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32959-Z
FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-33235 Filed Map No. Lot No. THIS CERTIFIES that the building ADDITIONS/ALTERATIONS Location Of Property: 1180 SMITH DR S SOUTHOLD (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 76 Block 3 Lot 12.1 Subdivision conforms substantially to the Application for Building Permit heretofore filed in this office dated APRIL 12, 2007 pursuant to which Building Permit No. 32959-Z dated APRIL 27, 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 ADDITIONS AND ALTERATIONS, INCLUDING DECK AND ENTRY PORCH, TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. The certificate iS issued t0 WALTER N GITLIN of the aforesaid building. (OWNER) SIIFFOLR CODNTY DEPARTMENT OF HHAI,TH APPROVAI, N/A ELECTRICAL NO. PLDMBSRS CERTIFICATION DATBD 07/09/08 Date: 08/20/08 3053175 06/02/08 or' ed Signature Rev. 1/81 FORM NO. 4 No: Z-33236 THIS CERTIFIES that the building ADDITIONS/ALTERATIONS Location of Property: 1180 SMITH DR S SOUTHOLD (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 76 Black 3 Lot 12.1 Subdivision conforms substantially to the Application for Building Permit heretofore filed in this office dated APRIL 12, 2007 pursuant to which Building Permit No. 32959-Z dated APRIL 27, 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 ACCESSORY TWO CAR GARAGE AS APPLIED FOR. The certificate is issued to WALTER N GITLIN (OWNER) of the aforesaid building. TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY Piled Map No_ Lot No. Date: 08/20/08 SIIFFOLK CODNTY DEPARTMENT OF HEALTH APPROVAI, N/A ELECTRICAL NO_ 3053175 06/02/09 PLDMBSRS CERTIFICATION DATED i ut rized Signature Rev. 1/81 Form No. 6 - TOWN OF SOUTHOLD ` BUILDING DEPARTMENT TOWN HALL ` ~ rJ 965-1802 i t APPLICATION FOR CERTIFICATE OF OCCUPANCY t----------'~? J 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: 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 wasting buildings (prior to April 9, 1957) noo-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. I£ 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 accessdry 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 D/ate. 7U-l 2z Z.U~7~ New Construction: (Old or Pre-existing Building: V (check one) /+ Location of Property: ~ l ~ J yVl ~'}-L-, l~! l N~ ~~c~ t r ~ cJU t,l~l0 (dam House No. ff Street Hamlet Owner or Owners of Property: l~ (~( }~ r` ~ t ~(- (i ,ti Suffolk County Tax Map No 1000, Section '~ (o Block 3 Lot I L U O I Subdivision Filed Map. Lot: Permit No.~~ Z ~( S4 ~ Date of Permit. I-1- 2l - O ~~ Applicant: doh n ~Je-c }a.n i ~ ld~ T c. Health Dept. Approval: ~- Underwriters Approval: Planning Board Approval: ` Request for: Temporary Certificate Final Certificate: V (check one) Fee Submitted: $ o? ~, (~ - ~- ~ 7 b ~ / Applicant Signature C ~~~33~~ }~GC`~~~~~ BY THIS CERTIFICATE OF COMPLIANCE THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 40 FULTON STREET -NEW YORK, NY 10038 1 a . ~ CERTIFIES THAT ~~ ~~ 3 ' Upon the application of upon premises owned by G & S ELECTRICAL CONTR. P.O. BOX 215 SOUTHOLD, NY 11971, Located at 1180 SMITH DR. SOUTH SOUTHOLD, NY 11971 Application Number: 3053175 WALTER GITLIN 1180 SMITH DR. SOUTH SOUTHOLD, NY 11971 Certificate Number: 3053175 Section: Block: Lot: Building Permit: 0 BDC: ns11 3 a ash Described as a Residential occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: Basement, First Floor, Second Floor, Detached Gazage, Outside, 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 tad Day of Juue, 2008. Narne tL Rate Alarm and emergency equipment Sensor 2 Appliances and Accessories Air Conditioner 3 Dish Washer t Exhaust Fan 1 Furnace 1 Oven 1 Service Service Disconnect: 0 Service1Phase3wService Rating200Amperes Wiring And Devices Disconnect Fixture Outlet Outlet Receptacle Receptacle 3 55 55 91 1 2 Continued on Next Page 0 0 0 0 0 0 0 0 0 0 0 0 1 of 2 Ratine ircuits Twe 0 Carbon Monoxide Above 1500 BTU 1.2 KVV F.H.P Gas 30 Amps 200 cb 31-100 amp Incandescent Fixture Gen, Purpose 30a Dry~eal 20a Appliance This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. 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 G & S ELECTRICAL CONTR. P.O. BOX 215 SOUTHOLD, NY 11971, WALTER GITLIN 1180 SMITH DR. SOUTH SOUTHOLD, NY 11971 Located at 1180 SMITH DR. SOUTH SOUTHOLD, NY 11971 Application Number: 3053175 Certificate Number: 3053175 Section: Block: Lot: Building Permit: 0 BDC: ns11 Described as a Residential occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located in/on the premises at: Basement, First Floor, Second Floor, Detached Garage, Outside, 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 2nd Day of June, 2008. Name ~ Rate Rating Circuits T~ve Receptacle 12 0 GFCI Receptacle 49 0 Gen, Purpose Switch 56 0 Gan, Purpose seal 2 of 2 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. Town Hall, 53095 Main Road P.O. Box 1 ] 79 Southold, New York 11971-0959 ~~o~$uFFOC,~oo o ~~ ~ r W • BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATION Fax (631) 765-9502 Telephone (631) 765-1802 Date: ~ /rJ /Q c~ Building Permit No. -s~o~g ,j Owner: lt~t? ~,e~ ! 9 i LL~ ~ vl (please print) ~ / Plumber: ~~° OY~ ~ ~ ~~ ~7 (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. ~ lum rs Signatur Sworn to before me this ~_ da of `1; L/" 20 U~ \ - L Notary Public, ,~1 ~n (/~ County v~cto L. LOPER Notary PubAt. SqU of New Yak tb.01L06070081 OuaGfred in Sulfdk~yJ~my~~ Canmission Fipiree ~ ~[~ 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. 32959 Z Date APRIL 27, 2007 Permission is hereby granted to: WALTER N GITLIN 1180 SMITH DRIVE S SOUTHOLD,NY 11971 for ADDITIONS AND ALTERATIONS TO AN EXISTING DWELLING & CONSTRUCTION OF AN ACCESSORY GARAGE AS APPLIED PER DEC/TRUSTEES 2 COS REQUIRED W/FLOOD PERMI at premises located at 1180 SMITH DR S SOUTHOLD County Tax Map No. 473889 Section 076 Block 0003 Lot No. 012.001 pursuant to application dated APRIL 12, 2007 and approved by the Building Inspector to expire on OCTOBER 27, 2008. Fee $ 504.00 Aut ure ORIGINAL Rev. 5/8/02 James F. King, President ~pF SO(/j~, Town Hall Jill M. Doherty, Vice-President ~O~ O~ 53095 Route 25 Peggy A. Dickerson l~[ ~ P.O. Box 1179 Southold, New York 11971-0959 Dave Bergen u+ ~c ~ T l h (631) 765 1892 Bob Ghosio, Jr. .'~' ~ ~ O 1 e ep one - ~~COU~'~.o Fax (631) 765-6641 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE # 0341 C Date: August 6, 2008 THIS CERTIFIES that the renovation of existing_dwelling with a first and second floor addition new entry way new decking~QUtters leaders and drvwells, 7' high fencing from house to Qarage and a 20' non-turf buffer area landward of the wetland line At 1180 Smith Drive South, Southold, New York Suffolk County Tax Map # 76-3-12.1 Conforms to the application for a Trustees Permit heretofore filed in this of£-ce Dated 09/15/05 pursuant to which Trustees Permit # 6224 Dated 10/19/05 and Amended on 02/14/07 and 03/19/08 was issued, and conforms to all of the requirements and conditions of the applicable provisions of law. The project for which this certificate is being issued is for the renovation of existine dwelling with a first and second floor addition, new entry, new decking gutters leaders and drvwells Thigh fencing from house to garage and a 20' non- turfbuffer area landward of the wetland line The certificate is issued to WALTER GITLIN owner of the aforesaid property. 'L- a Cy Authorized Signature 3a~s~ James F. King, President Jill M. Doherty, Vice-President Peggy A. Dickerson Dave Bergen Bob Ghosio, Jr. -~ 2 ~ 20~J~ _J February 14, 2007 ~o~~OF SOUjy~yy T • ~O BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Thomas C. Samuels Samuels and Steelman Architects 25235 Main Rd. Cutchogue, N.Y. 11935 RE: WALTER GITLIN 1180 SMITH DRIVE SOUTH, SOUTHOLD SCTM# 76-3-12.1 Dear Mr. Samuels: Town Hall 53095 Route 25 P.O. Box 1179 Southold, New York 11971-0959 Telephone (631) 765-1592 Fax (631) 765-6641 The following action was taken by the Southold Town Board of Trustees at their Regular Meeting held on Wednesday, February 14, 2007: RESOLVED, that the Southold Town Board of Trustees APPROVE the amendment to Permit # 6224 to construct a new entry on the north side of the house with dormers above on the existing structure, removal of the terrace on the south side of the house, and increase the size of the existing deck on the south side of the house, and all as depicted on the plans prepared by Samuels and Steelman Architects revised 2/5/07. This is not a determination from any other agency. If you have any questions, please call our office at (631) 765-1892. Sincerely, v ~~ James F. King President, Board of Trustees JFK/hkc Board Of Southold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. ~p~,~..A .....:.. DATE:._.october 1_9.,.2005 Walter Gitlin ISSUED TO _ ...................~....._..............:,..........:......................:... _....._.............................. _........._ .~u~l~nrt~tt~inn __ Pursuant to the provisions of Chapter b 15 of the Laws of fhe. State of New York, 1893; and Chapter 404 of the laws of-the State of New York 1952; and the Southold Town Ordinance en- titled :"REGULATING AND THE -PLACING. OF OBSTRUC~L(3NS IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, 6RAYEL OR OTHER MATERI;4LS.F$OM LANDS .UNDER TOWN WATERS;'•..'. and: in accordance with 'the Resolution of The Board adopted at a meeting held on __octobe~_ 1.9 2005_. and in consideration of the sum of j_,250..00.__... paid by Walter Gitlin r •~ - of ...................:.Southold........__._........_..........._._.. N. Y. and. subject to the Terms and Conditions listed on the reveroe side hereof, of Southold Town Trustees authorizes and permits the following: i Wetland Permit to renovate the existing residence with a first and second floor addition and new on- d I grade stone terrace with the conditions of drywalls to contain roof runoff, haybales during wnstruction, and a 20' non turf buffer landward of the wetland line, and all as depicted in the plan prepared by !~ Samuels and Steelman and last dated 9/9/05. all'in accordance with the detailed specifications as presented in the originating application. •x IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be affixed, and these presents to be sukiscn'bed by a -majority of the said Board .as of this date. Poliwoda __'_- Art9kU1'dster (absent) ' Trura!as New York State Department of Environmental Conservation Division of Environmental Permits, Region One SUNY@Stony Brook; 50 Circle Road; Stony Brook. NY 11790-3409 Phone: (631)444-0365 F.vC:(631)444-0360 Website: www.dec.state.ny.us PERMIT MODIFICATION Mr. Walter Gitlin 1180 Smith Drive South Southold NY 11971 Dear Permittee: March 6, 2007 NYSDEC #1-4738-00743/00003 Gitlin Property 1180 Smith Drive South Southold NY SCTM # 1000-76-3-12.1 Permit Expiration: 3/21/2011 v Your recent request to modify the above permit has been reviewed pursuant to 6 NYCRR Part 621 (Uniform Procedures Regulations). It has been determined that the proposed modification will not substantially change the scope of the permitted actions or the existing permit conditions. Therefore, the permit is modified to authorize: Renovation of the existing single family dwelling, elimination of the terrace, construction of a deck, front entry, garage, reconfiguration of the driveway and removal of a portion of it. All work shall be performed in accordance with the plans prepared by Thomas C. Samuels last revised on 2/5/07, and stamped NYSDEC approved on 3/6/07. This letter is a modification to the original permit, and as such, shall be available at the job site whenever authorized work is in progress. All other terms and conditions remain as written in a original permit. John A. Wieland ~~ Deputy Regional Permit Administrator cc: Samuels & Steelman Architects Marine Habitat Protection file DEC PERMIT NUMBER FACILITY/PROGRAM NUMBER(S) v_ PERMIT Under the Environmental Conservation Law EFFECTIVE DATE EXPIRATION DATE(S) March 21, 2011 I TYPE OF PERMIT ^ New ^ Renewal ^ Modification ^ Permit to Construct ^ Permit to Operate ~ ^ Article 15, Title 5: Protection of Wa- ^ 6NYCRR 608: Water Quality ^ Article 27, Title 7; 6NYCRR ters Certification 360: Solid Waste Management ^ Article 15, Title 15: Water ^ Article 17, Titles 7, 8: SPDES ^ Article 27, Title 9; 6NYCRR Supply 373: Hazardous Waste Management ^ Article 19: Air Pollution ^ Article 15, Title 15: Water Control ^ Article 34: Coastal Erosion Transport Management ^ Article 23, Title 27: Mined Land ^ Article 15, Title 15: Long Reclamation ^ Article 36: Floodplain Island Wells Management ^ Article 24: Freshwater Wetlands ^ Article 15, Title 27: Wild, ^ Articles 1, 3, 17, 19, 27, 37; Scenic and Recreational Rivers ^ Article 25: Tidal Wetlands 6NYCRR 380: Radiation Control PERMIT ISSUED TO TELEPHONE NUMBER Walter Gitlin ADDRESS OF PERMITTEE 1180 Smith Drive South, Southold NY 11971 CONTACT PERSON FOR PERMITTED WORK TELEPHONE NUMBER Samuels & Steelman Architects, 25235 Main Road, Southold NY 11971 631 734-6405 NAME AND ADDRESS OF PROJECT/FACILITY Gitlin Pro ert , 1180 Smith Drive South, Southold NY LOCATION OF PROJECT/FACILITY SCTM # 1000-76-3-12.1 COUNTY TOWN WATERCOURSE NYTM COORDINATES Suffolk Southold Goose Creek E:716.2 N:4546.9 Description of Authorized Activity Renovate and construct additions to the existing single family dwelling, a new garage, deck, two terraces, and remove a portion of the existing driveway. All work shall be performed in accordance with the plans prepared by Samuels & Steelman Architects last revised on 1/20/06, and stamped NYSDEC approved on 3/22/06. By acceptance of this permit, the permittee agrees tnat the permn is connngenr upon smcc compuancn wim me ~~~, eu eppucaoie regulaGOns, the Gener,.l Conditions specineo (see pines z_- at ane any opecrar ~onamons mauueu as pan ui uus pou„n PERMIT ADMINISTRATOR: ADDRESS Bldg. #40, SUNY, Stony Brook, NY 11790.2356 Jo .Wieland MRP ~THO IZEDSIG ATURE ~.~-^"' DATE --~-° "`"- Page 1 of 4 ~`~ ~ March 22, 2006 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION SPECIAL CONDITIONS 1. The storage of construction equipment and materials shall be confined to within the project work site and or upland areas greater than 50 linear feet from the tidal wetland boundary. 2. Necessary erosion control measures i.e., haybales, silt fencing, etc. are to be placed on the downslope edge of any disturbed area. This sediment barrier is to be put in place before any disturbance of the ground occurs and is to be maintained in good condition until thick vegetative cover is established. 3. Disturbance to the natural vegetation or topography greater than 25 feet seaward of the approved structure is prohibited. 4. During construction, concrete or leachate shall not escape or be discharged, nor shall washings from transit mix trucks, mixers, or other devices enter tidal wetlands and or protected buffer areas. 5. Roof runoff shall be directed to drywells a minimum of 100 feet landward of the tidal wetland boundary for immediate on-site recharge. 6. Removal of the portion of the driveway must occur within six (6) months of the commencement of project activities. 7. All fill shall consist of "clean" sand, gravel, or soil (not asphalt, flyash, broken concrete or demolition debris). 8. All areas of soil disturbance resulting from this project shall be stabilized immediately following project completion or prior to permit expiration, whichever comes first. The approved methodologies are as follows: a. stabilization of the entire disturbed area with appropriate vegetation (grasses, etc.). b. temporarily stabilized with straw or hay mulch orjute matting or other similar natural fiber matting within 1 week of final grading. Temporary stabilization shall be maintained until a mature vegetative cover is established. 9. If seeding is impracticable due to the time of year, a temporary mulch must be applied and final seeding performed at the earliest opportunity when weather conditions favor germination and growth, but not more than six months after project completion. 10. This permit does not authorize any alteration, expansion or replacement of existing septic systems. 11. There shall be no disturbance to vegetated tidal wetlands or protected buffer areas as a result of the permitted activity. 12. Any debris or excess material from construction of this project shall be completely removed from the adjacent area (upland) and removed to an approved upland area fordisposal. No debris is permitted in tidal wetlands and or protected buffer areas. 1E4738-00743/00003 I I PAGE 2 OF 4 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION NOTIFICATION OF OTHER PERMITTEE OBLIGATIONS Item A: Permittee Accepts Legal Responsibility and Agrees to Indemnification The permittee, excepting state or federal agencies, expressly agrees to indemnify and hold harmless the Departrnent of Environmental Conservation of the State of New York, its representatives, employees, and agents ("DEC") for all claims, suits, actions, and damages, to the extent attributable to the pemnttee's acts or omissions in connection with the permittee's undertaking of activities in connection with, or operation and maintenance of, the facility or facilities authorized by the permit whether in compliance or not in compliance with the terrns and conditions of the permit. This indemnification does not extend to any claims, suits, actions, or damages to [he extent attributable to DEC's own negligent or intentional acts or omissions, or [o any claims, suits, or actions naming the DEC and arising under Article 78 of the New York Civil Practice Laws and Rules or any citizen suit or civil rights provision under federal or state laws. Item B: Permittee's Contractors to Comply with Permit The pemtittee is responsible for informing its independent contractors, employees, agents and assigns of their responsibility to comply with this permit, including all special conditions while acting as the pemtittee's agent with respect to the permitted activities, and such persons shall be subject to the same sanctions for violations of the Environmental Conservation Law as those prescribed for the pemrittee. Item C: Permittee Responsible for Obtaining Other Required Permits The permittee is responsible for obtaining any other permits, approvals, lands, easements and rights-of--way that may be required to carry out the activities that are authorized by this permit. Item D: No Right to Trespass or Interfere with Riparian Rights This pernut does not convey to the pemuttee any right to trespass upon the lands or interfere with the riparian rights of others in order to perform the permitted work nor does it authorize the impairment of any rights, title, or interest in real or personal property held or vested in a person not a party to the pemtit. GENERAL CONDITIONS General Condition 1: Facility Inspection by the Department The permitted site or facility, including relevant records, is subject to inspection at reasonable hours and intervals by an authorized representative of the Department of Environmental Conservation (the Department) to determine whether the pemnttee is complying with this permit and the ECL. Such representative may order the work suspended pursuant to ECL 71-0301 and SAPA 401(3). The pemtittee shall provide a person to accompany the Departtrtent's representative during an inspection to the permit area when requested by the Department. A copy of this pemrit, including all referenced maps, drawings and special conditions, must be available for inspection by the Department at all times at the project site or facility. Failure to produce a copy of the permit upon request by a Department representative is a violation of this permit. General Condition 2: Relationship of this Permit to Other Department Orders and Determinations Unless expressly provided for by the Department, issuance of this permit does not modify, supersede or rescind any order or detemunation previously issued by the Department or any of [he terms, conditions or requirements contained in such order or detem¢nation. General Condition 3: Applications for Permit Renewals or Modifications The pernilttee must submit a separate written application to the Departnent for renewal, modification or transfer of [his permit. Such application must include any forms or supplemental infom~ation the Department requires. Any renewal, modification or transfer granted by the Department must be in writing. The permittee must submit a renewal application at least: a) 180 days before expiration of permits for State Pollutant Dischazge Elimination System (SPDES), Hazardous Waste Management Facilities (HWMF), major Air Pollution Control (APC) and Solid Waste Management Facilities (SWMF); and b) 30 days before expiration of al] other permit types. Subarission of applications for permit renewal or modification aze to be submitted to: NYSDEC Regional Permit Administrator, Region 1, SUNY Bldg #40, Stony Brook NY 11790-2356 General Condition 4: Permit Modifications, Suspensions and Revocations by the Department The Department reserves the right to modify, suspend or revoke this pemut in accordance with 6 NYCRR Part 621. The grounds for modification, suspension or revocation include: a) materially false or inaccurate statements in the permit application or supporting papers; b) failure by the pemuttee to comply with any [emus or conditions of the pemilr, c) exceeding the scope of the project as described in the permit application; d) newly discovered material information or a material change in environmental conditions, relevant technology or applicable law or regulations since the issuance of the existing pemtit; e) noncompliance with previously issued pemut conditions, orders of the commissioner, any provisions of [he Environmental Conservation Law or regulations of the Department related to the pemiltted activity. DEC PERMIT NUMBER PAGE 3 OF 4 1-4738-00743/00003 NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION ADDITIONAL GENERAL CONDITIONS FOR ARTICLES 15 (TITLE 5), 24, 25, 34 AND 8 NYCRR PART 608 (TIDAL WETLANDS ) 1. If future operations by the State of New York require an alteration in the position of the structure or work herein authorized, or if, in the opinion of the Department of Environmental Conservation it shall cause unreasonable obstruction to the free navigation of said waters or flood flows or endanger the health, safety or welfare of the people of the State, or cause loss or destruction of the natural resources of the State, the owner may be ordered by the Department to remove or alter the structural work, obstructions, or hazards caused thereby without expense to the State, and if, upon the expiration or revocation of this permit, the structure, fill, excavation, or other modification of the watercourse hereby authorized shall notbe completed, the owners, shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore to its former condition the navigable and flood capacity of the watercourse. No claim shall be made against the State of New York on account of any such removal or alteration. 2. The State of New York shall in no case be liable for any damage or injury to the structure or work herein authorized which may be caused by orresult from future operations undertaken by the State for the conservation or improvement of navigation, or for other purposes, and no claim or right to compensation shall accrue from any such damage. 3. All necessary precautions shall be taken to preclude contamination of any wetland or waterway by suspended solids, sediments, fuels, solvents, lubricants, epoxy coatings, paints, concrete, leachate or any other environmentally deleterious materials associated with the project. 4. Any material dredged in the conduct of the work herein permitted shall be removed evenly, without leaving large refuse piles, ridges across or along the bed of a waterway or floodplain, deposits within any regulatory floodway, or deep holes that may have a tendency to cause damage to navigable channels or to the banks of a waterway. 5. There shall be no unreasonable interference with navigation by the work herein authorized. 6. Ifupon the expiration or revocation ofthis permit, the project hereby authorized has not been completed, the applicant shall, without expense to the State, and to such extent and in such time and manner as the Department of Environmental Conservation may require, remove all or any portion of the uncompleted structure or fill and restore the site to its former condition. No claim shall be made against the State of New York on account of any such removal or alteration. 7. If granted under 6NYCRR Part 608, the NYS Department of Environmental Conservation hereby certifies that the subject project will not contravene effluent limitations or other limitations or standards under Sections 301, 302, 303, 306 and 307 of the Clean Water Act of 1977 (PL 95-217) provided that all of the conditions listed herein are met. 8. At least 48 hours prior to commencement of the project, the perrnittee and contractor shall sign and return the top portion of the enclosed notification form certifying that they are fully aware of and understand all terms and conditions ofthis permit. Within 30 days of completion of project, the bottom portion of the form must also be signed and returned, along with photographs of the completed work and, if required, a survey. 9. All activities authorized by this permit must be in strict conformance with the approved plans submitted by the applicant or his agent as part of the permit application. Such approved plans were prepared by Samuels & Steelman Architects last revised on 1/20/06. DEC PERMIT NUMBER PAGE 4 OF 4 1-4738-00743/00003 t ,. ~ ) 2 0~ i _J J Date: January 19, 2008 JAMES J. DEERKOSKI, P.E. 260 Deer Drive Mattituck, N.Y. 11952 (631)298-7116 To: Town of Southold Building Dept. Re: Framing/ Strapping/ Plumbing/ Fire Caulk Ir _ ~~ions Gitlin 1180 Smith Dr. S. Southold, NY Pennit# 32959 To Whom It May Concern: A Framing, Plumbing, Fire Caulking, and Strapping inspections was preformed on the above property, and it is deemed that all this work was done as per plan and meet all state and local building codes. A Pressure test was also performed on the entire Plumbing System. Any other questions please feel free to call. JAMES J. DEERKOSKI, P.E. 260 Deer Drive Mattituck, N.Y. 11952 (631)298-7116 Date: October 30, 2007 To: Town of Southold Building Dept. Re: First & Second Foundation Inspections Gitlin 1180 Smith Dr. S. Southold, NY Permit#32959 To Whom It May Concern: . ,, ___. _ iJ~~ g ~ T J iJ r,_ - First and Second Foundation inspections was preformed at the above-mentioned construction site, and the damp proofing was installed correctly and meets all state and local building codes. Any other questions please call. f\ Sitlcerely James ~~~eerkoski ~~ ,:; Z~ s~~ TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ]FOUNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ] 1 CATION [ ]FRAMING /STRAPPING [ FINAL [ ]FIREPLACE 8~ CHIMNEY [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT CONSTRUCTION [ ]FIRE RESISTANT PENETRATION ~~( 7~ TOWN OF SOUTFIOLD BUILDING DEPT. 765.1802 ~o~NOf SOUfy~~ ~~L-'~" "~ kJ G ~ ~ INSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING /STRAPPING [ ]FIREPLACE 8~ CHIMNEY [ ]ROUGH PLBG. [ ] INS~JLATION [ ti]" F/INAL [ ]FIRE SAFETY INSPECTION [ ] FlRE RESIS~IT CONSiRUC1'ION [ ]FIRE RESISTANT /~ REMARKS: ~ ~(' l ~t"i r~ DATE INSPECTOR TOWN OF SOUTNOLD BUILDING DEPT. 765.1802 1 NSPECTION [~ UNDATION 1ST [ ]ROUGH PLBG. [ ]FOUNDATION 2ND [ ]FRAMING /STRAPPING [ J FIREPLACE 8~ CHIMNEY [ ]INSULATION [ ]FINAL ( ]FIRE SAFETY INSPECTION DATE INSPECTOR [ ] FlRE RESISTANT CONSTRUCTION [ ] FlRE RESISTANT PENETRATION TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 1 NSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING /STRAPPING [ ]FIREPLACE 8~ CHIMNEY [ ]FIRE RESISTANT CONS'iRUC1 REMARKS: [ ]ROUGH PLBG. [ SULATION [ ]FINAL [ ]FIRE SAFETY INSPECTION [ ]FIRE RESISTANT PENETRATI01 1 ~..J DATE a Q INSPECTOR ~~~~ FIELD INSPECTION REPORT DATE COMMENTS ' ~F~-~, ~ FOUNDATION (1ST) ~ V _ ~ y ~ ------------------------------------ ~ /(1 ~ ~e '~ FOUNDATION (2ND) ~ ~ ~ ~ z /l~- © ~~ o ROUGH FRAMING & ~ PLUMBING _. ~ G ~'~ -1 INSULATION PER N Y - - - - V . . STATE ENERGY CODE ~ ~3 I C ~. 3 coJ ~ ~' FINAL ~~ A~ ~ ~ r _- 6~ /i/ 1 ADDITIONAL COMMENTS a~ =- ~ c2J <0 _ ~ _ ~ Z A __ ~ n ~' ---- _ t~ - ~ >C ro - - ~ __ -- - ~ y O O o<` 2 - - ~~ d ' - ~ ~ b y ^-, L _, r t SUMMARY REPORT P.eeen. oe.e.mu~n UNIFORM RESIDENTIAL APPRAISAL REPORT Eae xo. NF7003 Pro n Addess 1180 SmiM Drive Broth c' swMaa Stale NV 'Cade 11971 L I Desm bn DisMd'. 1000 Section'. 78 Black'. 3 Ld: 12.001 SMSAp5360 Cam $drdk Assessofs Parcel NO. N/A Tax Vear O6N] RE Taxesf 5272.56 5 ecbl ASSessmenlsi None Borrower N/A Cueenl Owner N/A 0¢u ant X Owner TeiMm Vacam Pro htsa abetl X Fee Si b LeawleM Pro'MT a PUD Contlominbm HUDNA On HORS Nme Aio. Ne' hbahoo0 a P 'x1 Name N/A Ma Rderence H M 28 H 41 Cenws Trad 1702.01 Sob Hire S N/A Date of Sale N/A De bn aM S amoud d ban cha s/corrcessbns to be tl Bela NIA L¢ntlerlCkenl Samuels antl Steelman Address 25235 Mom Road Culch ue, NV 11835 A raiser Dmatl G. StirrMreis Atltlress 236 L Isl entl Avenue Hdlstille N V 11742 Lrcatbn G018n X Sububan Rural BuiN up ^ Over 75% X 2545% ^ Under 25% Growth rate ^ Rapb X SMbb Skxv Pradrwnlnsm xcuParwy %^ Owner 51 le lsray housing PRICE A~ 300 Low New Rresertllentl use% One bmiy 80% 2-4lamiy Lentl use change X Not Xkety ^ ^kely g In process Property values ^ Increasing X Stabb OecXnkg Terem 6000 H' h 10M MliNamNy To. DemanNSUppty ShaRage ~ Mba6rs O.esgpy X VaraNp59N Predonknam '-. Comnwrcial 2% Markel time UiMa3 mos. X 3L mos. Overb mos. v®x 575 40 VedWwr 16% NOG: Race antl Me racial composlUOn of rlx neiphborlpod are np appraisal Yacton. Neighborhootl boundaries and charaderislics'. The boundariesdlhe soli rl9 hbahaod ae Man Raatl to Ma naM Teen Creek to 6ia eas H Neck m Me south antl Richmontl Creek to Me west. Factors Thal aped the marketabil4y o! the properties in the nelghborhoatl (praximey b empbymenl and emenaies, empbynx±nl alabilAy, appeal to market, etc): The auti acts na hbarhootl is redaninedl tom Rsritl d sin a tamil horrlea wmourxle0 farm Ientl tin vtls antl nuaerim. The subject has acmes m al rwcas su fedlides inclutlin sdrods sh uDlk bvaclbs marines arM recreadm fadll6es. Public Iren im to New Vak C is Eatl the Lm Islerxl Reil Roatl. SaMdd Tovm'a ecmank base is cvn d rimtlure fladn rounam and retal tretle Suffdk Coo has a tlivaree ecanam wiM stable am I ment. In recent rs Ma unem I merrc in SuNdk Ca has remanetl baow the national a because d oD roMh in tIV hi h lath antl servim industries. There are no known etlverse fedora that wauW n eflep the suD'ecl nei hbahootls cotl medca Markel conditions in the subject neighbarhoatl (including support for the abore condusbns related la IDe trentl d popeRY vaues, tlemantllwppy. antl marketing time - ~ such as data on competillve propertbs for sale in the neighborhood, description of the prevalence of sales antl financing concessions, eta): A review d sae transadims rewtlad in the $ufldk Ca Clerks offlm end z+a Me MuIU le Lislin SvMm d Lm Island ehovrs tea told been increasin ham Janu 1998 b June 2005. MJD a Lislin Service tlaa ea well es dlscussiona wAM local Drakes iMicales the the rites have becarle eleble antl lha ice txwse sots in 3 to 6 mmms. The skan ecmanic aM sacia corgiems a the im a with no adverse imluerKes a eNtlence d ai wise trentls a the went time, the oxeral outlook la Mena hbahaxl shwld remain s Pmjed In/ormetion ror PUDS (If applkabbl ~ - Is the developer/builder in comrel of the Home Owners' Association (HOA)? VES % NO Approximate trial number of oohs in the subject project N/A Approximate mlal number of units for sale in the subjett project N/A Describe common elements and recreational facilhies: N/A Dimensions 107 x 301 x 145 x 239 Topography Gvm SI n SNe area 70 Acre Lamr Ld Yes % No SpecHk zoning classification and description R 40 Residanm-Sin le Famil Zmbg wmplbnce ^Legal X^LeganaxnYUmgIGr4Maewedusel Illegal No zonig H' hest 8 best use as i roved: % Present use qha use ex bin Size T cal Fa The Area Shape Sli hll In ular Drainage A sAd use View Game Creek Utilities Publk OMer EledricNy X 100 Am C B. Gas X Wales X Sanitary sewer Ceas Slam sewx X OlFSite lmpmvemems Type Pubk PrNate Sired Asphat X CuNlguner Nme Sidewalk None Streetlights Nme ANe Nme tantlsrap:g T 'cal Dmreway Solace A at Apparent easements NmaA enl FEMq SDecbl Fkwtl Hazam Area X Yes Na FEM4 Zane AE Map Date 05Nal8B FEMA Ma No. 38103C0168G Comments (apparent adverse easements, encroachments, special assessments, slitle areas, ilbgal or legal nonconforming zoning, use, etc ): See abchetl edtlaTtlum. GENERAL OESGRIPTION of Unns 1 No E%TERIOR DESCRIPTION Fauntlation Pauretl Comreb FOUNDATION SMD Vea BASEMENT Area Sq.Ft. 927 INSULATION Rod R 11 x . No. of Sloiies 112 Type (Da.lAtq Daechetl Design (Style) C ExbtingrProposetl ExisD qge (YrsJ 34 Efledae a rs. 10.15 Ener'n Walls Mnl Roof Surface NShi b Gmlersb Dwnspls. Aluminum Window Type Dwbb HU StaMSaeens lhrrmeVVae/Yee Mandaduretl Hauw No OvN Spare Nme Basement Vea 9mp Pump Nare Dampness Nme Nded 5dtlenem Nme Nde0 IntesMtbn Nme Nokd %Finhhed 0 Ceiling NIA Walh NIA Fba N/A gatideEmy Vea CeBig Endose0 Walls Endose0 Fbor Norio Nane X ROOMS Fo LNb Dbb KAChen Oen Fami Rm. Rec. Rm. Bedrooms 1 BaNS Laund gher Area .Ft. ga~x 927 Leve11 1 1 1 1 1 927 Level2 E Atlic 883 Fbhhed area above rode contains: 4 Rooms; 1 6eboom s ; 1 Baths ; 1 590 u are Fed of Gross Lhi Area INTERIOR MateiiahlCmtlbbn Fbars Wood, Ca Mn I HEATING Type Hd water KITCHEN EQUIP. Rehigvalor %^ gTTIC Nme ^ AMENITIES Fiepbce(s)l1 ^X CAR STORAGE Nom ^ Wok 0 all Fuel ql RangelOven X^ Stais o Patio ^ GAn Ndcars TriMFinish Wood CadiioMV Dispowl ^ qop Sla'r ^ Deck Wood ^ ac ~ % Bath Wxnscd Cxemb Tib Ce0dmIlN New ~amHOOd ~ ly ~~ Fborb U ^ Fezeh ^ enlMd Doors Woad !blow Cae ghat Nara Microwave Heated Pod Laryon Ald Me ebwa vein sad mkidan. CuibilbMJIA Washer! X Finished Orivewa Vas Adtllional feaures (special energy efhcbnt items, etc.!'. Thve is en tleda etDC Met H finished wmltl atltl mate 863 uare fad d addttima livin s ace. Condition of the improvements, depreciation (physical, lundional, and exlernaq, repairs needed, qualKy of mnslmdion remodelinglatlditions, etc'. See a~hetl atldentlum. Adverse envkonmenlal conditons (such as, but not limited lo, hazartlous wastes, toxic substances, etc.) present in the Improvements, on the site, or in the immediate vicinity of the subject property', NOknoxna sent atlverse enNroanenta wWilima were rrotvlaMeDmedins 'm Mal vmultln 'vet affed Me vauedthe Nthe client hasacmcem a uelihetl anvirmmenlal should be wleulted. r~~wr wmro ass PAGE 10F2 rwweuar rm~roa ssr a~~.ee.,,.o xn,mwe aenu~ n,...:.m..«n SUMMARY REPORT M.a,.a.. 5...1.,., UNIFORM RESIDENTIAL APPRAISAL REPORT Flls NO. NF7003 ESTIMATED 517E VALUE ................ = t 1000,000 ESTIMATED REPRODUCTION COST~NEW OF IMPROVEMENTS: DxNling 1,590 Sq. FL ~ S 13500 = f 214,650 Bsml. 927 Sq. F1 ®3 30.00 = 27,810 Comments an Cost Approach (such as, source of cost estimate, site value, square loot calculation and for HUD. VA and FmHA. the estimated remaining economk life of the propenyp. Tha eelimele0 re raductlm costs ere cansitlaetl canmm mtl 'csl Fi bce, Deck, Cass Drt - 35,000 for this arcs. They were dedeed Oy surve in local builders. Those Garega'Capal 833 Sq. Ft. ~ t 50 W = 31,850 web ae sl nifirab hi bar that dha aem d SuNdk Can because 3 309 110 Total Estimated Cost New d the Me lack d cam dhim m the North Fork d Lm Isbnd. The .... ..... Less 75 Ph kal Furational External Est. Remain Econ. LAe: 82 ~ IBa method destimebn h aicel de mecietian was usetl in Chia 50 000 DePecktm E50 000 - f reiael. Tile eub'ect has a remainin emnanic life d 48 to 50 eas. ............... f 259,110 Depreciated Value of Impmremems Tha tldla arwunl d the e#artel W recielim is attrtbNetl to the sub'ed .... 'AS-is Valved Site lmpmvemems .......... f 5,000 Owelll antl atlachal im raremeMa ml INDICATED VALUE BY COST APPROACH ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ = t 1284100 ITEM SUBJECT COMPARABLE N0.1 COMPARABLE N0.2 COMPARABLE N0.3 1180 Smith Drive South Aadess smlhaa Proximh b Sub'ed Saks Pdce f N/A f f t PricdGross lH. Area f 000 m 3 9J f QI f m Data anNa Ver'dFalkn sources Carps lnc Ins ecem VAWE AD1lISTEENiS DESCRIPTION DESCRIPTION .HS DESCRIPTION .Ilse DESCRIPTION .HS Saks or Financing CaaR55iDM NYA ~ ~~ Date of SaWTime NIA LOtdtbn A e lice - Fee Sim le She ]O ACre Vkw Goose Creek De' natMA al C dcamumon Ava e e 34 Veers Contlhbn Gab Above Gratle rm : eene ' awe row : eenrs ' earn rm' sane ' see raa : ewne ' sale Roan Cmnl 4~ 1~ 1.00 Gmss LNi Area 7 590 5 Ft. 5 .Ft. S .Fl. Ft. BasenX+A EFnNetl Rmms Bebw Grade 927 S9F1. UrKmshetl ' Funa'ronal Uil' Aser e Heat ooNn Oil Hd wale E Elfmdhems Thermal Windows Gera elCar rt 2 Ca Att ParA, Pdk. Deck, Fee kce s.elc. Deck 1Fir lace Fence. Pool, etc. Nme Miscalkneous Nme ~ Nd Ad'. cob 0 X . ' 3 X . ' f 0 % ' f 0 ARASIed Saks Pace a1 COm rabk Gross: 0:0% NN: QO1i f 0 (AOrs: 0.8% 'FM: '.0. f 0 Gross: 0.0% Net: 0.016 f 0 Comments on Sales Comparison (including the subject property's compalibilAy to the neighborhood, etc. ~: See attached addendum ITEM Dale, Price antl Data SarteM pvwks wshk da I SUBJECT No iramfere in Vie pasta yeas. COMPARABLE N0.1 COMPARABLE N0.2 COMPARABLE N0.3 Analysis of any anent agreement o! sak, opikn, a lislkg d the wbject property antl anaFjsk of any pM saksdabjaiandmnpaabts wshk ore yeadihe tlale dappasak Title to Na su 'ed r has nor been can within the lest 3 To the best d m knaNed a me sub'ed is Iwt mrtentl lisletl mr has it been in Me lest 12 mmms. INDCATED VALUE BV SALES COMPARISON APPROACH ......... ............... ..... ....... , f N/A MICATm VALUE BY INCOME APPROACH ble EAimatetl MaM1et Remf N/A RAO.x Gmss Rert 'kr N/A =3 0 This appraisal6 made % 'asK wbjecllofhe repels, aleretbm.6sPecdwa aaxtlibm (sled OeUw wpjm to anpMkn Pa Pkre and yerhalkm. Cmdlkm dApPa'sal'. Tnis is a cam ale aisd reamte0 in a summ forma. All mm~N limaelbns .Tile tared assumes a caNlicafe a( acm m a cam lance eXlsts fa the au0eci im rneneMS. Final Reconciliation It is m inim ihal the total estmated lecemml mst of Ne sirudure less the h icel de redeb is E259,2 W. The puryose of this appraisal is la estimate the maAel value of the real property that is the wbJed d fhb report, bawd an the above contldkns antltMmMCalkn misigd antl limiting mMhions,aM market value definition that ore 4aletlnbe anaied Fredie Mac Form 4l9Fanre Mae Fwm 1001~1poised 6IB:1 I. IOVEI ESTNVITETIE MARKET VALUE, AEDEFINEO, OF THE REAL PROPERTY TINTIS THE SUBJECT OFIH5REIVRT,A50F 02232007 (WHp115TIE DATE OFINSPECTION ANOTHE EFFE TE OFTHS REPORTS TO BEf N/A APPRAISER: ,/ SUPERVISORVAPPRAISER (ONLYIF REOUREq: S aw ~1Qgys,Ia7 ~ Spnature ^DM ^D'd NOI Nanle D eltl G. Stirmveis GG~r Nane I^Wed PmpalY Date Report Sknetl 03H 3200] Oale R 5' netl Slate CafdNalkn a 45000023431 Sbie NV Sbte CenRCadan 1 Sbte Or Sate Licensed Sbte Or Sbb Liceme d Slate rremeas rmmm e~ss YAUt L UY L .an: wa..m iw o.. Pae~. wq nu see. m]v n n e~.awm.,m~ APPRAISAL SERVICES Permit q Permit Date REScheck Software Version 3.7.3 Compliance Certificate Project Title: The Gitlin Residence Report Date: oa/os/o7 Data filename: Z:\Common autocad filesWCTIVE PROJECTS\Gitlin\Gitlin.rck Energy Code: Location: Construction Type: Heating Type: Glazing Area Percentage: Heating Degree Days: Construction Site: 1180 Smith Drive South Southold, NY 11971 New York State Energy Conservation Construction Code Suffolk County, New York Detached 1 or 2 Family Non-Electric 20°k 5750 Owner/Agent: Walter Gitlin 1180 Smith Drive South Southold, NY 11971 Designer/Contractor: Tom Samuels Samuels and Steelman Architects 25235 Main Road Cutchogue, NY 11935 631-734-6405 Cnmpunnce: Passes Maxin,un, UA: 529 Your Home Ua~ 494 --> 6.6°I° Better Than Code {UA) Ceiling 1: Flat Ceiling or Scissor Truss: 1664 30.0 0.0 58 Wall 1: Wood Frame, 16" o.c.: 2700 19.0 0.0 129 Window A: Wood Frame:Double Pane with Low-E: 13 0.330 4 Window B: Wood Frame:Double Pane with Low-E: 14 0.330 5 Window C: Wood Frame:DOUble Pane with Low-E: 20 0.330 7 Window D: Wood Frame:Double Pane with Low-E: 19 0.330 6 Window E: Wood Frame:Double Pane with Low-E: 26 0.330 9 Window F: Wood Frame:Double Pane with Low-E: 25 0.330 6 Window G: Wood Frame:DOUble Pane with Low-E: 58 0.330 19 Window H: Wood Frame:Double Pane with Low-E: 60 0.330 20 Window I: Wood Frame:DOUble Pane with Low-E: 60 0.330 20 Window K: Wood Frame:Double Pane with Law-E: 22 0.330 7 Door 101: Glass: 37 0.330 12 Door 102: Glass: 80 0.330 26 Door 103: Glass: 19 0.330 6 Door 104: Glass: 93 0.330 31 Floor 1: All-Wood JoisUTruss:Over Unconditioned Space: 2700 19.0 0.0 127 The proposed building represented in this document is consistent with the building plans, specifications, and other calculations submitted with this permit application. The proposed systems have been designed to meet the New York Stale Energy Conservation Construction Code requirements. When a Registered Design Professional has stamped and signed this page, they are attesting that to the best of his/her knowledge, belief, and professional judgment, such plans or specifications are in compliance with this Code. Builde Designer Company Name Date The Gitlin Residence Page 1 of 5 REScheck Software Version 3.7.3 Inspection Checklist Date: 04/06/07 Ceilinga: ^ Ceiling 1: Flat Ceiling or Scissor Truss, R-30.0 cavity insulation Comments: Above-Grade Walls: ^ Wall 1: Wood Frame, 16" o.c., R-19.0 cavity insulation Comments: Windows: ^ Window A: Wood Frame:Double Pane with Low-E, U-factor: 0.330 For windows without labeled U-factors, describe features: #Panes -Frame Type Thermal Break? _ Ves No Comments: ^ Window B: Wood Frame:DOUble Pane with Low-E, U-factor: 0.330 For windows without labeled U-factors, describe features: #Panes _ Frame Type Thermal Break? Yes _ No Comments: ^ Window C: Wood Frame:Double Pane with Low-E, U-factor: 0.330 For windows wthout labeled U-factors, descdbe features: #Panes _ Frame Type Thermal Break? Yes _ No Comments: ^ Window D: Wood Frame:Double Pane with Low-E, U-factor: 0.330 For windows without labeled U-factors, describe features: #Panes -Frame Type Thermal Break? _ Yes No Comments: ^ Window E: Wood Frame:Double Pane with Low-E, U-factor: 0.330 For windows without labeled U-factors, describe features: #Panes -Frame Type Thermal Break? Yes No Comments: ^ Window F: Wood Frame:Double Pane with Low-E, U-factor: 0.330 For windows without labeled U-factors, describe features: #Panes -Frame Type Thermal Break? Yes _ No Comments: ^ Window G: Wood Frame:Double Pane with Low-E, U-factor: 0.330 For windows without labeled U-factors, describe features: #Panes _ Frame Type Thermal Break? Yes No Comments: ^ Window H: Wood Frame:Double Pane with Low-E, U-factor: 0.330 For windows without labeled U-factors, describe features: #Panes _ Frame Type Thermal Break? _ Yes No Comments: ^ Window I: Wood Frame:DOUble Pane with Low-E, U-factor: 0.330 For windows without labeled U-factors, describe features: #Panes -Frame Type Thermal Break? Yes No Comments: The Gitlin Residence Page 2 of 5 ^ Window K: Wood Frame:Double Pane with Low-E, U-factor: 0.330 Far windows without labeled U-factors, describe features: #Panes _ Frame Type Thermal Break? _ Yes _ No Comments: Doors: ^ Door 101: Glass, U-factor: 0.330 Comments: ^ Door 102: Glass, U-factor: 0.330 Comments: ^ Door 103: Glass, U-factor: 0.330 Comments: ^ Door 104: Glass, U-factor: 0.330 Comments: Floors: ^ Floor 1: All-Wood JoisVTruss:Over Unconditioned Space, R-19.0 cavity insulation Comments: Air Leakage: ^ Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. ^ Recessed lights must be 1) Type IC rated, or 2) installed inside an appropriate air-tight assembly with a 0.5" clearance from combustible materials. If non-IC rated, the fixture must be installed with a 3" dearance from insulation. Vapor Retarder: ^ Required on the warm-in-winter side of all non-vented framed ceilings, walls, and floors. Meterlals Identlfleatlon: ^ Materials and equipment must be installed in accordance with the manufacturer's installation instructions. ^ Materials and equipment must be identified so that compliance can be determined. ^ Manufacturer manuals for all installed heating and cooling equipment and service water hearing equipment must be provided. ^ Insulation R-values and glazing U-factors must be Gearly marked on the building plans or specifications. Duet Insulation: ^ Supply ducts in unconditioned attics or outside the building must be insulated to R-8. ^ Return ducts in unconditioned attics or outside the building must be insulated to R-4. ^ Supply ducts in unconditioned spaces must be insulated to R-8. ^ Return ducts in unconditioned spaces (except basements) must be insulated to R- ^Return duds in uncondhioned spaces (except basements) must be insulated to R-2. . Insulation is not required on return duds in basements. Duct Construction: ^ All joints, seams, and connections must be securely fastened with welds, gaskets, mastics (adhesives), mastic-plus-embedded-fabric, or tapes. Tapes and mastics must be rated UL 181 A or UL 181 B. Exception: Continuously welded and locking-type longitudinal joints and seams on duds operating at less than 2 in. w.g. (500 Pa). ^ The HVAC system must provide a means for balancing air and water systems. Temperature Controls: ^ Each dwelling unit has at lesat one thermostat capable of automatically adjusting the space temperature set point of the largest zone. Electric Systems: ^ Separate electric meters are required for each dwelling unit. Fireplaces: ^ Fireplaces must be installed with tight fitting non-combustible fireplace doors. ^ Fireplaces must be provided with a source of combustion air, as required by the Fireplace consirudion provisions of the Building The Gitlin Residence Page 3 of 5 Code of New York State, the Residential Code of New York State or the New York City Building Code, as applicable. Service Water Heating: ^ Water heaters with vertical pipe risers must have a heat trap on both the inlet and outlet unless the water heater has an integral heat trap or is part of a circulating system. ^ Insulate circulating hot water pipes to the levels in Table 1. Circulating Hot Water Systems: ^ Insulate circulating hot water pipes to the levels in Table t. Swimming Pools: ^ All heated swimming pools must have an on/off heater switch and require a cover unless over 20 % of the heating energy is from non-depletable sources. Pool pumps require a time clock. Heating and Cooling Piping Insulation: ^ HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F must be insulated to the levels in Table 2. The Gitlin Residence Page 4 of 5 Table 1: Mlnlmum Insulation Thlckness for Cfrculaling Hot Water Pipes Insulation Thlckness In Inches by Pipe Sizes Non-Circulating Runouts Circulating Mains and Runouts Heated Water Temperature (°F) Up to 1" Up to 1.25" 1.5" to 2.0" Over 2" 170-160 0.5 1.0 1.5 2.0 140-769 0.5 0.5 1.0 1.5 700-139 0.5 0.5 0.5 1.0 Table 2: Mlnlmum Insulation Thickness /or HVAC Pipes Insulation Thlckness In Inches by Plpe Sizes Fluid Temp. Piping System Types Range(°F) 2" Runou[s 1" and Less 1.25" to 2.0" 2.5" to 4" Heating Systems Low Pressure/Temperature 201-250 1.0 1.5 1.5 2.0 Low Temperature 120-200 0.5 1.0 1.0 1.5 Steam Condensate (for feed water) Any 1.0 1.0 1.5 2.0 Cooling Systems Chilled Water, Refrigerant and 40-55 0.5 0.5 0.75 1.0 Brine Below 40 1.0 1.0 1.5 1.5 NOTES TO FIELD: (Building Department Use Only) The Gitlin Residence Page 5 of 5 I ~ ,JUDITH T. TERRY TOW[`( CLERK I2EC15FRAR OF VITN. STATIS7lCS MARRIAGE OFFICIiR IiECORUS MANAGEMENT OITICER FREEDOM OF INFORMATION OFFICER ~S~F~OAL,t~~G F .: .. `r r ~ .,. ~'.~~ T, l yam, ~~~ ~.. 9 town Hall, 5]04$ Mam Road P.O. Rux 117 Southold. New Durk I I'171 Fax (SIAI 7(~5-IR'~ Telephone (51(~I 7GS-IRUI OFFICE OF THE TOWN CLERK 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 two (2) new forms to be used under the Flood Damage Prevent regulations of the Code of the Town of Southold: "Floodplain Development Permit Application" [FDP(93)), and "Certificate of Compliance for Development in Special Flood Hazard Area [C/C(93)]. I~Lslcr,I~ ....._ 'il , J 1 `~n~T~` T~f~ Southold Town Clerk August 25, 1993 APPLICATION # PAGE 1 of 4 TOWN OF SOUTHOLD FLOODPLAIN DEVELOPMENT PERMIT APPLICATION This form is to be IIlled out in duplicate. SECTCON L: GENERAL PROVISIONS (APPLICANT to read and sitml: L. No work may start until a permit k issued. 2. The permit may be revoked if any fake statements aze made herein. 3. IC revoked, all work must cease until permit k re-issued. 4. Development shall not be used or occupied until a Certificate of Compliance u issued. 5. The permit will expve i[ oo work k commenced within six months of issuance. 6. Apphcaat is hereby informed that other permits may be required to fulfill local, state and federal regulatory requ'tremcnts. 7. Applicant hereby gives consent [o the Local Administrator or his/her representative to make reasonable iaspeuiom requ'ued to verify compliance. 8. I, THE APPLICANT, CERTIFY THAT ALL STATEMENTS HEREIN AND IN ATTACHMENTS TO - THIS APPLICATION ARE, TO THE BE~ST~,O1F,,M,Y KNOWLEDGE, TRUE AND ACCURATE. (APPLICANTS SIGNATURE) F~7.~'YI.W~ ^ DATE ©~ © ~~ SECTION 2• PROPOSED DEVELOPMENT (To be completed by APPLICM"I~ NAME ADDR_S TELEPHONE ~,blebllh~l.~1A'Yt~1,~A-Z,~ ~SZ55 ArL~fn) ~.D. CecTeHoC~rx; lb`~-b4os BUILDER .{^~ sS~TfhUl I ~~ Ot4KtUtaob J]R SauT({oC.~ ?101 - I sR~} ENGINE RE ~ PROJECT' LOCATION: To avoid delay in processing [he application, please provide enou¢6 information to easily identify the project location. Provide the street address, lot aumbu or legal description (attach) and, outside urban areas, [he distance to the nearest intersecting road or well-known landmark. A sketch attached to this application showing the projeu locatioo would be helpful. ~ 18 D SM rrrl ('2o,a-v SouTN , .S~uTt-+ol.o ~ Goose c~t~K FDP(93) APPLICATION r PAGE 2 OF a DESCRIPTION OF WORK (Check all applicable bows): A. STRUCTURAL DEVELOPMENT ACTIVITY STRUCTURE TYPE ~j Ij° ~id~60 New Structure l$"Residential (1-4 Family) ^ Addition ^ Residential (Mort than 4 Family) ~/'~S6o0 ~ Alteration ^ Non-residential (Floodproofmg? ^ Yes) ^ Relocation ^ Combined Use (Residential & Commeraal) O Demolition ^ Manufactured (Mobile) Home (In Manu- ^ Replacement factored Home Park? ^ Yu) ESTIMATED COST OF PROJECT S /~_ B. OTHER DEVELOPMENT ACTIVITIES: ^ Fill ^ Mining O Drilling ^ Grading ^ Excavation (Except for Svuctural Developmeot Checked Above) ^ Watercourse Alteration (Including Dredging and Channel Modifications) ^ Drainage Improvements (Including Culvert Work) ^ Road, Svicet or Bridge Construction ^ Subdivision (New or Expansion) ^ Individual Water or Sewer System ^ Other (Please Specify) After completing SECTION 2, APPLICANT should submit form to Local Adminisva[or for review. 4EPTtnN 3• FLOODPLAIN DETERMINATION fTo be completed by LOCAL ADhSINiSTRATORI The proposed development is located on FIRM Panel No. .Dated The Proposed Development: ^ Is LIQ'[ lorated in a Special Flood Hazard Area (Notify the applicant that the application review u complete and NO FLOODPLAIN DEVELOPMENT PERMIT IS REQUIRED). ^ Is located is a Specal Flood Hazard Area. FIRM zone designation iu ].1;0-Year flood elevation at the site is: Ft. NGVD (MSL) ^ Unavailable ^ The proposed development is located in a tloodway. FBFM Panel No. Dated ^ See Section 4 for additional instructions. SIGNED C~ APPLICATION # PAGE 3 OF 4 SECTION 4• ADDITIONAL INFORMATION REOUiRED (To be comnlctcd by LOCAL ADMiNiSTRATORI The applicant must submit the documents checked below before the application can be processed: ^ A site plan showing the lowtioa of all existing structures, water bodies, adjacent roads, lot dimensions and proposed development. ^ Development plans, drawn to scale, and specifications, including where apphcablc: details for anchoring structures, proposed elevation of lowest floor (indudiag bazement), types of water resistant materials used below the lust floor, details of (loodproofmg of utilities located below the Ctrs[ floor and details of enclosures below the Ctrst ^oor. ^ Subdivision or other development plans (I[ the subdivision or other development exceeds SO lots or S ages, whichever u the lesser, the applicant must provide 100-year flood elevations if they are not otherwise available). ^ Plans showing the extent of watercourse relota[ion and/or landform alterations. ^ Top of new fill elevation Ft. NGVD (MSL). ^ Floodproofmg protection level (non-residential only) Ft. NGUD (MSL). For floodproo[ed structures, applicant must attach certification from registered engineer or architect. ^ Certification from a registered engineer that the proposed activity is a regulatory tloodway will not result in an increaze is the height of the 1l)D-year Aood. A copy of all data and calculations supporting this Cording must also be submitted. ^ Other: SECTION 5: PERMIT DETERtatrNATION fTn hr t a t, r nrsi ADMIN[ RATOR) I havt determined that the proposed activity. A. ^ Lt 8. ^ Is not in conformance with provisions of Local Law # , 19 .The permit is issued subject to the conditions attached to and made part of this permit. SIGNED DA' Ir BOX A is checked, the Local Administrator may issue a Development Permit upon payment of dcsignatnd fee. If BOX B is checked, the Local Administrator will provide a written summary of de(icienciu. Applicant may revise and resubmit an application to the Local Administrator or may request a bearing from [hc Board of Appeals. C~ APPLICATION to _ PAGE 4 OF 4 APPEALS: Appealed to Board of Appeals? ^ Yes O No Hearing date: Appeals Board Decision -- Approved? O Yes ^ No SECTION 6: AS-BUTLT ELEVATIONS fTo be submitted by APPLICANT before Certificate of Compliance ~s issuedl 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 Hieh Hazard ens, bottom oC lowest structural member of the lowest floor, excluding-piling and columns) is: FI'. NGVD (MSL). 2. Actual (As-Built) Elevation of floodproofmg protection is FT. NGVD (MSL). NOTE: Any work performed prior to submittal of the above information is at the risk oC the Applicant. SECTION 7: COMPLIANCE ACTION (To be comnlet~d by LO AL ADMINi TRATORI The LOCAL ADMINISTRATOR will complete this seaiou as applicable based on inspeuion of the projett to ensure compliance with the commttnit}~s local law Cor flood damage prevention. INSP$CTIONS: DATE BY DEFICIENCIES? OYES ^ NO DATE BY DEFICIENCIES? ^ YES ^ NO DATE BY DEFICIENCIES? ^ YES ^ NO SECTION 8• CFRTIFi('eTC nc r MP ! N F!T h coma) r d by T MAr 4DA1iNISTRATORI Ccrti[irate of Compliance issued: DATE By; Attachment B SAMPLE CERTIFICATE OF COMPLIANCE for Development in a Special Flood Hazard Area i ~ TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE FOR DEVELOPMENT IN A SPECIAL FLOOD HAZARD AREA (OWNER MUST RETAIN THIS CERTIFICATE) PREMISES LOCATED AT: OWNERS NAME AND ADDRESS: PERMIT NO. PERMIT DATE CHECK ONE: ^ NEW BUILDING ^ EXISTING BUILDING O VACAI~'T LAND 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) rvwty yr awirt~ri,u BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1$02 FAX: (631) 765-9502 www. northfork.net/Southold/ PERMIT NO. Building Inspector Examined ,20 Approved ,20 Disapproved a/c Expiration , 20 ~ RPR~ ~i~ ~. Date ~ , 20~ INSTRUCTIONS a. is application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 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 waterways. c. The work covered by this application may not be commenced before issuance of Building Petmit. 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. £ 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. ~ZA~ (Signature of applicant or name, if a corporation) (Mailing address of plicantT State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises Do you have or need the following, before applying'- Boazd of Health 3 sets of Building Plans_ Planning Boazd approval Survey Septic Form N.Y.S.D.E.C. Trustees Contact: Mail to: 4d ~'L~A,NAM Phone:~3t~--Cp~~ TION FOR BUILDING PERMIT Tl.(~l~ (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 N of land on House Number Street County Tax Map No. 1000 Section~Block_~ Subdivision Filed Map No. (Name) work will be done: BU1Lll1N(i YERMl'1' AYYLICA'1'lUN CHB;CKLIS'1 Hamlet Lot C~,Ob~ Lot 2. State existing use and occupancy of premises and intended use and a. Existing use and occupancy a~ilWh'L~ ~F}N11W I proposed cotstruction: b. Intended use and occupancy SQ.K~,e. 3. Nature of work (check which applicable): New Building ~ Addition Repair Removal Demolition Other Work Alteration~~ Descri tion 4. EstimatedCost_ ~~~~r00p! `~~~ ~'(5~n0' ~~~'tFee ( p ) (To be paid on filing this application) 5. If dwelling, number of dwelling units Q ~(~ Number of dwelling units on each floor If garage, number of cars tU10 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. Nft ' al / ~ it i If 7. Dimensions of existing structures, if any: Front ~ ` I Rear 5 "~ Depth Sot ~ 1 Height ~I'-(o'' Number of Stories tl1UO IUL~~ryLEA,Ij Dimensions o sa a structure with alterations or additions Month 1. ~b 1-Joinh! ~I'_I.~r pp i ~ Front C4 ~ ~ 1 ~I Rear ~~ -~ I -Number of Stories 'CUh 1T Dimensions of entire new constructtion: >"ront ,~~j ~ Rear ail Height ~ 9l- ~ ~ '' Number of Stories 9Af~ ~/ ~~ U 9. Size of lot: Front___ ~~ It ~a l Rear '~~ `V ~ Depth c~~ O • ~g t 10. Date of Purchase Name of Former Owner 1 I .Zone or use district in which premises are situated a~-' 12. Does proposed construction violate any`zoning law, ordinance or regulation? YES- NO V 13. Will lot be re-graded? YES NO Y Will excess fill be removed from premises? YES NO 14. Names of Owner of remises_wQ~eY'~~A,-L Address. 1~n1.1,~G~ Phone No. ~¢ c- g Name of Architect p~ ~ Address Phone No ~ ) ~_ Name of Contractor~~(lryli Address _-Phone No. °!(Q;5- t ~QA- 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES '~ NO * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED. b. Is this property within 300 feet of a tidal wetland? *YES/ NO * IF YES, D.E.C. PERMITS MAYBE 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 'J L ~ ~1~'WIU~~ being duly sworn; ueposes and says that(s)lze is the applicant (Name of individual signing contract) above named, (S)He is the (Contractor, 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 tme 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. Swom to before me this ~_ day of 20~ Cam. Notary Public PQTRICIA RICK~RliS Notary Public, State of New York No. 01 RI6042467 Qualified in Suffolk County Commission Expires May 3Q, 2~- ae~t, e) I~~ Signature of Applicant 61-~11n 3~-~5~ "7~-3- ~a Erosion, Sedimentation and Storm-water Run-off Control Plan ASSESSMENT FORM Yes No EXEMPTIONS:. _ / A. Does this project meet the. minimum standards for classification as an Agricultural Project. ~/ Note: If you. answered Yes to any of the above, a Storm•water, Grading, Drainage & Erosion Control. Plan is not required. ------------------------------------------------------------------- ACTIONS. REQUIRING THE SUBMISSION OF ASTORM-WATER, GRADING, DRAINAGE & EROSION CONTROL PLAN CERTIFIED BY A DESIGN PROFESSIONAL. IN THE. STATE. OF NEW YORK. Item Number: (A Check Mark (/) for each question is required for complete application) Yes No ]. Will this project retain all Storm-Water Run-off generated on Site? (This will include all run-off created by site clearing and/or construction activities as well as all Si I / / te mprovements and the permanent creation of impervious surfaces.) ^ t 2. Will this project require any land filling, grading or excavation where there is a change to the natural existing grade involving more than 200 cubic yazds of material within any parcel? ^ 3. Will this application require land disturbing activities encompassing an area of five thousand (5,000) square feet of ground surface or more? ^ 4. Is there a Natural Water course running through the site or is this project within One hundred (100). feet of wetlands or a beach? © - 5. Will there be site prepazation on slopes which exceed fifteen (15) feet of vertical rise to One hundr d (100) feet of h i t l di t ? / ^ e or zon a s ance Y 6. Will driveways, pazking areas or other impervious surfaces direct Storm-Water Run-off i t d/ i n o an or n the direction of a Town Right-of--Way? ^ ~/ 7. Will this application require the placement of material, removal of vegetation and/or the construction of any item within the Town Right-of--Way or road shoulder area? ^ (This item. does not include the installation of driveway aprons.) 8. Will there be site prepazation within the one hundred (100) year floodplain of any watercourse? Note: If any answer to questions one. through eight is answered. with a check mark in the Box, aStorm-water, Grading, Drainage & Erosion Control. Plan is required and must be submitted for review prior to issuance of any building permit. ---------------------~E-E _~!T~-f'~'=-N -------------------------- STATE OF NEW YORK, ~ D~ y-C-OU~~N"T"Y'O~F_~`1~rkp~~S`i"^"~~.-~...~...~ .............. ss That I, .....G~.~r(,~YIL~(,p....ht...pL.~{.yg,FvCl(.g .............. being duly sworn, deposes and says that he/she is [he applicant for Petmit, (Name of individual signing Document) And that He/She is the Ia'~C~ r~`~~.....j~9E''.......e~~.T(~~/v ~~~) .............................................. (Owner, Contractor, Agent, Coryorate OfLcer, etc.) Owner and/or representative of the Owner or Ownei s, and is duly authorized [o perform or have performed the said work and to make and file this application; that all statements contained in this application are true [o the best of his knowledge and belier; and that [he work sill be performed in the manner set forth in the application filed herewith. Sworn to before me this; ~~,,~~,,, ,~~ATRICIA RICHARDS Notary Public:..... : U~! t,I!.:K+4Q2fFy.Pubiic, State of ~Iew York No. 01816042467 Qualified in Suffolk County Comtttlasdon Expires May 3q.3pYE Zt~l a ~. ~ .............dayof...1.°1~.......................20~.~ (Signature of Applicant) ,, y ,~ a TOWN ., ;~. 3 3 `~ ~ cl - OF SOUTHOLD i-~rtOPERTY RECORD CARD /''1-1 OWNER STREET " "~~j VILLAGE DISTRICT SUB.. LOT ~ _ ~"' //ff~~ /j ~ lIC / /V • L / ~ TJ Yf .. ;. ! Y ~~yy//Pp .FORMER W ER j ~ • L ~/ / ~TO ~ N E F ACREAGE n , ~/rJ. ~ ~ l L E°°f r w. ~ S W TYPE OF BUILDING ~ RES. ~ 1V SEAS. VL. FARM COMM. IND. CB. MISC. Est. Mkt. Value LAND IMP. TOTAL DATE REMARKS ~'~ N6P-Fiw~a'~p~"C~ l~,i TJd ~~ ...,, ~~ ,,rr~~ CJtsr ~ ~ /.E ~/S ~ ~ ~- ~~ ~ ~° Ddl~ W MxiLa .DES2 r~FF;-~L nv o sryv a-,p/Gfo ,F' t! (33'0 >3 EST oo ~ V~ ~) /yo ~ '~Zv al syo o ~~S/J_3 B ( J t•« ( x K~ ~, ~~I 4 /2ov ~ ~ SSG e--a ~ ~'~~ 9 -L z - mi/~a 'f~ ~ zS ooU /2o d S~iov S~1v '~ s P G. AG ~~'~ BUI DINGCONDITI N~a' Ca~k~,v eJc .~ NEW NORMAL BELOW ABOVE _ FRONTAGE ON WATER ~ O U / L. "'~ 1/r+'O Farm Acre Value Per Acre Value FRONTAGE ON ROAD Tillable 1 BULKHEAD ~Ilable 2 DOCK Tillable 3 Woodland Swampland Brushland / House Plot Total M. Bld ' ~" Foundation Bath ~ / Extension i - _ 8 ~I ~ ~3 _ ~ g 7 ,~ Basement j FJ ~ 4 ~ Floors ~ 0 ~. /~ ~ ' Extension ! _ ~~ Ext. Walls _ ~- - WOOp 5 N ~N ,Interior Finish ~i ' HLL J3D Extension I I ~ Fire Place ~, rS _ Heat _ ! 5 -~ Porch - Roof Type ' - t! Porch i Rooms 1st Floor ~ ~! Breezeway I Patio ~ ~ Rooms 2nd Floor ! I Garage ~ ~ s. ~ ~ r ' L ~ it 8~ L Driveway ~ Dormer _ ~~ ~~ , ~ ! '~3 7 3 i i y .y ~ ~-- TOWN OF SOUTHOLD PROPERTY RECORD CARD .~. ~ ~ ~ , NI - l OWNER STREET VILLAGE DIST. SUB. LOT FORMER OWNER _ t '~E ACR. w. P: ~ i ~ ~ y ~ ._.~ ~ S C.~ ~~ ~ y~ Cs ,~.~~ TYPE OF BUILDING RES. SEAS. VL. 3Z3 FARM COMM. CB. MICS. M~Ct. Value LAND iMR. TOTAL DATE REMARKS - j~J O / ~ D S F1 L£ 9/~ s e o a uJ ~'~ ~F 9 ~n ra ~d o s e NGc.r S u ,~ 9 c 7 f~ ber 2 '+= ~ AGE BUILDING CONDITION NEW NORMAL BELOW. ABOVE FARM Acre Value Per Acre Value Tillable FRONTAGE ON WATER Woodland FRONTAGE ON ROAD Meadowland DEPTH House Plot BULKHEAD Total DOCK