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Home My WebLink About32593-Z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY Date: 09/24/07 No: Z-32618 THIS CERTIFIES that the building INGROUND SWIMMING POOL Location of Property: 1205 PT (HOUSE NO.) County Tax Map No. 473889 Section 114 PLEASANT RD (STREET) Block 1 MATTITUCK (HAMLET) Lot 4 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated DECEMBER 22, 2006 pursuant to which Building Permit No. 32593-Z dated DECEMBER 22, 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 INGROUND SWIMMING POOL WITH RAISED STONE TERRACE, HOT TUB, & NEW WALKWAY AS APPLIED FOR. The certificate is issued to EDWARD & ADRIENNE SOLOMON (OWNER) of the aforesaid building. SUFFOLK COUNTY DBPARTMEIIT OF HEALTH APPROVAL N/A 09/18/07 ELECTRICAL CERTIFICATE NO. 3045467 N/A PLUMBERS CERTIFICATION DATED ~ze~ Rev. 1/81 - :::: ~,;-:'i :]? 30 :~-:~-:C L: 3;;:=.J [:iG G~? .;._a::~,::='::'r~ :Ot.iN ::..'...:..:. . ~iJ3-~.:C2 }.-P?!.l:CA::::CN :.Jtl C=:::\::?:':A:: ,~? ;C:::l.;-? _~~'7C~ A. Thi3 d9P~:'':2t'::''Qn ]lUst: be :illed in ";" ::n;:e':,;t"':..:~::- ';? ~:!k .=.r:d :3,':Jm:"c:2~ :J :::e 'Ju:,,:',::'::"::'~ :n3pec:Jr '..;~:n t.:;.e :OJ....:..Jr..,;:..:lg: :o~ :'.'2~,j Juild..:'...::g J:' J.i2:,w' '.152: 1 :2..:12.1 3u=~Tey J: ?rJge:-::," :.;:..:~ i'':'':'J.!.''".'1t2 L":":.2.c:"Jn -J~ 2.1':' JL::.2.d.:'..:l:Ss. ?::~?~:-::: :"'::":::5, ~:=:eC3. and ~nusual natur=.l J:- :J?ogra?h'::"~ :2.2.C~r~s. c:.nal Approval from :iealt:-t LJept. .Jc "..;at,:!." 5UP?':? 2.!":.a 5e,:...-2:-2~e-'i':'s,?csa':"'l3-.; :':;:::::.) J. Approval or clact:'ical i~s:~lldt'::"~n :rJffi 30a== J: :::'~ ~::Q2~~ri:==3. ...;.. 3wot"':l stata!D.en': :l:''Jm !?lumoer C8.:-::...::r:..ng :::2.C :::e so:'-:e:r ".13<2'0. .:'..n 3?Si:28 ''::Jnc.3.:''::S 1.:55 :ian 2/ ~O ot ~:: lead. J. Commerc~al jui~ciingl L,dustr~al ju~~d~~g, ~u~:~?~= Lesi~a~ces dne 5~~~~a= ju~:~~~gs and- i:lstallations. a cer':~.::.cat: oi Cod~:.;mp :',ian":2 ':70m 3.!'C:~:': ac ~ ,Jr 2~g:':1ee= responsible for the ~uild.ing. 6. Suomi: ?lanning Soard. Appro1Tal of campl:!::d 5:':2 ?lan requ:::'reme~t3. 3. For existing buildings (?r~or to l~ril ";Jre-ex:'.3tLTlgrr land uses: 1. Acc~rata 5urley or ?roperty 5how:.~g al: ?rJper~? l:.~es, 5:~ee~3. unusual Qatural or :bpographic :=at~~es. 2. A ?rcper1y completed applica::.on and ~ CCC5ea: :0 ~~s?ec: 5i~~ed If a C~rt:.=icata or Occ~?ancy ~5 denied. :ja 3uilj:.~g I2S?ec:or reasons therefor in Nricing to :~e app~~c2~t. 9, 1957) :lon-,.:oni"or:ili:lg '..lses, or . .... Ju::._c~n'.ss 3.na . .... . JU~_J.~:;,g .3.nc. jy :~= appl:'~2nc. :3.ha:: scate :::;.e c. Fees , .. Ce!:'tiii'':3.ca 'Jt Occ'..l?anc~' - ~.Ie~,.; ~':.;e.;...;..':":1g 525.00, .-\.dd':::'::.ons :ci,:.;el2.:.::,?; 3:5 .;JO, Al:erations to dwelli~g 525.00, 3wi~i~2 Addit:..ons to lccessor7' building 525.00. C2r~i:icat= or Occ~pancy In ?re-~xi.5t':::'~g Copy of Cer:i:icace or Occ'..lpancy - .25c Upaa:ed Car~i=icate or Occupancy - 550.CO T~mporar7 Car:ificaea or Occ~pa~cy - lesiae~tial 5L3.00, :ommeroial 5i5.00 ,cal 3:5.JO, Ac=essor:' 3us~=es3es 3S0.~O. 3uill.:::.~z - 3100.JO Ju.:::.2.:':":1g 525.1':;0, o , j . J. _." / 0-_ _ ,__, Ja:~,.~..~o,j..0a,..;;J.CQ7.................. ~ew Consc_CJc...1.on........... Old Or ~ ..-:::-,=X_~,-_!lg 3u__j_:l6................. Location or Property... 1 a.Q.5... ft;,... .l?.\~o.:~~:~..FJt: JS09:-q. . . . . . . . . . . .m@~~. . . . . . . House :io. S t::ee t 3:arc.l e t Onwer or Ow~ers of Properey.. .Ed Wo..f?.~. .t\.~\ .\.e..n(\~.. S.Q.\om.o.n.......... 1000, Section....I.\ 4..... .31oc:<..0 0.0 I..... .'"ot.... Q. Q.tf...... County T~x Map ~o Subdi';i3iun. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :::''::'2:-:' ~'Ia? . . . . . . . . . . . L..:> t. . . . . . . . . . . . . . . . . . . . . . Permie ~o. 3.~5~l~."l.Daea Or per.nit.ld.\~\aW<p.~OO~icancEck(X;),J.d.,Aan&?r.~. %Q\c:m:n :Iealch :)e?c. A~proval.. ..... ......... ......... .:]r:.::.:::-:;-::':2::3 ..l_P9r:;.;:=..:...................,....... ? lanni::~ 3oa=i A~p roval. . . . . . . . . . . . . . . . . . . . . . . . X 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. 32593 Z Date DECEMBER 22, 2006 Permission is hereby granted to: EDWARD & ADRIENNE SOLOMON 508 HARTUNG DR. WYCKOFF,NJ 07481 for : INGROUND SWIMMING POOL WITH RAISED STONE TERRACE, & NEW WALKWAY AS APPLIED FOR. at premises located at 1205 PT PLEASANT RD MATTITUCK County Tax Map No. 473889 Section 114 Block 0001 Lot No. 004 pursuant to application dated DECEMBER 22, 2006 and approved by the Fee $ 150.00 Aut Building Inspector to expire on JUNE ORIGINAL Rev. 5/8/02 r!I~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ I Located at ~ Application Number: I Section: ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ I ~~r!I ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ E!Iii!ffi!~il!lE!~r!I BY THIS CERTIFICATE OF COMPLIANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET - NEW YORK, NY 10038 CERTIFIES THAT Upon the application of upon premises owned by JIM SAGE ELEC. INC. PO BOX 38 GREEN PORT, NY 11944-0038, EDWARD SOLOMON 1205 PI. PLEASANT RD. MATTITUCK, NY 11952 1205 PT. PLEASANT RD. MATTITUCK, NY 11952 3045467 Certificate Number: 3045467 Block: Building Permit: ns11 BDC: Lot: Described as a occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: pool, Outside, PoollSpa, 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 and/or 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 18th Day of September, 2007. Name OTY Rate Ratin. Circuit Im Appliances and Accessories Pooll Spa Bonding Pool Heater Panels o o Gas 100 12 Wiring and Devices Fixture Receptacle Receptacle 20a Pooll Spa Pooll Spa GFel 3 0 3 0 1 0 (Swimming Pool): This certificate covers compliance at the date ofinspection only. Because of unusual environments it is advisable to have frequent test and/or repairs made by a qualified person. seal I of 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. James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0178C Date December 22. 2006 THIS CERTIFIES that the in-ground swimming pool and fence At 1205 Point Pleasant Rd.. Mattituck , Suffolk County Tax Map # 114-1-4 Conforms to the application for a Trustees Permit heretofore filed in this office Dated 3/27/06 pursuant to which Trustees Permit # 6345 Dated 4/19/06 Was issued, and conforms to all of the requirements and conditions ofthe applicable provisions of law. The project for which this certificate is being issued is for an in-ground swimming pool and fence. The certificate is issued to EDWARD & ADRIENNE SOLOMON owner of the aforesaid property. r-c7<~ Authorized Signature 3 J.-s13 z.. TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1 ST [ ] FOUNDATION 2ND [ ] FRAMING I STRAPPING [ ] FIREPLACE & CHIMNEY [ ] RRE RESISTANT CONSTRUCTION ~ REMARKS: ?~ [ ] ROUGH PLBG. [ ] INSULATION [~FINAL Ii ~ [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT PENETRAnON c C?, DATE s-lf--07 INSPECTOR ~ ~L. - ---~---- --- ~--~- -- JfJ-S73 Z- TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING I STRAPPING j)<FINAL [ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPECnON [ ] RRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION REMAR~: I~ ~ ~-b;~ ~, uJ'~'~ft,'~j4 ~ ~ ifF, ~ ~~r~~~~ ~~)~ ~~-?3 , ~) ~~~ ~~ t:v-- hd::~, {~~~~ 3~j DATE If - 1,3J - () 7 INSPECTOR ~ ~ I . . . , " FIELD INSPECTION REPORT DATE I COMMENTS . ~.. \I'll"J '-')~ ~.., tv'" t~ -z ~o c::. . VI ~ . ~. . ~. ~ := ~~ .., ~ 1-' ~ ; ,.. ~ """'l \ LI ...r .-'> E;" FOUNDATION (1ST) . FOUNDATION (2ND) ROUGH FRAMING & PLUMBING --_..._-- ---. -----. INSULATION PERN. Y. ---- STATE ENERGY CODE If--jg- '1 . jO~ I'J. .0 ~ ~ -" -IJ..- /J.,d, ) 0, "'.At ). ,,-4.>\ ~;;Q" (' ~ - -Jo., v (/ __~ ~ FINAL . . .<7JJ~-h7 f~ () ;; k ~ I'\.A V J '" tI- ::::I. AlII A C ()/~O, (jA 1J.. l. ./ " J-./j. J v (If ~t "b ~ . ~ ~ 1--- . ADDITIONAL COMMENTS ....t.... CO.e -;';?Ol'S.....l"u.9'" ,L ~'" 1).Jj~ 8'Q I~~O{,. --- . ----~._---_._.- ..- __...._____m. ~l"J .....~ ~~ 0. .., ~ 15 z := l"J ~ .., := o l"J .. ~ Board Of Southold .Tooo Trustees SOUTHOLD, NEW YORK PERMIT NO. .....5 ~ ~. t. DATE: .!d~.y-. .Z.~.....2.0.01 ISSUED TO ....In.tg1:::;S.cience...~l'e.h..AsS6ciates.;..-In:e; ...oi'i".. behalf ff RO~R T .pELLJaRINI ,t\uh,orti!unOU . Pursuant to the provisions of Chapter 615 of the Laws of the State of New Yon:, 1893: ancl Chapter 404 of the Laws of the . State of New York 1952~ ane! the Southolcl ToWn Ordinance en- . titlecl."REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBUC LANDS ane! the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN. W A TERS:t~, lind in accorclance with the Resolution of The BOarcladoptecl at a meeting held on -.Ma.Y'...24,....zooi ........:... ancl1n consideration of the sum of $.....~.~~~o.o. .... paicl by .~~.~.:.:.!3.~!~~S.~.- R~!?~i!r.r;;h....As.s.oicates.....IJU:~..m.._."";'-...-r.---:._...' T~~~.eram~~1.ti~~;....iirl~......~~..m:~ Y~v:~ su~e:' :;r::;, of Southolcl Town Trustees authorizes. and permits the folloWing:. Wetland Pennit to remove ex~sling n..'Sidence and shed, rc.locale I,he cxisHnr.: '.'Y'ater tower, construct new residence with accessory structures, inst:lll new ~ar.itar,. system lINt driveway. No site disturbance will occur closer Ihan 75' from Ihe wetland btJWldOlY. Staked h.ybaies arounJ lbe lop of lbe bluff during conslnIclioll. al in ac:c:ordance with the detailed specifications as presentecl in . the originating apprlClltion. . IN WITNESS WHEREOF, The said Board of Trustees here- by causes its COI'fXl~at~ S~al to be affJxedi and these P!esents to be su\:isC!1'bed by a .mlIlor1ty of the said Board as of !hls clat.. Tnuim , James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1892 Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD April 19, 2006 Samuels and Steelman Architects 25235 Main Rd. Cutchogue, NY 11935 RE: EDWARD & ADRIENNE SOLOMON 1205 POINT PLEASANT RD, MATTITUCK SCTM# 114-1-4 -'......:; Dear Mr. Samuels: The Board of Town Trustees took the following action during its regular meeting held on Wednesday, April 19, 2006 regarding the above matter: WHEREAS, Samuels and Steelman Architects as agent for EDWARD & ADRIENNE SOLOMON applied to the Southold Town Trustees for a permit under the provisions of Chapter 97 of the Southold Town Code, the Wetland Ordinance of the Town of Southold, application dated March 27, 2006, and WHEREAS, said application was referred to the Southold Town Conservation Advisory Council and to the Local Waterfront Revitalization Program Coordinator for their findings and recommendations, and, WHEREAS, a Public Hearing was held by the Town Trustees with respect to said application on April 19, 2006 at which time all interested persons were given an opportunity to be heard, and, WHEREAS, the Board members have personally viewed and are familiar with the premises in question and the surrounding area, and, WHEREAS, the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the proposal complies with the standards set forth in Chapter 97 of the South old Town Code, 2 WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, RESOLVED, that the Board of Trustees approve the application of EDWARD AND ADRIENNE SOLOMON to construct an in-ground swimming pool and enclosure fence with the conditions that there be a dry well for pool backwash and the two fences in the intertidal area be removed back to the toe of the bluff and all as depicted in the plans prepared by Samuels and Steelman Architects revised 4/27/06. Permit to construct and complete project will expire two years from the date the permit is signed. Fees must be paid, if applicable, and permit issued within six months of the date of this notification. Inspections are required at a fee of $50.00 per inspection. (See attached schedule.) This is not a determination from any other agency. Fees: $50.00 Very Truly Yours, J,m.. Fe 0<' 1r President, Board of Trustees JFK/hkc :::l j:: (j (1 " (1 - c > ) d cc: Inter-Science 'oj :OIl , C 0 ... ~ ~ oJ .J .. ... ~ . 1. '.: ." .. . . ~ New York State Department of Environmental Conservation Division of Environmental Permits Rm 219, Building 40-SUNY Stony Brook, New York 11790-2356 Telephone (631) 444-0365 Facsimile (631) 444.0360 '\ ~ Erin Crotty Acting Commissioner LEITER OF NON-JURISDICTION May 8, 2001 , --' Mr. Robert Pellegrini 4515 Stillwater Road Cutchogue, NY 11935 Re: Pellegrini property, Home Pike Road, Southold, NY SCTM# 1000-114-1-4 DEC# 1-4738-02871/00001 Dear Mr. Pellegrini: Based on the information you have submitted, the New York State Department of Environmental Conservatiol has determined that: The property landward of the 26' elevation contour as shown on the survey of this property prepared by Joseoh Inaeano dated November 1, 1999, last revised Aoril 2, 2001 , is beyond the jurisdiction of Article 25 (Tidal Wetlands). Therefore, in accordance with the current Tidal Wetlands Land Use Regulations (6NYCRR Part 661) no permi is required under the Tidal Wetlands Act, Please be advised, however, that no construction, sedimentation, ( disturbance of any kind may take place seaward of the tidal wetlands jurisdictional boundal)', as indicated above, without a permit It is your responsibility to ensure that all necessal)' precautions are taken to prevent any sedimentation or other alteration or disturbance to the ground surface or vegetation within Tidal Wetland jurisdiction which may result from your project. Such precautions may include maintaining adequate work area between the tidal wetland jurisdictional boundary and your project (I.e. a 15' to 20' wide construction area) or erecting a temporary fence, barrier, or hay bale berm, necessary Please be further advised that this letter does not relieve you of the responsibi ' permits or approvals from other agencies. I I ,I :' John Wieland Permit Administrator .20_ .20_ BUILDING PERMIT APPliCATION.em! Do you have or llOCC11he fbnowing, bofore app BoardofHca1th . 3 sets ofBulldlDgPlaas Survey, PERMIT NO.:~d S ~ '::?Z Chack Sep1io Fonn N.Y.S.D.B.C. Trustees Contact: Mail to: fOWN OF SOUTHOLD IJUlLDING DEPARTMENT rOWN ~~ mumow, NY 11971 l'EL: '/65-1002 !5r.....m"l! !\pproved Disapproved ale , ~ Phone: Buildin8 Inspector ~ <CO<:( Date September 11 .2~+- APPLICATION FOR BUILDING PERMIT. INSTRUcrIONS a. This application MUST be COII!Pl~y filled in by typewriter or in lnk and submitted to the Building Inspector 4 3 sets of plans, aoc:urato plot plan to scale. Fee accordiDgto scb.edu1e. . . b. PlOt plan sbowiDg location of lot and ofbuilcllngs on premises, relationship to a4ioining premises or public streets !Ile8S, and waterways. . c. Tho work covmd by this app1icatlon may not be Qcmwm""ced before issuance of Building Pcanit. d. Upon apptOVlIl of this application, the Bul1dhig ~or will issue a Bul).ding Pcanit to the applicant. Such a p shall be kept on the premises available for inspcctlon ~ the work. e. No building shall be occupied or used in whole or in part for any pUIpOse what-so-cve:r UIItll a Certificate of 0 is issued by the Bui1c1ing Jnspcctor. . . APPUCATION IS BEREBYMADB to the Building Dcpartmcnt.for the issuimcc ofaBuildingPcanit pmsuant to th Bull/ling Zone Ordlnancc of the Town of Southold, Suffolk Ccnmty, New Yotic, and other applicable Laws, Ordinances or R.cgulat:ions, for the construction of buildings, additions, or alterations or for removal or lk:mo1ition as hcrcln described. The applicant agrees to COII!PlY with all applicable laWs, ordinances, building code, housing code, and regulations, and to. admit authorized inspectors -on piemiscs and in builcIing for nccesll8IY .inspections. Robert Pellegrini (SigDaturo of applicant or DlIDIO, if a corporation) c/o Inter-Science Resea~ch Associates, Inc. PO Box 1201, Southampton, NY 11969-1201 (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber. or build OWner EDWARD & ADRIENNE. SOLOMON (as on the tax roll or latest deed) [f applicant is a corporation, signature of duly authorized officer Name of owner of premises (Name and title of cmporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which proposed work will be done: 1205 Pt. Pleasant Road (Home Pike Road) House Number Street Mattituck Hamlet Lot 4 Lot 8 9 10 0 11 ComtyTaxMapNo.1000 Section. 114 SubdivUrionMap of Point Pleasant (Name) Block 1 Filed Map No. 720 , Z. ~tate ~ use and occupancy ofpremis~ and inten<!ed use and occupancy of proposed construction: I a. Existinguseandoccupancy S1ngle Fanuly Residence . lb. Jntendeduseandoccupancy Single Family Residence ..; .. 1 . 3, ature of work: (check which applicable): New Building X Addition Alteration epair Removal Demolition x Other Wark: '<:lo 'W:J f . 4, stimated Cost $475,000,00 (Description) Fee Blank check made payable to "Town of Southo (to be paid on filing this application)enclc Number of dwelling units on each floor only one story is approximately 41' x 20' structure(s) propos 5, dwelling, number of dwelling units 4 garage, number of cars existing gargae 8. business, cOmmercial or mixed occupancy, specify nature and extent of each type of use. Not app Ii cable Reger to site plan (irregular shape) . ensions of existing structures, if any: Front Rear Depth eight A pprox. 25' Number of Stories 1 ' 6. 7. imensions of Same structure with altellltions or additions: Front ' Rear , Not'app11cable - existing residence to be demolished. epth Height Number of Stories '" ' p,;oposed structure will pl;l.ssess irregular s~.<: refer to nnenslons of entire new construction: Front Kear ' _uqJW eight Approx 19" Number of Stories 1 site F 9. ize oflot: Front Approx. 180' Rear Approx, 373'. Depth Approx 400'. . (2.17 acres) Name ofFOIDler Owner Solange Falzone ne or use district in which premises are sitUated R-40 oes proposed ~on violate any zoning law, ordinance or regulation: No Ri ta and Robert ames of Owne.r of premiseS' elleqri ni ame of ArchitectStambert~Aferiat ame of Contractor Burger Construction Will exc;esS :fill be removed from premises: YFR NO. It-necessary ,4515 Stillwater Rd Address...,2>tchoque. NY Phone No. 734-6346 Address 126- 5th AVI:) 't\IV Phone No?, ~ -.,r::r::JtJ :1 Address rnt-t"'hngnA JoJV Phone No. 7":!d_I:\?17 13. 15. this property within 190 feet ofa tidal wetland? *YES x NO wetland Permits - . IF YES, SOUTHom TOWN TRUSTEES PERMITS MAY BE REQUIRED Enclosed. 16. rovide survey, to scale, with acc;urate foundation plan and distances to property lines. Enc losed 17, elevation at any point on property is at 10 feet or below, must provide topographical data on survey. ST TE OF NEW YORK) SS: OF ,) Scott Dobr iner being duly swom; deposes and says that (s)be is the lIJliIHlIlaI1lX agent (Name of individual signing contract) above named, e is the Agent (Contractor, Agent, Corporate Officer, etc.) of s 'd owner or owners, and is duly authorized to perform or have perfonned the said WOIX and to JDlIke and file this applicatit that all statements contained in this application are true to the best ofhis knowledge and belief, and that the WOIX will be p rmed in the manner set forth in the application filed therewith. 200' ~. N