTUAL LOT SIZE FROM?TAX CARD ��I tjc y ACTUAL LOT SIZE: )3 096 SQ
REQUIRED REQUIRED 264 REQUIRED
FRONT:15 ' PROPOSED:_' SIDE YD: 16 '/_AS ' PROPOSED: 9.3 V ` REAR: 3S ' PROPOSED:?
LOT COVERAGE: ALLOWED: 26 % EXISTING: sf % NEW: sf % TOTAL:/9(f sf/S%
CORNER? YES oWQ WAT ER FRONT? YE OR NO DESCRIPTION:
LOTS 40,000SF --100-24. Lot recognition. (CREATED before June 30, 1983), UNDERSIZED LOTS FROM
JAN.1997 100-25. Merger. (A nonconforming at anytime after July 1, 1983.)
sd. AaCJ k 4-/4-
PROJECT DESCRIPTION: ADD ALT ACC OR N/D: ��z 3-+ #,5'07 7-
AGENCY PERMITS REQUIRED FOR REVIEW
NEEDED
TOWN SPETIC PERMIT: YES or
SUFFOLK COUNTY HEALTH DEPT: YES or 8 BED #): DTEII: / / PERMIT#:R10-
NEW YORK STATE DEC: PRE-DEC 9/1/7 or NO ^► T a i
SOUTHOLD TOWN TRUSTEES: or NO
TOWN ZONING BOARD APPROVAL: ES r NO 4 F07
TOWN PLAN. BOARD APPROVAL: YES o N
FLOOD COMPLIANCE ZONE: PRE-FIRM 3/18/80 P NEL #: /r6 FLOOD ZONE:Arq- ?�
NYS ENERGY: YES ONO EGRESS: VENT: LIGHT:
NOTES:
i ur G v z /o Oct
107
FEE STRUCTURE: FOUNDATION: SF
FIRST FLOOR SF
SECOND FLR : /ld SF INIT OTHER TOTAL
TOTAL: SF FEE FEE FEE
TOT( SF)- ( SF)= SF X $ _$ +$
APPLICATION s
PAGE 1 of 4
TOWN OF SOUTHOLD
FLOODPLAIN DEVELOPMENT PERMIT APPLICATION
This form is to be filled out in duplicate.
SECTION 1 GENERAL, PROVTSTONS fAPPLICANT to read and sirml-
1. No work may start until 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 it re-issued.
4. Development shall not be used or occupied until a Certificate of Compliance is issued.
5. The permit will expire if no work is commenced within six months of issuance.
6. Applicant is hereby informed that other 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 THEST OF MY 4 EDGE,TRUE AND ACCURATE.
(APPLICANT'S SIGNATURE69
41
DATE 5-23
SECTION 2 PROPOSED DEVELOPMENT (To be completed by APPLICANM
NAME ADDRESS TELEPHONE
APPLICANT,
r/tGrS�a�l � H/Irt /Y r u/r tZ
BUILDER
T / r e�eiSSetn
ENGINEER
PROJECT LOCATION:
To avoid delay in processing the application, please provide enough information to easily identify the project
location. Provide the street address, lot number or legal description (attach) and, outside urban areas, the
distance to the nearest intersecting road or well-known landmark. A sketch attached to this application showing
the project location would be helpful. ,,DD ,/
(00 a. �ilCr, -Road �p 410(�N/7
FDP(93)
APPLICATION = _
• PAGE 2 OF C
DESCRIPTION OF WORK (Check all applicable boxes):
A. STRUCTURAL DEVELOPMENT
ACTIVITY STRUCTURE TYPE
❑ New Structure ❑ Residential (1-4 Family)
❑ Addition ❑ Residential (More than 4 Family)
F�[Alteration ❑ Noo-residential (Floodproofmg? ❑ Yes)
❑ Relocation ❑ Combined Use (Residential & Commercial)
❑ Demolition F ❑ Manufactured (Mobile) Home (In Manu-
0 Replacement factured Home Park? ❑ Yes)
ESTIMATED COST OF PROJECTS ZOA6
B. OTHER DEVELOPMENT ACTIVITIES:
❑ Fill ❑ Mining ❑ Drilling ❑ Grading
❑ Excavation (Except for Structural Development Checked Above)
❑ Watercourse Alteration (Including Dredging and Channel Modifications)
❑ Drainage Improvements (including Culvert Work)
11 Road, Street or 1 Adge Construction
❑ Subdivision (New or Expansion)
❑ Individual Witer or'Scr Systom/
{y1
❑ Other (Please SpecTy)
After completing SECTION 2, APPLICANT should submit form to Local Administrator for review.
ECTION 3 FLOODPLAIN DETERMINATION (To be comoleted by LOCAL ADhfINISTRATOR)
The proposed development is located on FIRM Panel 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 PERMIT IS REQUIRED)'
❑ Is located in a Special Flood Hazard Area.
FIRM zone designation is
100-Year flood elevation at the site is: Ft. NGVD (MSL)
❑ Unavailable
❑ The proposed development is located in a floodway.
FBFM Panel No. Dated
❑ See Section 4 for additional instructions.
SIGNED DATE
APPLICATION H
.+ PAGE 3 OF 4
SECTION 4 ADDITIONAL INFORMATION REQUIRED (To be completed by LOCAL ADMINISTRATOR)
The appfirant must submit the documents checked below before the application can be processed-
O A site plan showing the location of all existing structures, water bodies, adjacent roads, lot
dimensions and proposed development.
❑ Development plans, drawn to scale, and specifications, including where applicable:details for
anchoring structures, proposed elevation of lowest floor (including basement), types of water
resistant materials used below the first floor, details of floodproofmg of utilities located below
the first floor and details of enclosures below the first floor.
Also
❑ Subdivision or other development plans (If the subdivision or other development exceeds 50
lots or 5 arses, whichever is the lesser, the applicant must provide 100-year flood elevations
if they are not otherwise available).
❑ Plans showing the extent of watercourse relocation and/or landform alterations.
❑ Top of oew fill elevation Ft. NGVD (MSL).
❑ Floodproofmg protection level (non-residential only) Ft.NGVD (MSL). For
floodproofed structures, applicant must attach certification from registered engineer or
architect.
❑ Certification from a registered engineer that the proposed activity in a regulatory floodway
will not result in any increase in the height of the 100-year flood. A copy of all data and
calculations supporting this finding must also be submitted.
❑ Other:
SECTION 5: PERMIT DETERMINATION (To be completed by LOCAL ADMINISTRATOR)
I have determined that the proposed activity. A. ❑ Is
B.❑ Is not
m conformance with provisions of Local Law f—, 19_ The permit is issued subject to the conditions
attached to and made part of this permit.
SIGNED , DATE
If BOX A is checked, the Local Administrator may issue a Development Permit upon payment of designated
fee.
If BOX B is checked, the Local Administrator will provide a written summary of deficiencies. Applicant may
revise and resubmit an application to the Local Administrator or may request a bearing from the Board of
Appeals.
APPLICATION s
PAGE a OF a
APPEALS. Appealed to Board of Appeals? ❑ Yes ❑ No
Hearing date:
Appeals Board Decision --- Approved? ❑ Yes ❑ No
Co❑ditions
SECTION 6� AS-BUILT ELEVATIONS (To be submitted by APPLICANT before Certificate of Compliance
is issued
The following information must be provided for project structures. This section must be completed by a
registered professional engineer or a licensed land surveyor (or attach a certification to this application).
Complete 1 or 2 below.
1. Actual (As-Built) Elevation of the top of the lowest floor, including basement (in Coastal High Hazard
Areas, bottom of lowest structural member of the lowest floor, excluding piling and columns) is:
FI. NGVD (MSL).
2. Actual (As-Built) Elevation of floodproofmg protection is FI-. NGVD (MSL).
NOTE: Any work performed prior to submittal of the above information is at the risk of the Applicant.
SECTION 7• COMPLIANCE ACTION (To be completed by LOCAL ADMINISTRATOR)
The LOCAL ADMINISTRATOR will complete this section as applicable based on-inspection of the project to
ensure compliance with the community's local law for flood damage prevention.
INSPECTIONS: DATE BY DEFICIENCIES? ❑ YES ONO
DATE BY DEFICIENCIES? ❑ YES ❑ NO
DATE BY DEFICIENCIES? ❑ YES ❑ NO
SECTION 8• CERTIFTCATE OF COMPLIANCE(To be completed by LOCAL ADMINISTRATOR)
Certificate of Compliance issued: DATE BY:
Attachment B
SAMPLE
CERTIFICATE OF COMPLIANCE
for Development in a Special Flood Hazard Area
TOWN OF SOUTHOLD
CERTIFICATE OF COMPLIANCE
FOR DEVELOPMENT IN A SPECIAL FLOOD HAZARD AREA
(OWNER MUST RETAIN THIS CERTIFICATE)
PREMISES LOCATED AT: PERMIT NO.
PERMIT DATE
OWNERS NAME AND ADDRESS: CHECK ONE:
❑ NEW BUILDING
❑ EXISTING BUILDING
0 VACANT LAND
,;1,'
THE LOCAL ADMINISTRATOR IS TO COMPLETE A. OR B. BELOW:
A. COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF
LOCAL LAW #_, 19_
SIGNED: DATED:
B. COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF
LOCAL LAW # , 19_, AS MODIFIED BY VARIANCE #
DATED
SIGNED: DATED:
C/C(93(
DEPARTMENT OF THE ARMY
NEW YORK DISTRICT, CORPS OF ENGINEERS
JACOB FEDERAL BUILDING
NEWW YORK,YORK, N.V. 10278-0090
REPLY TO
ATTENVON OF November 6, 2000
Eastern Permits Section
SUBJECT: Joint Application with New York State Department of
Environmental Conservation
Ann and Marshall Horwitz
160 Crescent Ave.
Leonia, NJ 07605
Dear Mr. & Ms. Hormitz:
We have recently received a copy of the Joint Application
for permit you filed with the New York State Department of
Environmental Conservation (NYSDEC) .
Please be advised we have reviewed the copy of the Joint
Application sent to this office by NYSDEC. Based solely upon the
information provided, it appears that a Department of the Army
permit is not required for your proposal .
The Department of the Army regulates construction activities
in navigable waterways and discharges of dredged or fill material
into waters of the' United States, including inland and coastal
wetlands . If your proposal would involve such work, and has not
been portrayed as such in your Joint Application, you should
contact this office immediately so that a project-specific
determination can be made as to whether a Department of the Army
permit will be required.
Any inquiries can be directed to this office at (212) 264-
6731 .
Sincerely,
*es W. Haggerty
, Eastern Permits Section
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