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Home My WebLink About33105-Z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY Date: 06/13/07 No: Z-32402 THIS CERTIFIES that the building ACCESSORY Location of Property: 3055 DELMAR (HOUSE NO.) County Tax Map No. 473889 Section 125 DR (STREET) Block 4 LAUREL (HAMLET) Lot 8 SUbdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 24, 2007 pursuant to which Building Permit No. 33105-Z dated JUNE 5, 2007 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is "AS BUILT" ACCESSORY ABOVE GROUND SWIMMING POOL IN THE REQUIRED REAR YARD WITH FENCE TO CODE AS APPLIED FOR. The certificate is issued to ROBERT & MARIE COLWELL (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. 3033859 05/31/07 N/A PLUMBERS CERTIFICATION DATED ~~p~ uthorized Signature Rev. 1/81 FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-32403 Date: 06/13/07 TIllS CERTIFIES that the building ACCESSORY SHED Location of Property: 3055 DELMAR (HOUSE NO.) County Tax Map No. 473889 Section 125 DR (STREET) Block 4 LAUREL (HAMLET) Lot 8 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 24, 2007 pursuant to which Building Permit No. 33106-Z dated JUNE 5, 2007 was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is "AS BUILT" ACCESSORY STORAGE SHED IN THE REQUIRED REAR YARD AS APPLIED FOR. The certificate is issued to ROBERT & MARIE COLWELL (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF REALTII APPROVAL N/A ELECTRICAL CERTIFICATE NO. N/A PLUMBERS CERTIFICATION DATED N/A /i;:tiz1!!:::- Rev. 1/81 Form No.6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 i Li'J J, I APPLICATION FOR CERTIFICATE OF OCCUPA~CY L -----,~'~- --.J bl..-U ,. OtP.. i ',,__ Jr"",'" OF !5"'THQ'P i This application must be filled in by typewriter or ink and submitted to the Building Department with the following:-- $. , OD (\( u",de(l..LJ('rfers ce,ti-lfic, ""Pao \ 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 2/1 0 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: 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 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. New Construction: Old or Pre-existing Building: (check one) Location of Property: ~5S ~ iYYI.I 'br-i V~ House No. Street Owner or Owners ofproperty~~r=+ ~ ('()a-r; c [' t"l111 d I Suffolk County Tax Map No 1000, Section \~5 Block Y Lnl.Arl"'"J Hamlet Lotg Permit No. Filed Map. Applicant: Underwriters Approval: Lot: Subdivision Date of Permit. Health Dept. Approval: Planning Board Approval: Request for: Fee Submitted: $ Temporary Certificate ,,:2r; . b () Final Certificate: '~ (check one) ~ ~xJ1Q Applicant Signature ~Jl.,(,') ~~ ~ c, CO z.. '3,,}. '1 0 2.. -s\)ed Form No.6 TOWN OF SOUTHOLD BUlLDING DEPARTMENT TOWN HALL 765-1802 ) ,~ \i r< , , , ( ,') I (' uJL ) · _~, ~,~;~-- Dic7 -J : i'\J (". ~r'" THO' ; , t.:.) I I 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: 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/ I 0 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 nses: 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 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. Old or Pre-existing Building: ~\f(\{)("' D\\ Y€?'- House No. Street Owner or Owners ofPropertY':fV;\y'r+- ~ moire ('D\\.Ld. \ Suffolk County Tax Map No 1000, Section \';:;)."j Block ~ New Construction: Location of Property: ~DSF'\ (check one) l f\\ }.U~ , Hamlet Lot 2 Subdivision Filed Map. Applicant: Lot: Permit No. Date of Permit. Health Dept. Approval: Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Final Certificate;~ (check one) Fee Submitted: $ ,!) ~ . CD ~~(~ :<\pphcant Signature &..t.c. l J G ~ (p co-f,. 3JL[o3 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. 33105 Z Date JUNE 5, 2007 Permission is hereby granted to: R & M COLWELL PO BOX 546 MATTITUCK,NY 11952 for : INSTALLATION OF AN ABOVE GROUND SWIMMING POOL IN THE REAR YARD. FENCED TO CODE, "AS BUILT" at premises located at 3055 DELMAR DR LAUREL County Tax Map No. 473889 Section 125 Block 0004 Lot No. 008 pursuant to application dated MAY 24, 2007 and approved by the Building Inspector to expire on DECEMBER 5, 2008. Fee $ 500.00 !~~~A~ CJ-L I Authorized Signature ORIGINAL Rev. 5/8/02 FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 33106 Z Date JUNE 5, 2007 Permission is hereby granted to: R & M COLWELL PO BOX 546 MATTITUCK,NY 11952 for "AS BUILT" CONSTRUCTION OF AN ACCESSORY SHED AS APPLIED FOR at premises located at 3055 DELMAR DR LAUREL County Tax Map No. 473889 Section 125 Block 0004 Lot No. 008 pursuant to application dated MAY 24, 2007 and approved by the Building Inspector to expire on DECEMBER 5, 2008. Fee $ 200.00 ~M. CJJ~ Authorized Signature ORIGINAL Rev. 5/8/02 [!J.[!J I BY THIS CERTIFICATE OF COMPLIANCE THE I ~ NEW YORK BOARD OF FIRE UNDERWRITERS ~ ~ BUREAU OF ELECTRICITY ~ ~ 40 FULTON STREET - NEW YORK, NY 1 0038 ~ ~ CERTIFIES THAT ~ ~ ~ ~ Upon the application of upon premises owned by ~ ~ ~ ~ JOHN LUDEMANN ROBERT COLWELL ~ ~ PO BOX 621 3055 DELMAR DR ~ ~ NEW SUFFOLK, NY 11956 LAUREL, NY 11948 ~ ~ ~ ~ Located at 3055 DELMAR DR LAUREL. NY 11948 ~ ~ ~ ~ Application Number: 3033859 Certificate Number: 3033859 ~ I Section: Block: Lot: Building Permit: BDC: ns11 I ~ Described as a occupancy, wherein the premises electrical system consisting of ~ = electrical devices and wiring, described below, located inion the premises at: = ~ Outside, Pool/Spa, ~ ~ A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed ~ ~ herein, was conducted in accordance with the requirements of the applicable code andlor standard ~ ~ promulgated by the State of New York, Department of State Code Enforcement and Administration, or other ~ ~ authority having jurisdiction, and found to be in compliance therewith on the 31st Day of May, 2007. ~ mI Name OTY Rate Ratio!! Circuit ~ m:J ~ Miscellaneous ~ ~ supply power to self contained ~ ~ hot tub and above ground pool ~ ~mringandD"iceS ~ ii!I Disconnect I 0 60a Paoli Spa ii!I ~ GFCI Cirouit Breaker 1 0 40a Pool/ Spa ~ ~ Receptacle 1 0 GFCI ~ ~ Switch 1 0 General Purpose ~ ~ (Swimming Pool): This certificate covers compliance at the date of inspection only. Because of unusual environments it is advisable to have ~ F.il frequent test and/or repairs made by a qualified person. F.il ~ ~ ~ ~ ~ ~ ~ ~ ~ seal ~ ~ ~ ~ 1 of 1 ~ ~ ~ I This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. I [!J~~~[!J FIELD INSPECTION REPORT DATE I FOUNDATION (1ST) FOUNDATION (2ND) 1--- ROUGH FRAMING & PLUMBING __ INSULATION PER N. Y. STATE ENERGY CODE FINAL --c-- -- 1----- 1--- f----- 1----- --f---- --- COMMENTS ----------- ------ ---- VO\>J ~~ ooi"i ~~ "" Ii: -'~ t~ Wz ~~ -- '" ~ ~..., r. - n (,-1.-0- .I2L J- H&:t - wt-- ~ OK I A-c; -f rrtA...I- ^ I. j, tYUL tJ 1:: --h- " A AM c.JJ 0 h-,,;} 1 U ,y ADDITIONAL COMMENTS - - f ~ ~ 1. - ----- ~ ~ <><(j o z \ gj ~ ..., := 1:1 i"i ... ~ liYlr(20 -d I BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health --. ) 4 sets of Building Plans ~~-'>:1e.. PoD J Planning Board approval -., ... Survey Check ~ --:....-1 Septic Form N,Y,S.D.E.C. Trustees Contact: Mail to'1h ~ 5'-tt.o N~r1CnM'~ ~'( \\95;) Phone 10'3\ - ~"8 - l ;;2L.!3 fOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 www.northfork.net/Southoldl PERMIT NO. 1;3'0" b ;pfj ,24 r;;, 20 tfL Examined Approved Disapproved ale Expiration I 0) ~ II W ~~rLICATION FOR BUILDING PERMIT lrUL '2' 2fJJU Date rY\n /1 d Y. INSTRUCTIONS ~ tit ~ _ 1.1<... ' a. TlHiHlp~i1.~ati~ LD etely 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 "'J, Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant Such a permit shall b1.: kept on the premises available for inspection throughout the work. ',e. No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an addition six months, Thereafter, a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein described, The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in building for necessary inspections. ,20M "IMMED lATELY" ENCLOSE POOL,1D CODE UPON COjllPLt=TION BEFORE. "WA TEA" '"Po ~ ~ ~d (\~-.1lli~ UNDERWRITERS CERTIFICATE (Mailing address of applicant) State whether applicant is owner, lessee, agent, ~~~t, engineer, general contractor, electrici;m, plumber or builder Dlllj(y\' ~ . (l APPROVED AS NOTED Nameofownerofpremise;-R~ aU~ (_D\UY"~ ritl7 ;>, 3!o.;,-~ As 'b t tax roll or lates m- IJ . . '/1~ If applicant is a corporation, signaturel~.. . . )tC!\lltllxit:eli offiCf.'f FEE: 5'2>0. _ 31':1./1 U~C:lv U 1'\1 L1"\ Vii r -' '- NOTiFY BU'.DI' '3 'Jttbtt;TrAENT AT (Name and title of corporate oW~l>HOU'lCERTIF I CA', 765.1802. 8 A J "Ivl FOR THE . . ' . J . F0LLOWIr-.", Ir,~~l::;TIOt~S: OF OCCUPANCY 1. FC~!N::~AT~O!, . ',' '0 REQI.:'RED , FC" "OUH ~ r, '.!!'RETE AI,L CONSTRUCTION SHALL 2. .FOU'3rt ' FR"~M',NG '& PLUMBING ME-F,'f iHE REQUIREMENTS OF T:ljI:JNSULATiON r.om;SOFNEWYORKSTATE4. FINAL - CONSL' .,T/ON MUST BE COMPLE, ~ Fd C,O. ALL CONSTRU,~T,ON SHALL MEET THE EMENTS OF THE CODES OF NEW I HflN N OR CONSTRUCTION ERRORS. '8 Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. I. Location of land on which proposed wo k will be done: D House Number Street Count yTax Map No. 1000 Section ~ Subdivisionl.L\uc21 C N. ~ :\-eS (Name) Block l.\ Filed Map No. Lot Lot 2. State existing use and occupancy of a. Existing use and occupancy b. Intended use and occupancy 3. Nature of work (check which applicable): New Building Repair Removal Demolition Addition Other Work Alteration (Description) 4. Estimated Cost Fee 5. If dwelling, number of dwelling units If garage, number of cars (To be paid on filing this application) Number of dwelling units on each floor 6. Ifbusiness, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Height Number of Stories Rear Depth Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Height Number of Stories 9. Size oflot: Front--1j 5 Rear \L\o Rear Depth Depth -LLIC\ .3Lt 10. Date of Purchase Name of Former Owner II. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation? YES ~ NO V- ... : 13. Will lot be re-graded? YES ~ NO LWill excess fill be removed from premises? YES ~ NO ~ Po &+ fj./.J. Address Haftttu::!t: NY 11'79 Phone No. (,,3\ (;)'18 7 ~3 Address Phone No Address Phone No. 14. Names of Owner ofpremisesBJ.p~f~ (;fuY1.1 Name of Architect Name of Contractor 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES _NO V- * 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 .~ -- * IF YES, D.E.C. PERMITS MAY BE REQUIRED. , ) J ~d 16. Provide survey, to scale, with accurate foundation plan and distances to property lim:t~: \'''' .1 , , 17. If elevation at any point on property is at 1 0 feet or below, must providetop6graphical data on survey. STATE OF NEW YORK) SS: COUNTY OFSil\"l"'i7\.)t-L-- 0\a.r\e..- r(juY11 being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the ~ (Contractor, Agent, Corporate Officer, etc.) ,Pi . , ~ .I:':T:W of said owner or owners, andis d~ly authorized to perform or have p~rfol{P~~ i~faimrk and to make and file this application; that all statements contamed m thiS apphcatlOn are true to the best of hiS kilbW1ed~ arld-tJehef; and that the work Will be performed in the manner set forth in the application filed therewith. Swom m b<fure m, <hi, j; ~~; .,n~n Notary Public. . M8.ANIE V.1IIKll* NoIIry PtMc. SlIII III NIw VIIk No. 4llllI712 QuIlled In UaIl CouIIy ""'''I\l~""," ElCIlIrIe Od. '8. .>ti) 0 1 ~l;O ~17Q.o Signature of AppliCant PERMIT NO. 33/ot ~ BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying') Board of Health 4 sets of Building Plans Planning Board approval Survey ~+ti1> Cheek ~ I -j,...>., Septic Form N.Y.S.D.E.C. Trustees Contact: Mail to:+>O rx,'L 5'~to {,y:t\-h-tu{l ~ N l{ I \ q 5 cO Phone lo3 \ - ;;)Q'3 - ., d. Y9' TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 www.northfork.net/Southoldl Approved Disapproved ale v ~, ztl ~ {{zOQl Examined Expiration 11 S, zoot !!Cv.JL,. Building Inspector , , ~I ZA ~ _ 0\PPLICATION FOR BUll.DING PERMlI i\1UL Date, 20 07 . 00' b' 9is'6\J1!~OLO INSTRUCTIONS .__~'d _--- a, !tis 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. rd. 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 ofthe 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. ~u.O l1Q, dQQ (Sig alure of apphcant or name, If a corporatIon) lfl~ (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder /t$ BoJlL.."- Name of owner of premises , DATE:.5 VJ 8P.t./ (As on the tax roll or latel"i:~eed) 7 nO c.' If applicant is a corporation, signature of duly authorized officer NOTIFY BUllDI~3- [.!;;P~'1TMENT AT ~ 765.1802 8AMiO 4":'1 FOR THE (Name and title of corporaw.uUlIOtr)' t\1"CY OR FOllOWING INSPEl WXJS: USE .IS UNf,A...W.. FUL 1. FCUNDATION . 1...0 REQUIRED Builders License No. lJ"\ FOR POURED CO,~CRETE Plumbers License No. ~ TE. ;: ~~~~~~O~RAMING & PLUMBING Electricians License No. , . 4. FINAL. CONSTRUCTION MUST Other Trade s LIcense No. BE COMPLETE FOil C.O. All CONSTRUCTION SHAll MEET THE I. Location of land on which proposed work will be dtll:le. . CONSTRUCTIO~~:'=TS OF THE CODES OF NEW ~. MEET THE REQUIREME . NOT RESPONSIBLE FO House Number Street CODES OF NEW YOR' OR CONSTRUCTION ERRORS. County Tax Map No. 1000 Section Subdivision Lau. re.1 C~~ (Name) \~5 Fs\-o:\-e .s Block Filed Map No. i..J Lot ~ Lot 3. Nature of work (check which applicable): New Building Repair Removal Demolition Addition Alteration OtherWork ~)l.1'S1o~~ OUui ~<}€'cr~ (D ri tion) 4. Estimated Cost Fee 5. If dwelling, number of dwelling units If garage, number of cars (To be paid on filing this application) Number of dwelling units on each floor 6. Ifbusiness, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: FrontlD I Height q , Number of Stories Rear ID I Depth I ~ / Dimensions of same structure with alterations or additions: Front Rear Depth Height Number of Stories 8. Dimensions of entire new construction: Front Height Number of Stories Rear Depth 9. Size oflot: Front )15 Rear_I 40 Depth i4Q. 34 10. Date of Purchase Name of Former Owner II. Zone or use district in which premises are situated "\ 12. Does proposed construction violate any zoning law, ordinance or regulation? YES_NO V-- 13. Will lot be re-graded? YES_NO V"\Vill excess fill be removed from premises? YES ~ NO ~ , Po &o-t 5'-1(.. 14. Names of Owner ofpremise~AddresslYl\i1lT1-,fll( #j.f Name of Architect Address Name of Contractor Address I\9S.;>Phone No.t-,-==)\ Phone No Phone No. ;;A'if 7~43 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO V-- -- * 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 ~ * 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 .>vA'\? 0L- r<\a.rie~ r d \. ,.,U being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the ~ (Contractor, Agent, Corporate Officer, etc.) '"" ') of said owner or owners, and is duly authorized to perform or have Perf'?m:lidlthe SFiili;~ork an' to make and file this application; that all statements contained in this application are true to the bestofhis"iMOWl~dge lllid belief; and that the work will be performed in the manner set forth in the application filed therewith.:,; , ., 'q :1:l T ,-' i...i I , .! ..--J"\.. Sworn to before me thi~ A ~daYOf ,v~~ r ~ry ~r-. Notary Public 20 11 7 ,- ,1AC1 i r:, 1". j '~J"o C'ffjjneW Signature of Applicant MElANIE V.BROWN NolIry NIlt, .... III.... YOlk Nt. 4lllII712 QuIlled III UaIt c:au.y Clnlmllllon EliphI Od. 19, :2ff'D C; 1 ~ CiJ,r~~'E :in. iA "."'S!..E fI.J.'t,-5 ~F.C r:-....'S~f~J Cl....~.;,;;. 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