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Home My WebLink About32882-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPARNCY No: Z-33403 Date: 11/21/08 T~IS CERTIFIES that the building ADDITIONS Location of Property: 980 DEEP HOLE DR MATTITUCK (HOUSE NO.) (STREET) (HAMLET) County Tax Map NO. 473889 Section 115 Block 12 Lot 14 subdivision Piled Map No. __ Lot No. __ conforms substantially to the Application for Building Permit heretofore filed in this office dated APRIL 4, 2007 pursuant to which Building Permit NO. 32882-Z dated APRIL 4, 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 ADDITION WITH ROOF TOP DECK, FRONT AND REAR DECK ADDITIONS AND BILCO DOOR ADDITION TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. Ge certificate is issued to LORRAINE WENDT of the aforesaid building. ( OWNER ) S~FOLKCO~%~i-fDEPART~qTOF~/~{;~PPR0%r~L N/A Rlat-rKIC3%L CERTIFICA~ NO. 4016131 10/24/08 PLUMBERS CERTIFICATION DA'£~D N/A ~ized Signature Rev. 1/81 Form No. 6 TO~VN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 20' This APPLICATION FOR CERTIFICATE OF OCCUPANCY application must be filled in by typewriter or ink and submitted to the Building Department with the following: 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 froxn 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 f¥om architecl or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. Bo For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, building and unusual natural or topographic features. 2. A properly completed application and consent to inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons theretYr in writing to the applicant. C. Fees 1. Certificate of Occupancy - Nexv dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00, Swinnning pool $25.00, Accessory building $25.00, Additions to accessory building $25.00, Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building- $100.00 3. Copy of Certificate of Occupancy - $.25 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 . Old or Pre-existing Building: (check one) Location of Property: ~(~j ~~~ t~r'"~r~_ · L/* _/~__ -t House No. t Hamlet Owner or Owners of Property: ('~ ~ .~ .) Suffolk County Tax Map No 1000, Section Subdivision _ NC} Pemfit No. ,~ a? ~' ~'~.~ Health Dept. Approval: Block OO1~ Lot Filed Map. Lot: Applicant: L ~ ~rl ~,.~Afl~l..~ Underwriters Approval: Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ 4,O~"~,- OO Final Certificate: (check one) ~p~icant ~igu~t-~r~ 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 BRIAN BROOKS ELEC. INC. BOX 1001, 455 BEEBE DR CUTCHOGUE, NY 11935, LAURIE WENDT 980 DEEPHOLE DRIVE MATTITUCK, NY 11952 Located at 980 DEEPHOLE DRIVE ~.~,TTITUCK, NY 11952 Application Number: 4016131 Section: Block: Lot: Certificate Number: 4016131 Building Permit: . 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: First Floor, sun room,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 cede 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 z4m Day of October, 2008. Name QTY Rate Rating Circuits Tvoe AddifionalCharges as built 2000 sunroom and service(100a) Service Service Disconnect: 0 100 cb Service1Phase3w Service Ratingl00Amperes Wiring And Devices Dimmer 2 0 120 V Fixture 7 0 Incandescent Outlet 7 0 Fixture Outlet 10 0 Gen, Purpose Receptacle 2 0 GFCI Receptacle 7 0 Gen, Purpose Switch 2 0 Gen. Purpose Continued on Next Page I of 2 seal 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 BRIAN BROOKS ELEC. INC. BOX 1001, 455 BEEBE DR CUTCHOGUE, NY 11935, LAURIE WENDT 980 DEEPHOLE DRIVE · M?TTITUCK, NY 11952 Located at Application Number: 4016131 Section: Block: Described as a Residential 980 DEEPHOLE DRIVE MA'rTITUCK, NY 11952 Certificate Number: 4016131 Building Permit: . BDC: Lot: ns11 occupancy, wherein the premises electrical system consisting of electrical devices and wiring, described below, located'in/on the premises at: First Floor, sun room,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 24tb Day of October, Name OTY Rate Rating Circuits Tvoe An as built visual inspection, of the delineated electrical installation, determined that an obvious hazard is not present and tl~ installation is 2 of 2 seal This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. 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. 32882 Z Date APRIL 4, 2007 Permission is hereby granted to: LORRAINE WENDT 28 FIDDLERS GREEN DR HUNTINGTON,NY 11743 for : CONSTRUCTION OF ADDITION & TWO DECK ADDITIONS TO AN EXISTING SINGLE FAMILY DWELLING THIS PERMIT REPLACES BP # 29644 at premises located at 980 DEEP HOLE DR MATTITUCK County Tax Map No. 473889 Section 115 Block 0012 Lot No. 014 pursuant to application dated APRIL 4, 2007 and approved by the Building Inspector to expire on OCTOBER 4, 2008. Fee $ 150.00 ORIGINAL Rev. 5/8/02 FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 29644 Z Date AUGUST 12, 2003 Permission is hereby granted to: LORRAINE WENDT 28 FIDDLERS GREEN DR HUNTINGTON,NY 11743 for : CONSTRUCTION OF ADDITION & TWO DECK ADDITIONS TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR; THIS PMT REPLACES BP26575Z. at premises located at 980 DEEP HOLE DR MATTITUCK County Tax Map No. 473889 Section 115 Block 0012 Lot No. 014 pursuant to application dated AUGUST 12, 2003 and approved by the Building Inspector to expire on FEBRUARY 12, 2005. Fee $ 150.00 Authorized Signature ORIGINAL Rev. 5/8/02 FORM NO. 3 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Hall Southold, N.Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) PERMIT NO. 26575 Z Date JUNE 13~ 2000 Permission is hereby granted to: LORRAINE WENDT 28 FIDDLERS GREEN DR HUNTINGTON~NY 11743 for : CONSTRUCTION OF ADDITION AND TWO ATTACHED DECKS. at premises located at County Tax Map No. 473889 Section 115 pursuant to application dated MARCH Building Inspector. 980 DEEP HOLE DR Block 2~ 2000 MATTITUCK 0012 Lot No. 014 and approved by the Fee $ 175.00 / Authoriz~Signature Rev. 2/19/98 ORIGINAL FORN 1~0. I TO~/N OF SOUTHOLD BUILDING DEPARTNENT TOI~I HALL SOUTHOLB, N.Y. 1197 ! TEL: 765- 1802 ~3 SETS OF PLANS ............... · -~ SURVEY ........................ -/CHECK ......................... Dare .... 3/. ......... a~ ,20.~t.4 a. This application mast be ccnpletely filled in by typerite! or i0 ink ,apfl sutnitted to the Building Inspector ~ri. 3 sets of plans, accurate plot plas ~o scale. Fee according to schedule. b. Plot plan mht~aing location of lot and of buildings on pr~nises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout of property mast be draun on the diagr~n ~ahich is part of this application. ¢. The ~ork covered by this application may not be co,tranced before issuance of Building Permit. d. b'pon appro~l of this application, the Building Inspector xrill issue a Building Pemit to the applicant. S~ch pemit shall be kept on the praises available for inspection thrunghont the ~ork. e. No Building shall be occupied or used in daole or in part for may lmrpose ~hatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATI(I~ IS lt~0~t ~ to the Building Bepartment for the isana~ce of a Building Permit pursuant to the Building Zone Ordinance of the To~n of Sonthold, ~uffolk Connty, ~ York, and other applicable La~s, Ordinasces or Regulations, for the cormtruction of buildings, additioas or alterations, or for rgmval or den~litien, as herein described. The applicant agrees to canply ~fith all applicable la~, ordinmces, building code, hotming code, and regulatiuns, and to admit authorized inspectors on premises and in ~ilding for necessary in~ections. ............ (~;ign~ture of applicant, or nane, if a corporation) State ~ae~er applicator is oaeer, lessee, a~ent, architect, engineer, general e~trector, electrician, plumbe~.Jor builder (as on the tax roll or latest deed) If applicant is a co~poratiun, signature of tluly authorized officer. (Name and title c~ corporate officer) Builders License No ........................ .. Plm~ers Lite,:me No .......................... Electricians License No ...................... Other Trade's License No ..................... 1. Location of land on ~ahich proposed ~ork ~rill be done .............................................................. throe Nm~er Street ~ralet co~t~ ~p no. ,~ seetion ...U..~.. ...... nl~ ...[...ae. ....... ~ot ..Ct.i...q ....... Subdivision ...................................... Piled lqap No ................ l~t ............... (~) 2. State existing use and occupancy of prenises and intended use and occupancy of proposed construction: a. sting ~. ~v~L*J,e ur ~[ ~o~o~ ~ch ~ppl]caOle): ~ ~ildi~ .......... ~i~i~ .~ ...... ,~terati~ .~ ..... l~ir. ~ ..... ~l ............. l~liti~ .~ ...... Oiler ~ ~ripti~) 4. Es~i,~t~ ~s~ ..~.~.~.~..Q..~..~.~ f~ .............................................. (to ~ ~id ~ fili~ this a~li~i~) ~. If ~lli~, ~imr of ~lli~ anirs ..~ ......... ~r of ~lling ~ita ~ e~ fl~r .... J. .......... If garde, ~r of cars ...... ~ ................... 6. If ~i~ss, ~rcial or ~ ~, ~i~ ~ture ~ ~tant o[ e~ ~ of ~ ...................... 7. Di~i~s off ~isri~ st~s, if ~: ~t ................ ~ar ............... ~pth ................. Igi~t ......................... ~r of Stories .... [ ................. Di~i~ o~ ~ st~e ~ith alterati~s or ~iti~s: ~t ............... ~ar ............... ~pth .................... ~i~t .................... ~r of Stories ............... 8. Dismnsi~ of entire ~ ~st~tim: ~t ................ ~ar ............... ~p~ .............. I~i~lt ......................... ~r of Stories ..................... 9. Si~ of lot: ~t .................... ~ar .................... ~pth .................... 10. ~te o[ R,rda~ .f..~.~ ......... ~ of Four ~ ~'~ ~ 'E. ~lI ~C~UI&~ ..... ' ..............~ ~ I le~ ,~. ~ or ~ ~,,~,,~ ,, ~,~ ~,~, ,~ ,i~ ..... ~.~..~ 0 ................................ ~' ~'~'"Z'"T;- 12. ~s ~o~ ~t~ti~ violate ~ ~i~ 1~, o~i~ or ~1ati~: ..................... ,:~~ . ~ 13. gill lot~~~..gill~sa fill~ ~~: ~ ~~'~ ,~. ~ o~ ~r o~ ~,Lo.~.c~.~~,~.C ........................ ~g. ff~a~ ~ o~ ~,~.~ ~. ~,..~.,..(~.~.. ~,, .............................. ~ ~ ............... · ~ of C~tr~tor ................................... ~ress ............................... ~ ~ ............... 15. Is Offs p~r~thin ~ f~t off a ti~l ~tl~ ~ ..~. ..... ~ .......... PLOT DIAG~ I~ate clearly ~ disti~tly all ~ildi~, ~r ~isti~ or ~, ~ i~i~te all ~t~ d~nai~s ~ p~r~ li~s. Gi~ st~t ~ bl~ ~r or ~rlpti~ ~co~i~ to ~, ~ ~ st~t ~s ~ i~i~te ~tlmr interior or ~r lot. .......................................................... ~i~ duly ~m, ~s ~ ~s t~t ~ is O~ a~lim~t of i~ivi~l si~ing m~, the (~tractor, ~nt, cor~rate officer, etc.) ~id ~r or ~rs, a~licati~; ~at att stat~nCs tt~ ~ will I~ ~r~o~ Jn tl~ ~n~r ~t forth in ~e a~li~ti~ fil~ ~. to ~fore ~ ~is ...~.~ ....... ~y o~ ~.~. :z0. a~... LINDA J. COOPER Nota~t Public, State o{ New Yo~ No. 4~22563, Suffolk. CeuntY Term Expires December 31, (Signatur~ of Applicant) TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ] INSULATION [~] FINAL IRE SAFETY INSPECTION [ ] FIRE RESISTANT CO#STRUCTION [ ] FIRE RESISTANT PENETRATION REMARKS: DATE /'~ -''~ ~ '~ ~ INSPECTOR 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ~U..GH PLBG. [ ] FOUNDATION 2ND [/--']"INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION REMARKS: ~~/~'~ ~ DATE ~ INSPECTOR 765-1802 BUILDING DEPT. INSPECTION [~FOUNDATION 1ST [ ] ROUGH PLBG. ] INSULATION [ ] FOUNDATION 2ND [ [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION REMARK~ DATE INSPECTOR 765-1802 BUILDING DEPT. INSPECTION [ ] FO/VNDATION 1ST [ ] ROUGH PLBG. [ ] F/OUNDATION 2ND [ ] INSULATION [ VFRAMING [ ] FINAL [ ] FIREPLACE&~CHIMNEY 765-1802 BUILDING DEPT. INSPECTION [~] F~uNDATION 1ST [ ] ROUGH PLBG. / [ ~J FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE ~CHIMNEY REMARKS: ~~ 765-1802 BUILDING DEPT. NSPECTION [~:/] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION2ND [ ] INSULATION [ ] FRAMING [ ]FINAL [ ] FIREPLACE & CHIMNEY REMARKS: ~ ~"~~ DATE /~////0"O INSPECTOR~~ ROUGH FRAME. INSULATION PER N. Y. STATE ENERGY Ii CODE II DEC PERMIT NUMBER 1-47~8-02251/00001 FACILITY/PROGRAM NUMBER(S) ( NEW YOR[ STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATLON PERMIT Under the Environmental Conservation Law IEFFECTIVE DATE February 14t 2000 EXPIRATION DATE(S) February 14, 2005 TYPE OF PERMIT · New 0 Renewal [] Modification [] Permit to Construct [] Permit to Operate [] [] Article 15, Title 5: Protection of Waters Article 15, Title 15: Water Supply Article 15, Title 15: Water Transport Article 15, Title 15: Long Island Wells [] 6NYCRR 608: Water Quality [] Certification [] Article 17, Titles 7, 8: SPDES [] [] Article 19: Air Pollution Control [] [] Article 23, Title 27: Mined Land Reclamation [] [] Article 24: Freshwater Wet[ands Article 27, Title 7; 6NYCRR 360: Solid Waste Management Article 27, Title 9; 6NYCRR 3T5: Hazardous Waste Management Article 34: Coastal Erosion Management Article 36: FLoodplain Management Article 15, Title 27: Wild ..... O Articles 1, 3, 17, 19, 27, 37; Scenic and Recreational Rivers · Article 25: Tidal Wetlands 6NYCRR 380: Radiation Control PERMIT ISSUED TO TELEPHONE NUMBER LorraLne Wendt (516) 673-608~ ADDRESS OF PERMITTEE 28 Fiddlers Green Drive~ Huntingtonr NY 11743 CONTACT PERSON FOR PERMITTED ~ORK Nelsonr Po~e & Voorhisr 572 Wait Whitman Roedt Melville, NY NAME AND ADORESS OF PROJECT/FACILLTY Wendt property~ 980 Oee~oLe Driver Mattituckr ~Y 11952 LOCATION OF PROJECT/FACLLLTY TELEPHONE NUMBER 11747-2188 (516) 427-5520 SCTM #1000-115-12-14 COUNTY TC)WN Suffolk Southotd DESCRIPTION OF AUTHORIZED ACTIVITY: NYTM COORDINATES E:709.3 N:4540.4 Construct a 12 foot by 20 foot addition, a 6 foo~ by 12 foot platform/step, and a deck for an existLng single family dwelling. Remove existing concrete patio and plant with non-fertilizer dependent grass. ALL work shall be performed in accordance with the plans stamped RYSDEC approved on 2/14/00. By acceptance of this permit, the permittee agrees that the permit is contingent upon strict compliance with the ECL, att applicable regulations, the Ge~pecified (see page 2 & 3) and any Special Conditions iecluded as part of this permit. ~ PEI~T AO~NISTRRTOR: Roo~l 121, Stony Brook, NY 117~0-2356 DATE Page 1 of 4 February 14~ 2000 NEW YORK DISTRtCT~ CORPS OF ENGINEERS JACOe K. JAVITS FEDERAL BUILDING ' HEW YORK, N.Y. 10278--0QgQ Eastern Permits'Section Apri~ 22, 1999 SUBJECT: Joint Application with New York State Department of Environmental Conservation .Lorraine Wendt 28 Fiddlers Green Drive Huntington, New York 11743 Dear Ms. Wendt: We have recently received'a copy of the Joint Application for permit you filed with the New York State Department of Environmental Conservation (NYSDEC). Please be advised we have reviewed the copy of the Joint Application sent to this office by NYSDEC. Based solely upon the information provided, it appears that a Department of the ~_rmy permit is not re.quired-for your proposal. The Department of the Army reDulates construction activities 'in navigable waterways and discharges of dredged or fill material into waters of the United States, Sncluding inland and coastal wetlands. If your proposal would involve such work, and has not been portrayed as such in your Joint Application, you should contact this office immediately so that a project-specific determination can be made as to whether a Department of the Army permit will be required. ~y inquiries can be directed to this office at (212) 264- 3912, 3913, 6730, or 6731. zees W Haggerty- Board Of $outhold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. /"J~ (~ ~ DATE: =~ept. 23, 1998 ISSUED TO LORRAINE WENDT utl ri ati u Pursuant fo the provisions of Chapter 615 of the Laws of the State of New York, 1893; and Chapter 404 of the Laws of the State of New York 1952: and the Soufhold Town Ordinance en- titled "REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;!'. and in accordance wlfh the Resolution of The Board adopted afa meeting held on 9/23/98 19 and in consideration of the sum of $ 150.00 paid by L~z~ne W~r~dt of Mattituck N.Y. and subject to the Terms and Conditions listed on the reverse s~de hereof, of Southold Town Trustees authorizes and permits the following: Wetland Permit to relocate basement storm door from western Ride of house to southern side, remove existing porch and replac~ with a 12'X20' enclosed room, a raised 12'X28' deck to same heigh as en~lgsed roqrn, a ~qpf ,ove4~ a~'XS' .~orc~h & replace ,stei~ls in fronten tn accoraance with the aeta~ea specrncatmns as presenTea of the originating application, house with new steps, place haybales along wetla[~ ~j~NEES~j~EI~6~;' c~nr~t~i~¥d r~OoOafrdtU~c~dsfees here- by causes ifs Corporate Seal to be affixed, and these p.resenfs fo be subscribed by a majority of the sa~d Board as of thts date. . Absent ~Alher~ ,!. g;rup~ki.,.. Jr. JUDITH T. TERmlY TOWN CLER~ RECORI)S MYkNAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER 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)]. TOWN OF Sou'rt!OLD Southold Town Clerk August 25, 1993 TO~N OF SOUTHOLD APPLICATION PAGE i of 4 FLOODPLAIN DEVELOPMENT PERMIT APPLICATION This form is to be filled out in duplicate. SECTION t: GENERAL PROVISIONS (APPLICANT to read and sil~n): 1.. No work may start until a permit is issued. 2. Thc permit may be revoked if any false statements are made herein_ 3. If revoked, all work must cease until permit is re-issued. 4. Development shall not be used or occupied until a Certificate of Compliance is issued. 5. The permit will expire if no work is commenced within six months of issuance. 6. Applicant is here. by informed that other permits may be required to fulfdl local, state and federal regulatory requirements. 7. Applicant hereby gives consent to the Local Admi~strator or his/her representative to make ~;eaiouable inspections required to verify compliance. 8. I, THE APPLICANT, CERTIFY THAT ALL STATEMENTS HEREIN AND IN ATTACHIvlENTS TO SECTION 2: PROPOSED DEVELOPMENT (To be comoleted by APPLICANT) 'NAME APPLICANT,, BUILDER ADDRESS TELEPHONE ENGINEER /-,,3/-'6,73-6 R E : To avoid delay in processing the application, please provide enou.p..h information to easily ideutif7 the project location. Provide the street address, lot number or legal description (attach) and, outside urban areas, the distance to the nearest imersecting road or well~lmown la~clmark. A sketch attached to this applicatiou showing the project location would bc helpful. FDP(93) APPLICAT]ON ~ PAGE 2 OF 4 DESCRIPTION OF WORK (Check all applicable boxes): A. STRUCTUI:CAL DEVELOPMENT ACTIVITY STRUCTURE TYT'E [] New Structure [] Addition [] Alteration [] Relocation [] Demolition [] Replacement E] Residential (12, Family) [] Residential (More than 4 Family) [] Non-residential (Floodproo£mg7 [] Yes) [] Combined Use (Residential & Commerdal) [] Manufactured (Mobile) Home (In Manu- factured Home Park? I-I Yes) ESTIMATED COST OF PROJECT $ B. OTHER DEVELOPMENT AUI 1 VITIES: [] Fill [] Mining [] Drill~g [] Grading [] Excavation (Except for Structural Development Checked Above) · [] Watercourse Alteration (Including Dredging and Channel Modifications) [] Drainage Improvements (Including Culvert Work) [] Road, Street or Bridge Construction [] Subdivision (New or Expansion) [] Individual Water or Sewer System [] Other (Please Specify) Alter complet~g SECTION 2, APPLICANT should submit form to Local Administrator for review. ~ECTION $: FIOQDPI~IN DETERMINATION {nfo be completed ~v LOCAL ADMINISTRATOR) The proposed development is located on FIRM Panel No. , Dated The Proposed Development: F1 h HQT located in a Spedal Flood Ha~rd Area (Notify the applicant that the application review i~ complete and NO FLOODPLAIN DEVELOPMENT PF_.RM1T IS REQUIRED). FI Is located in a Special Flood Hazard Area. FIRM zone designation is 100-Year flood elevation at the site i~: Ft. NGVD (MSL) [] Unavailable [] The proposed development is located in a floodway. FBF'M Panel No. Dated [] See Section 4 for additional instructions. SIGNED DATE APPLICATION PAGE 3 OF 4 SECTION 4: ADDITIONAL INFORMATION REQUIRED (To be completed bv LOCAL ADMINISTRATOR] The applicant must submit the documents checked below before the applicafon can be proc~sed: [] A site plan showing the location of all ex/sting structures, water bodies, adjacent roads, dimensions a_nd proposed development. [] Development plans, drawn to scale, and spedfications, including where applicable: details for anchoring structures, proposed elevation of lowest floor (including basement), types of water resistant materials used below the ['u-st floor, details of floodproo£mg of utilities located below the tn'st floor and details of enclosures below the first floor. ALso, Subdivision or other development plans (If the subdivision or other development exceeds 50 lots or 5 acres, whichever is the lesser, the applicant must provide 100-year flood elevations if they are not otherwise available). [] Plans showing thc extent of watercourse relocation and/or landform alterations. [] Top of new I-ill elevation Ft. NGVD (MSL). Floodproofmg protection level (non-residential only) Pt. NGVD (MSL). For floodproofed structures, applicant must attach certification from registered engineer or architect. Certification from a reg/stered engineer that the proposed activity in a regulatory floodway will not result in any increase in the height of the 100-year flood· A copy of all data and calculations supporting this finding must also be submitted. [] Other: SECTION 5: PERMIT DETERMINATION (To be comoleted by LOCAL ADMINISTRATOR) I have determined that the proposed activit)c. A. [] Is B. [] Is not in conformance with provisions of Local Law # , 19 attached to and made part of tlxis permit. · The permit is issued subject to the conditions SIGNED , DATE If BOX A is checked, the Local Administrator may issue a Development Permit upon payment of designated fee. If BOX B is checked the Local Administrator will provide a written summary of deficiencies. Applicant may revise and resubmil an appfication to the Local Administrator or may request a hearing from the Board of Appeals. APPEALS: Appealed to Bomrd of Appeals? [] Yes C] No Heazing date: Appeals Board Decision -~- Approved? C] Yes Conditions [] No APPLICATION PAGE 4 OF 4 SE(TFIQN 6: A~-BUILT ELEVATIONS (To be submitted by APPLICANT before Certificate of Compliance is issued) The following information mnst be provided for project structures. This section must be completed by a registered professional engineer or a licensed land surveyor (or attach a c~rtificafion to tiffs application). Complete 1 or 2 below. 1. Actual (As-Built) Elevation of thc top of the lowest floor, including basement (in (~oa~tal High Hazard Axeas, bottom of lowest structural member of the lowest floor, excluding piling and columns) is: FT. NGVD (MSL). 2. Actual (As-Built) Elevation of floodpruofmg protection is FT. NGVD (MSL). NOTE: .amy work performed prior to submittal of the above irdormation is at the risk of the Applicant. ~;ECTION 7: COMPLIANCE ACTION (To be comvleted bv LOCAL ADMINISTRATOR) The LOCAL ADMINISTRATOR will complete this section as applicable based on inspection of the project to ensure compliance with the community's local law for flood damage prevention. INSP'E. CTIONS: DATE BY DEFICIENCIES? [] YES [] NO DATE BY DEFICIENCIES? I"1 YES [] NO DATE BY DEFICIENCIES.'? [] YES r-i NO SECTION 8: CERTIFICATE OF COMPLIANCE/To be comnleted by LOCAL ADMINISTRATOR) Certificate of Compliance issued: DATE: BY: Attachment B SAMPLE CERTIFICATE OF COMPLIANCE for Development in a Special Flood Hazard Area TOWN OF SOUTHOLD CERTIFICATE OF COMPLIANCE FOR DEVELOPMENT IN A SPECIAL FLOOD HAZARD AREA (OWNER MUST RETAIN THIS CERTIFICATE) PREMISES LOCATED AT: PERMIT NO. PERMIT DATE OWNERS NAME AND ADDRESS: CHECK ONE: [] NEW BUILDING [] EXISTING BUILDING [] VACANT LAND THE LOCAL ADMINISTRATOR IS TO COMPLETE A. OR B. BELOW: COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF LOCAL LAW # , 19 SIGNED: DATED: COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF LOCAL LAW # , 19__, AS MODIFIED BY VARIANCE # , DATED SIGNED: DAT~:D: C/C(93) TOWN OF SOUTHOLD I~ROPERTY RECORD CARD OWNER FORMER OWNER RES.~, S~S. LAND IMP. Farm Till~le 1 Tillable 2 VL. TOTAL NORMAL Acre FARM DATE LOT DISTRICT SUB. ACREAGE TYPE OF BUILDING COMM. IND. I CB. I MISC. _r l/¢,1~ ~T~O~'/' b BELOW ABOVE ~ .~r *cr~ W,ue REMARKS Tillable 3 Woodland Swam~l~L Brushland House Plot Total Ex~nsion Basement I /~, ~ L_ ' Floors ' ' Extension Fire Place ~ 2'.~ . Hem . ~ ~J Porc~ ~ Rooms Jst Floor Breezewa ~atio C6~,~,~ /~ Y ~ f Rooms 2nd Floor Garage Driveway O.B. NE. Iq O~L/: 1000-115-1G014 5£0, ,.$//D. dO8 ~722 ,)'/O l ~ ?°-40'-40"t41 '~,70 +~.8 '~" I10.00 POLR DEEP HOLE 5URVEY OF' PROPERTY 'h (q74.zS) P~gc. I =~. mot, l ."~,_ ' "k ¢ $/tuqt~d at o~4 4 r f l rUC t6 TOWN OF ,50UTHOLO SUFFOLK COUNTY NEW YORK SC~ kE : 1":30' 6urve,~l CchtiflCd to: WILLIAM I/VEND[ LOt~RAIN£ I/VEl, IRT Surve[t~cl b~l SMITH ~' dUNG PATGHOOU~, N. K DA TUM: N6 VD gM E-3 73 EL. ~1. 499 ii - ., ~ .,'~ ~ ~o'~ '~ A~PR~YED AS NOTED 765-1~2 9 ~ ~ 4 P~ FOR 4: FINAL - CO~ST~UCTIO~ S~T~ CO~S~UCTIO~ · CODES NOT RESPONSIBLE FOR , , ,. , OCCUPANCY OR USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY