HomeMy WebLinkAbout32008-Z
FORM NO.4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-32554 Date: 08/23/07
THIS CERTIFIES that the building ADDITION
Location of Property: 4170
(HOUSE NO.)
County Tax Map No. 473889 Section 123
CAMP MINEOLA RD
(STREET)
Block 5
MATTI TUCK
(HAMLET)
Lot 21.2
Subdivision
Filed Map No.
Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated
APRIL 27, 2006 pursuant to which
Building Permit No. 32008-Z
dated
MAY 16, 2006
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 ADDITION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR.
The certificate is issued to RAYMOND & MARIE VILLANUEVA
(OWNER)
of the aforesaid building.
N/A
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO_
07-0898
08/06/07
07/17/07 BURTS RELIABLE, INC.
PLUMBERS CERTIFICATION DATED
~ff~~"'"<'
Rev. 1/81
.
Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
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APPLICATION FOR CERTIFICATE OF OCCUPANCY
tn.O .. DEP'~.
L~T('IYVN OF ~,..., 'THO'
This application must be filled in by typewriter or 1I1k 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 2/1 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
I. 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, Conunercial $15,00
New Construction:
Date.
Old or Pre-existing Building: l/
f!..A10 P 1-1/ NEO L-jC)
~-G-j, /1 /}.{9f)/}
{/ /
( check one)
120
f..1A 7 n rUCk
Hamlet
41'7D
House No,
Owner or Owners of Property: 1=:>1'2.
Location of Property:
Street
.
t:.> 011 e I ~
Bl~c~ , ')
Filed Map,
V I U...J::-.j
N V6vA
Z/. z.
Suffolk County Tax Map No 1000, Section
(2.t:!jYNo"-Jf.)
/23
Lot
Subdivision
Lot:
Pel111it No,
----- -...
Date of Permit.
Applicant:
Health Dept. Approval: __
Underwriters Approval:
Plmming Board Approval: _________
Request for:
Temporary Certificate
Final Certificate:
(check one)
Fee Submitted' $
2f3. /)0
dtLtk)H;o/&/?U
Applicant Signature
(AM.... 7d. JI.f3
c.Oc3J..55Y
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)
16, 2006
PERMIT NO.
32008 Z
Date MAY
Permission is hereby granted to:
RAYMOND VILLANUEVA
86-51 PALERMO STREET
HOLLISWOOD,NY 11423
for :
ADDITION TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR;
FLOOD PERMIT INCLUDED
at premises located at
4170 CAMP MINEOLA RD
MATTI TUCK
County Tax Map No. 473889 Section 123
Block 0005
Lot No. 021.002
pursuant to application dated APRIL 27, 2006 and approved by the
Building Inspector to expire on NOVEMBER 16, 2007.
Fee $
279.10
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I Authorized Signature
ORIGINAL
Rev. 5/8/02
r~\'I/'l ,.,all. 53095 MOln q,y)j
PO. 80> 1179
SC'~lr,oJd, New Yorx 1 HJ71
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L_T('W~ QF sr""~THO'cL-'
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
C E R T I FIe A T ION
Date:~
Building Permit No. ::s d 00 8
Owner Q "'.1.&4-~ t /"f1L.crl 'C V; I \ OJ Ir\U e vlA..
: \ '(,. '\Please Print)
Plumber _0ur-n ~e);4.bk l(\(
(please print)
I certify that the solder used in the water supply system contains less
than 2/10 of 1% lead.
;n/J /5~"
(plumbers signature)
Sworn to before me this
, lJl-.. day of JJ\ 1
Notary Public. <;?~ Jfv IL
20Q2
County
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fialwy r'vtl,c- i P/'(PJ
BERNADETTE L TAPliN
NOTARY PUBlIC 114844893
State of Mew York
~esiding in Suffolk County
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32002-2:-
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] I~L
[ ] FRAMING I STRAPPING [v(FINAL A
[ ] FIREPLACE & CHIMNEY [] FIRE SAFE
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
Cu
REMARKS:
DATE 7/3110
I
INSPECTOR
I
3 J-o 0 y Z
TOWN OF SOUTH OLD BUILDING DEPT.
765.1802
INSPECTION
] FOUNDATION 1 ST
] FOUNDATION 2ND
] FRAMING I STRAPPING
] FIREPLACE & CHIMNEY
] FIRE RESISTANT CONSTRUCTION
[ ] ROUGH PLBG.
~INSULATION A...',
[ ] FINAL
[ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT PENETRATION
REMARKS:~~
~-'
DATE
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INSPECTOR ~ ~
3 J-o 0 '6 7--
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST
[ ] FOUNDATION 2ND
[ ] FRAMING I STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] FIRE RESISTANT CONSTRUCTION
[ ] ROUGH PLBG.
P<J INSULATION
[ ] FINAL
[ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT PENETRATION
REMARKS:
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INSPECTOR ~ ~
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TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING I STRAPPING [] FINAL
[ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRucnON [ ] FIRE RESISTANT PENETRAnON
REMARKS: -M~/~OJ-1~. ~
I
DATE
INSPECTOR
3 'J-oo '1 7-
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[
[
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[
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JKl FOUNDATION 1ST
[ ] FOUNDATION 2ND
M FRAMING I STRAPPING
, ..........
[ ] FIREPLACE & CHIMNEY
[ ] RRE RESISTANT CONSTRUCTION
REMARKS:
~
] ROUGH PLBG.
] INSULATION
] FINAL
] FIRE SAFETY INSPECTION
] FIRE RESISTANT PENETRATION
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DATE I?- r~- tJ ,
INSPECTOR ~ ~
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TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
P<f FOUNDATION 1 ST [] ROUGH PLBG.
[ ] FOUNDATION 2ND [] INSULATION
[ ] FRAMING I STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS:
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DATE 11-tJ-1 ~ a?
INSPECTOR ~, ~
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TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
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<<ROUGH PLBG. ~
[ ] INSULATION
[ ] FINAL
[ ] FIRE SAFETY INSPECTION C~
[ ] FIRE RESISTANT PENETRA~
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[ ] FOUNDATION 1 ST
[ ] FOUNDATION 2ND
[ ] FRAMING I STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] FIRE RESISTANT CONSTRUC'nON
REMARKS:
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DATE
INSPECTOR ~r~
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PROFESSIONAL ENGINEER
1725 HOBART ROAD I PO Box 616 SOUTHOLD, NEW YORK 11971
TEL: 631.765.2954 . FAX: 631.614.3516 . e-mail:joseph@fischelli.com
Date:
Reference:
July 17, 2007
BP # 32008
Southold Building Dept
PO Box 1179
Southold, NY 11971
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Dear Sir,
I have inspected the damproofing at 4170 Camp Mineola Road in Mattituck and certify
that it is in compliance with NY State Codes.
JosepH Fischetti, P.E.
VillmlllL'Va d;'n~~'lillg=t.mc
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FIELD INSPECTION REPORT
DATE
COMMENTS
FOUNDATION (1ST)
0' " " ~;g
\I/')q-l)", A:t' V~ j),~..o- 0:)(-, /--;" JI't;/;; \\ g, ~
( ::-.-- ~()_ n >I- h: ,J).. ~ '::" ;:: 1\0 ~ t- .t V 1. _"A =l
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17-,I't-d/ /'l.,f2I7--A "oAJ-, k Jj'-. /l). A I-J - . -/ ~ "'2 j, ,
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FOUNDATION (2ND)
ROUGH FRAMING &
PLUMBING
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INSULATION PER N. Y.
STATE ENERGY CODE
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PERMIT NO.
3~of[v
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
Check
Septic Form
N.Y.S.D.E.C.
Trustees
Contact: . r /In lJ-r.JefI-
Mail to: ft (t3efJ ::::Jit'V1 (J
[@V/W{;ICX/t2J-.1i3
Phone: fa::?! 7~ 1-
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
www.northfork.netlSouthoId/
Examined
1/
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,
,20 Ok>
,20~
Approved
Disapproved ale
Expiration
1(110
/
2007
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Building Inspector
APPLICATION FOR BUILDING PERMIT
i27
Date tft2ul ~1
,20~
INSTRUCTIONS
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a. This applicati6fi1\ttfST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4
sets of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or
areas, and waterways.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a permit
shall be kept on the premises available for inspection throughout the work.
e. No building shall be occupied or used in whole or in 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.
1::Rl<A y H 01\1 D e k4DEVi L1..J..k/c.M
(Signature of applicant or name, if a corporation)
t(;(y - 6/ 'Tp u;e J-10 ST
(Mailing address of ~p~licant)
flDLL ISuJOO D N ,Yo / /423
State whether applicant iG;n~ lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
~ N EI2.
Name of owner of premises
uk'.. f2..A Y M D I-J r,:) S H0"'J H iAfl~ V I LL,t\N Vf'JA
I
(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: ;....1 El ..,- T I ru r k...
4/ ~() C/:1/-lp ,fG-11;()f:-(iL;4 (<0 I ,-, I V'
House Number Street ' Hamlet
County Tax Map No. 1000 Section I Z 5
Subdivision
Block 5
Filed Map No.
Lot
Lot
2/. Z.
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ifGf"'5/ f::>E3f..t I
b. Intended use and occupancy
1<. f'"'S I b6101
3. Nature of work (check which applicable): New Building
Repair Removal Demolition
4. Estimated Cost r$- ,,~ OZ7. CO
Addition
Other Work
/ 'Z5TOfO( 51D{3 /iPVI/7CJt/.
Ie DECc-:;;.
A teration
(Description)
Fee
5. If dwelling, number of dwelling units I
If garage, number of cars Aj/ yf
6. Ifbusiness, commercial or mixed occupancy, specify nature and extent of each type of use.
(To be paid on filing this applic,ation)
Number of dwelling units on each floor (/J
,I
hi /d'
1
7. Dimensions of existing structures, if any: Front
Height Number of Stories
Rear
Depth
Dimensions of SJlr;ne structure wi~h alterations or additions: Front -3 r; J
Depth "5 ":> Height 70 1 Number of Stories
I
8. Dimensions of entip:, new construction: Front / 8
Height (.5 ' Number of Stories
0,/7 /
Rear ./' /
2-..
?, f7 I
Depth '.J fL.
Rear
'2.
lei
9. Size oflot: Front 1"2'5.03
Rear
~Y'G
Depth /-71/ 15 '7, ? I
10. Date of Purchase (P' e&
Name of Former Owner
11. Zone or use district in which premises are situated
12. Does proposed construction violate any zoning law, ordinance or regulation? YES_ NO X
13. Will lot be re-graded? YES_ NO x' Will excess fill be removed from premises? YES_ NO X
l:J2. ~M l-( D 1\4 D" ILL A. N l) t V J.i P€U3.erft'L -=r /-I()(.M7I,;/ (-0;> 1.../ Y
14. Names of Owner of premises . Address 1J:7lj1.ljl - -Phone No.-7/p> cP:?9 . 44'_4P.
Name of Architect ;:: <;M'.0~1 c/PJlH'6iTIff"Address t;C?ql/JtYY5IiY(1flJ Phone No 77 t/ "Z'?9<j
Name of Contractor .111'1!J t?0~ /Yl/V,e Address //,l/7777UCZ- Phone No.
15 a. Is this property within 100 feet ofa tidal wetland or a freshwater wetland? *YES_NO X
* 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 )
1?1c.J.fJ4/f'f) fl. /M1";<IIF being du1y sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
(~He is the
/luf3/Jr
(Contractor, Agent, Corporate Officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;
that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be
performed in the manner set forth in the application filed therewith.
Sworn to before me this ~
;:;((.1 day of 20 0 ~
b)./uyw, ,<YY)lY<91A./
Notary Public
~{)J)d a !W~r~
Signature of Applicant
EILEEN S. SANTORA.
~TAR.Y PUILIC, St.t. of tWw Yodr;
No. 30-4916018
QUlllified in NasIlIU Coullt!
Commission Expires I , I ~ I ()
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Permit #
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Permit Date
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REScheck Software Version 3.7.3
Compliance Certificate
Project Title: New 2 story Addition with Crawl
Report Date: 05/08/06
Data filename: C:\Program Files\Check\REScheckWillanueva.rck
Energy Code:
New York State Energy Conservation
Construction Code
Suffolk County, New York
Detached 1 or 2 Family
Non-Elec1ric
18%
5750
Location:
Construction Type:
Heating Type:
Glazing Area Percentage:
Heating Degree Days:
Construction Site:
4170 Camp Mineola Road
Mattituck, NY
Owner! Agent:
Joseph Fischetti, PE
1725 Hobart Road
Southold, NY 11971
631.765.2954
Designer/Contractor:
Assembly
..... .
.: ..... .. . - .. . . . ~",
Ceiling 1: Flat Ceiling or Scissor Truss:
Wall 1: Wood Frame, 16" D.C.:
Window 1: Wood Frame:Double Pane:
Floor 1: All-Wood JoistlTruss;Qver Unconditioned Space:
600
896
163
600
30.0
19.0
0.0
0.0
0.350
21
44
57
20
30.0
0.0
proposed building represented in this document is consistent with the building plans, specifications, and other calculations
s bitted with this permit application. The proposed systems have been designed to meet the New York State Energy Conservation
C ruction Code re uirements. When a Registered Design Professional has stamped and signed this page, they are attesting that
to t bes f his/he and professional judgment, such plans or specifications are in compliance wi this de.
~l<.
Builde
Date
Proje
Eile
.
New 2 story Addition with Crawl
Page 1 of 1
" ,,......
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. 'ftIP'ITH T. TERRY
to Wl'I CLERK
,
IlEGISTnAJ1 or VlTN. STAllSl1CS
MArH1I^GF. orTICI.:n
RECOf1IJS MNi^GfMENT OITICEIl
fl1EEDOM Of INfOfUMTlON OfflCW
,3;;).ODf]
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P.O. nn. 1171}
Sltl1l11old. New. Yurl.: 1
Fox (.') 1(" 7<'>~'IR"
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OFFICE OF THE TOWN CLERIC
TOWN OF SOUTHOLD
THIS IS TO CERTIFY THAT THE FOllOWING RESOLUTION WAS ADOPTED BY THE
SOUTHOlD TOWN BOARD AT A REGULAR MEETING HELD ON AUGUST 24, 1993:
RESOLVED that the Town Board of the Town of Southold hereby adopts
"Floodplain
two (2) new forms to be used under We Flood Damage Prevent regulations ..I
0; the Code of the Town of: Southold:
f\pplication" (FDP(93) I. and /Certificate
Special Flood Hazard Area [e/C(93)].
of Compliance
Development Permit
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(/1 Develeprnen t in
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Southold Town Cle,k
August 25, 1993
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BUD. Or:?!
TOW;4 OF S0Ul110LD
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APPLICATION #
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TOWN OF SOUTHOLD
FLOODPLAIN DEVELOPMENT PERMIT APPLICATION
This form is to be filled out in duplicate.
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SECTION I: GENERAL PROVlSIONS (APPLICANT to read and sirn);
1. No work may start unW . permit is wued.
2 Tbe permit may be revoked if any false sl.temenl.l ue made herein.
3. If revoked, all work must cease until permit is re-issued.
4. Development shall nol be used or occupied until a CertifiC<lte of Compliance is issued.
5. The permit will expire if 00 work is commenced within six months of issuance.
6. Applicant is hereby infnrmed th.t other permil.l may be required to fulfill local, st.te aJld federal regulatory
requirement&.
7. Applicant hereby gives coosenlto the Local Administrator or his/her represent.tive (0 make reasonable
. inspections required to verily compliance. .
8. I, THE APPLICANT, CERTIFY THAT ALL STATEMENTS HEREIN AND lJ'i A TTACHMEJ'ITS TO
_ THIS APPLICATION ARE, TO THE BEST OF MY KNOWLEDGE, TRUE AND ACCURATE.
(APPLICANT'SSIGNATURE)~ IWPY/)JwJMA, DATE U' /qO(o' .
) I
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//SECTION 2: PROPOSED DFYELOethENT ITC'Se comDlcled bv APPLlCANl1
NAME ADDRESS
APPLICANT ElL E E IV -3i li!hDaq (p Fj() V AAJ 570 N
BUILDER -...J ("---'\ 'Brzo:=.t: l-"::1~ N I-C
ENGINEER. 1.--+ I /' ~ 1
. "-/;'\:lSe-Pl-J 't""X-I'-t-ell\
TELEPHONE
tz.IJ ~~~)'4 '2 TCJ -4
fRomCf LOCATION:
To .void del.y io prooo.s.sing tbe .ppOWlUO'" plc..,e provide eoough information to easily ideotify the project
location. Provide the street addrus, lot oumber or Icg<ll description (attach) and. outside urba.o areas, tbe
dislllDCC to the nearest intersecting road or wcU-KnO\lfll Giidmarl A skelch attached to Lhi.5 application sbowing
(he project location wouJd be belpfuJ
4/'7D
'PI)(. N ()
QA~1 P WIN cO/Ai 11:':0
40'3fJ'7Y'''I ~d 1'2") 'F6Ik.
00:111 ~ 'g ih,{J~
FDP( 93)
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APPL/CA TION ;'!
PAGE20F'
DESCRIPTION OF WORK (Check all appuGlblc boxes)
A ,TRlJCTURAL DEVELOPMENT
ACTIVITY
STRUCTURE TYPE
o New Structure 2t:ResidentiaJ (I i ,.Jly)
'l>(' Addition 0 Residential (More than 4 F:undy)
o Alteratioo 0 Noo,residential (FloodprooClng? 0 Yes)
o Relocatioo 0 Combined Use (Resideotial & Commercial)
o DemoUlioo I' 0 Manu(actured (Mobile) Home ([0 Manu,
o Replacemeot (aeluredJ1ome P~k7 0 Yes)
ESTIMATED COST OF PROJECT S /}t); f1{lO. ()c)
(
B. OTHER DEVELOPMENT ACI1VlTIES:
o Fill 0 Mining 0 Drilling 0 Gnding
o ExC3vation (Except (or Structural Development Cbecked Above)
o Watercourse Alteralioo (lDcludiog Dredging aod Channel Modificalions)
o Drainage Improvements (Including Culvert Work)
o Roa:rit., Street or Bridge ConstructioD
o :Su~jvisioQ (New or Expansioo)
o ~ilividua1 Water or Sewer SYSlem
o Otber (PI=se Specify)
/
!
After completing SECTION 2, APPLlCA.l'fT shouJd submit form to L..oc.a.J Adminislraror for revicw.
SECTION); FLOODPLA.lN DETERMINATION eTo be comulcted bv LOCAL ADl>ffNlSTRATORl
Tbe proposed devctopmen( lS loca{cd 00 F1RM Panel No.
Dated
The Proposed DevelopmeDt:
o Is t;!QI 10CHed in . Special FlOO<i Hwud Area (Notify the .ppUant that the applkntion
review is complete ODd NO FLOODPLAIN DEVELOPMENT PERMIT IS REQUIRED).
o ls located io . Special AOO<i H lIMd Area.
J..IRM ronc dc....:;ignation i.s
lOO,YeaJ nood ekvation althe site ls: Ft. NOVO (MSL)
o Unavail.ble
o The propo5cd development is lou(ed in a lloodway.
FBFM Panel No. Dated
OSee SUllon <1 (or ~drliljona in:;lrI!(lioo.1
SICNED
fA /L/pt
A/ DATE &, /9,tI/J
. ------- --~--._-----
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APPLICATION >'I
PAGE] OF4
-
SECTION 4: ADDITIONAL INFOf\MnION REOUIRED (To he comnleted by LOCAL ADMINISTnATORj
The appuClJ)t must submit the documeniS checked below before tbe appucation ClJ) be processed:
o A site plan sbowing the location of all cmtlng structurcsf wate.r bodies, adi.aceDt roads, lot
dimcnsioU5 aJld proposed development.
o DeYelopmeol plans, drawn lo,calc, and speciocat4;Jns, iocludio~ wbere applicable: <lelails (or
ancboring slructures, proposed elevation of lowest Ooor (including basemeot), Iypes o( waler
resistant materials used below lhe rlIst Ooor, dctaili of noodprooflDg of uiilities located below
the orsl Ooor aDd details of eoclosures below the Or" Ooor.
Also.
o Subdivisioo or otber developmcol plans (I( tbe subdivisioo or olher developmenl exceeds 50
10ls or 5 acres, wbicbever is tbe lesser, the applicanl !!!Jill provide lOO-year Oood elevations
if they are oot olberwise available).
o PI31lS showing the extenl of watercourse relocation 3lld/or l311dform a1teratioDS.
o Top of new mJ elevatioo
Ft. NGVO (MSL).
o AoodprooCUlg protection level (non.residential only) Fl.' NOVO (MSL), For
Ooodproofed slructure.s, -:!lppl.ic.aol must aUacb certification rroro r~gislered eDgineer or
architeCl. / ,t/-
o Certification [rom a-r;~s{ercd engineer tha( {he proposed activit in a regulalory Uoodway
will not r~ul{ in .!UlY increase in tbe height oC the tOO-year naod. A copy of all data and
ca1cu1ations supporting this rt.nding must also be submitted.
o Gtbe"
SECTION 5: PERMIT DETERMINATION ITo be comDleled bv LO<':AL ADMINISTRATOR)
[ have delermined tbat tbe proposed activity: A. 0 ls
B.O Is Dot
in conformance with provisions of Local uw r1 , 19 The permit is issued subject to tbe cooditlons
attached to and made part nf t~nnil.
SIGNED tIL(/{ 0h/t'f:tJ/l . DATE j;,/c}-tf;
If BOX A is chec~ed, tbe Local AdminLllrator may lIsue a DevelopmeDt Permit upoo payment o( designated
ree.
If ~OX B is checked, tbe Local Admirustrator wlJI provide a YvTitlCO summary o( dcncicncics. Applica.nl may
rc'llSC and resubmil a.I1 application 10 the Local Administrator or may request a bearing (rom tbe Board of
Appeals
.r-.,
..
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APPLICATION #
PAGE 4 OF 4
APPEALS. Appealed 10 Board of Appeals' 0 Yes 0 No
Hea.ring dale:
Appeab BUii,d Di;....~;lJU --- AfJP,v~!..,j? 0 Yo 0 ~10
Coowtio0.5
SE:CTION6: A's.OUILT ELE:VATlONS ITo be submitted bv APPLICANT before Certificate of ComDliance
is issued)
The foUowiog information must be provided for project structures.. This sectioD must be completed qy a
registered professioDal eDgineer or a ticcDSed land surveyor (or attach a certification to llUs apptication).
Complete I or 2 below.
L Aelual (As.Built) Elevation of the lop of ihe lowesl noor, includiog basemenl (in Coastal Hi2h Haza'rd
Areas, bollom oC lowest structural member of tbe lowesl Ooor, excluding piling and columns) is:
FT, NGVD (MSL).
L . " Actual (As,Buill) Elevation oC OoodprooHng protectio. is FT, NOVD (MSL).
I -. "
I I .' I
1'1U'J~: Any work performed prior to submittal/of the above information is a( lhe risk ;6[ !.he Appl;:ca.nL
/ j // /
SECTION 7,: COMPllANCE ACTlON ITo be [omDlcted bv LOCAL ADMINISTRATOR)
The LOCAL ADflHNISTRATOR will complete lbis section as applicable based 00 in..speuioo of the projcc( (0
ensure compliance 'lrilb the community's locaJ law for Oood damage preventioo.
INSPECTIONS: DATE
DATE
DATE
DEFICIENOES? 0 YES 0 NO
DEFICIENOES? 0 YES 0 NO
DEFICIENOES? 0 YES 0 NO
BY
BY
BY
SECTION 8: CERTIFICATE OF COMPLlANCEITo be [omnleled by LOCAL AD~llNlSTRATOR)
CcrtlIicale of CompUance issued: DATE:
BY:
, .
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t't._
,
JJ ~~
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l>.ttacllIDent B
/
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/ 8Al{~.LE
CERT~JICATEj)F COKPLIANCE
for Development in a special Flood !iazard Are~
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TOWN OF SOUTHOLD
..
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CERTIFICATE OF COMPLIANCE
FOR DEVELOPMENT IN A SPECIAL FLOOD HAZARD A.REA
(OWNER MT'ST REH TN THIS r:ERTlFICATE)
PREMISES LOC~TED AT: ~ J N
41'7D L/7~P V'VI/ 50LA
Hf)Til jOCr
en
'-=SLoan
PERMIT NO.
PERMIT DATE "-'10-_',-\ \ '" ,'2tDCp
CHECK ONE:
o NEW BUILDING
-m::X:ISTING' BUILDING
o VACANT LAND
OWNERS NAME AND ADDRESS:
KAY H t:ll',h) \1 \ L-U" N I )eJ A
)
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THE LOCAL ADMINIS'DtATOR IS TO COMPLETE A, OR B. BELOW:
A. COMPLIANCE IS HEREBY CERTIfIED WITH TIlE REQUIREMENTS OF
LOCAL LAW # ,19
SIGNED: - DATED:
B. CmilPLIANCE IS HEREBY CERTIFIED WITH TIiE REQUIREMENTS OF
LOCAL LAW # I 19_, AS MODIFIED BY VARIANCE #
DATED
SIGNED: DATED:
C I c: 191)
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SUF FOLr~ CO
HEALTH OEPT APPROVAL''''
H 5 NO c;': ,c~_ : ,-'.3
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I' STATEMENT OF INTENT
THE WATER SUPf'L Y AND SEWAGE DISPOSAL
SYSTEMS FOR THIS RESIDENCE WILL
CONFORM TO THE STANDARDS OF THE
I SUFFOLK CO DEPT OF HEALTH SERVICES,
(51
APPLICANT
PEI'T. OF HEAL TH
APPROVAL OF
SUFFOLK COUNTY
SERV ICES - FOR
eONSTRIJCT1ON ONL Y
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;H':S.RE'F,Nli: ~-w~!aa
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HEAL TH DEPT APPROVAL
H. S NO 3S<..:~(.;; IRS
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STATEMENT OF INTENT
THE WATER SUPPL Y AND SEWAC;E DISPOSAL
SYSTEMS FOR THIS RESIDENCE WILL
CONFORM TO THE STANDARDS OF THE
SUFFOLK CO, DEPT, OF HEAL TH,SERVICES,
(51
,SUFFOLK COUNTY OEPT,
:SE:RVICES '- ,F'OR,-
'CONSTRuCTiON ONL Y
~p~~j.~,~-.{. ~,~~.~~
.,,', iiH::S;REF, NO.:" 85.~;la8 ,,-
:IA:PP~6"EO: ;
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APPLICANT
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oWNERS AOO~ESS:;
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OF HEALTH
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APPROVAL or!
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to ,t.:, a9$,qf!i3as Of the landing in~i.
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