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Home My WebLink About33083-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-33484 Date: 01/13/09 THIS CERTIFIES that the building ALTERATIONS Location of Property: 375 GOOSE CREEK LA EXT (HOUSE NO.) (STREET) County Tax Map No. 473889 Section 78 Block 8 Subdivision Filed Map No. __ Lot No. SOUTHOLD Lot 20 ( HANLE T ) conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 21, 2007 pursuant to which Building permit No. 33083-Z dated MAY 29, 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 APARTMENT IN AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR PER ZBA #5930, DATED 9/14/60. The certificate is issued to JULIA VIDULICH of the aforesaid building. ( OWNER ) SUFFOLK CO,IFf"f DEPARTMENT OF HEALTHAPPROVAL N/A ELE~-£K£CAL CERTIFICATE NO. 08-5506 10/20/08 pLD)~ERS CERTIFIC3%TION DA'rF~3 02/19/10 PECONIC PLUMBING & HEAT Rev. 1/81 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIIqCATE OF OCCUPANCY This application must be filled in by typewriter or ii'&: and submiued Io the Building Department xvith the followi~lg: 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 sexverage-disposal (S-9 3. Approval ofelecthcal installation fi'om Board of Fire Undem, riters. 4. Sworn statement from plumber certifying that the solder used ni system contains less than 2/10 of 1% lead 5. Co~m-ner¢ial building, industhal building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architecl ol engineel ~esponsible fo~ the building 6. Submit Planning Board Apluoxal ofcompleled sile plan iequitelnents B. For existing buildings (prior to April 9, 1957) non couf(n ming uses, or buildings ~n(l p e-ex st ng laud uses: 1 Accurate survey of plope~%' showing all i~xope[ty lines, stl eers, building and tmusuaI natmal or tol>ographic features 2 A properly completed application aim o:)nst:nt t<) n~;l*C,: I 5~[(llcd by the appltcam Ifa Certificate of Occupancy deuied, the Building Inspect~; shall xlale the mas(ms tltc~t:fot ID w~qting to tile applicant C. Fees I Ce~lificateofOccupaac5 Ncx,, tx: j, S2$ 00 Addition IodwellingS2500, Alterations to dweliing $25 00, Sx~ immmg pool $2500, A(c cssol 5' btfildin~ S25 00, Additions Io acccssol y 1ouilclm.r! $2500, Businesses $50 00 2 CelxificateofOccupancyonlhe_cxtstinggu c I' $10000 3 Copy of CeNificate of Occup ulc5 - $ 25 4 Updated Oe~ificate of ()ccul)an('f 5 TclnpOlal-y Ce~lificale of()(cupa~a~y [teddential $15 ()(), Commercial ~1 ~ 0( ~ ) New Construction: v/ Old ol ['~e existing Buitdiug: LocationofPropmty: ~ ~OD5~ C ~d~ Z~fl~ House N<). St~ ce~ Owner o~ Owners of PlopcNy: ~]'& ~ l~kl ~ (check one) Hamlet Suffidk C<',unty'Fax bdap No 1000, St*c~ion ~ g . Bk)ck ~'__. ~ Lot ~ O __ Subdivisioa _ Filed Map_ I or: Health Dept Approval: ....... Undemq e's Approval Plamfing Board Approval: Request for: Temporau' Certificate Pinal Cc~lificalc: Fee SuNmtted: (check one) pplicant Signature Electrical Inspectors, Inc. 308 East Meadow Avenue East Meadow, NY 11554 Office: (516) 794-0400 (631)396-7474 Fax: (516) 794-5854 Website: www.electricalinspectors.com Emil: info@el~ctricalinspectors.com Mail To: M. Gaudio Electric Matt Gaudio 67 Hitching Post Lane Glen Cove, NY 11542 License#: 3970-ME Certificate Number: 08-5506 Municipality: Southold, Town Of Inspector: 124 Issue Date: 10/20/2008 Property Address: Julia Vidulich 375 Goose Creek Lane Southold, NY 11971 ELECTRICAL APPROVAL CERTIFICATE AREAS LISTED BELOW ARE APPROVED BY INSPECTION AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE No visual defects were found for the electrical inspection provided. No obvious unsatisfactory conditions were found in the areas herein below only. Residential Closed Wall Inspection/Wires Snaked 2nd Floor Apartment Above Garage: Bathroom, Kitchen. 2- Duplex Receptacles, 3- GFI Receptacles, 2- Switches, 1- 50Amp Range, 1- Dishwasher. 3- Recessed Fixtures, 1- Paddle Fan.* Richard M. Bivone President Philip F. Goehring Chief Elec~ical Inspector Not valid unless signed by an 1. EI~ECTR1CAL INSPECTORS, INC. is not responsible for the existing conditions at the subject premises. 2. ELECTRICAL INSPECTORS, INC. is not responsible fi*r corrections, upgrading or replacement of existing electrical violations at the subject premises, Any corrective work shall be solely the responsibility of the property owner. ELECTRICAL INSPECTORS, INC. DOES NOT WARRANTY OR UNDERWRITE THE EI,ECTR1CAL CONDITIONS AT THE PREMISES. 3. ELECTRICAl, INSPECTORS, INC. only recognizes the National Electric Code, the Building Codes of New York State all volumes and Local Municipal Codes, as Authorized by The Department of State Codes Division, via Village, Town or City Board Resolution. 4. AN ELECTRICAL SURVEY consists ora visual examination of the premises ONLY: Electrical Inspectors Inc. will co~nply with the requirements of NFPA 73, latest edition Chapter I, Section I- I, 1-2. If violations exist, a Notice ot' Violation (NOV) will be issued requiring correction by a licensed electrical contractor. After the violation has been con'ected, a re-inspection will be conducted and if approved a certificate shall be issued. 5. A SURVEY CERTIFICATE does not examine the actual wiring or devices unless all walls are opened and wires and devices are exposed prior to the survey being conducted. 6. A CERTIFICATE is non-transferable. 7. AN ELECTRICAL INSPECTION consists of an examination of wiring and installations during the rough sieges of construclion. After completion of the construction a final inspection will be conducted at which time a certificate will be issued provided no violation exist. In the event no inspection is requested during the rough stages of construction ELECTRICAL INSPECTORS, INC. will perform a CLOSED WALL SURVEY that consists oF a visual inspection of the wiring and installations only. Since access is limited, ELECTRICAL INSPECTORS, INC. shall bear no responsibility for any detects or violations at the premises. 8. ELECTRICAL INSPECTORS, INC. shall not be responsible to remove any walls in order to conduct an electrical inspection. 9. ELECTRICAl, INSPECTORS, INC. will only release infi)r~nation, certificates and reports to the applicant after payment for services rendered have been paid in full. 10. ELECTRICAL INSPECTORS, INC. assumes no liability t'or the results of its inspections. 11. The agreement nmy not be changed orally. Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971-0959 Fax (631) 765-9502 Telephone (631) 765-1802 BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATION Date: Building Permit No. Owner: Plumber: Ot/I. } ~_~ (~D ~ (please pr~qt) (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. Sworn to before me this day of. , 20 Notary Public, County Notmy FLdm~ Stm d liew Yod~ NO. 01L06070081 OJaalied in Cmnadsden Expkls c~-/ 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. 33083 Z Date MAY 29, 2007 Permission is hereby granted to: JOSEPH & JULIA VIDULICH PO BOX 1348 SOUTHOLD,NY 11971 for : ALTERATIONS TO AN EXISTING DWELLING, CREATING AN ACCESSORY APARTMENT AS APPLIED FOR PER ZBA #5930 at premises located at 375 GOOSE CREEK LA EXT SOUTHOLD County Tax Map No. 473889 Section 078 Block 0008 Lot No. 020 pursuant to application dated MAY 21, 2007 and approved by the Building Inspector to expire on NOVEMBER ,~~ ~ 0o.oo ---------~t ho~e ~ /gnature ORIGINAL Rev. 5/8/02 APPI~,ALS BOARD MEMBERS Ruth D. Oliva, Chairwoman Gerard P. Goehringer James Dinizio, Jr. Michael A. Simon Leslie Kanes Weisman Mailing Address: Southold Town Hall 53095 Main Road · EO. Box 1179 Southold, NY 11971-0959 Town Annex/First Floor, North Fork Bank 54375 Main Road (at Youngs Avenue) Southold, NY 11971 htlp://sourholdtown.north fork.net ZONING BOARD OF APPEALS TOWN OF SOUTHOLD Tel. (631) 765-1809 ° Fax (631) 765-9064 FINDINGS, DELIBERATIONS AND DETERMINATION MEETING OF SEPTEMBER 14, 2006 ZBA Ref. 5930 - Street & Locality: Julia Vidulich 375 Goose Creek Lane, Southold CTM 78-8-20 SEQRA DETERMINATION: The Zoning Board of Appeals has visited the property under consideration in this application and determines that this review falls under the Type II category of the State's List of Actions, without further requirements under SEQRA. The Zoning Board of Appeals held a public hearing on this application on August 31, 2006, at which time written and oral evidence were presented. Based upon all testimony, documentation, personal inspection of the property, and other evidence, the Zoning Board finds the following facts to be true and relevant: REQUEST MADE BY APPLICANT: The Applicant-Owner requests a Special Exception under Zoning Code Article III, Section 280-13B, sub- section 13 of the Zoning Code, to establish an Accessory Apartment within the existing principal building. The applicant resides in the dwelling, and the dwelling has a Certificate of Occupancy of record, noted as Cf z9309 dated November 20, 1978 for a single-family dwelling, and Certificate of Occupancy Ct z-31029 dated July 7, 2005 for additions and alterations to the dwelling. PROPERTY FACTS/DESCRIPTION; This property is 19,999 square feet in area with 100 feet along a private road (Goose Creek Lane) and 200 feet in depth. The property is improved with a single-family dwelling and detached accessory shed, shown on the August 13, 2003 survey prepared by John C. Ehlers. FINDINGS OF FACT In considering this application, the Board has reviewed the code requirements set forth pursuant to Adicle III, Section 280-13B(13) to establish an Accessory Apartment and finds that the applicant complies with the requirements for the reasons noted below: 1. The Accessory Apartment will be located on the second floor in conformity with Section 280-13B(13), as proposed. The accessory apartment will contain less than 40% of floor area of the entire dwelling structure. 2. Julia Vidulich has applied and confirms that she has owned and resided at the property, and that she will continue her ownership and residence of the main unit as a single-family dwelling. 3. The applicant's plans comply with the on-site parking requirements and provide for a total of three (3) parking spaces on site, two for the principal use and one for this new Accessory Apartment. 4. The applicant's building complies with the code requirements of a dwelling unit as defined in Section 280-13 of the Zoning Code. Page 2 - September 14, 2006 ZB # 5930 - Julia Vidulich CTM 78-8-20 5. The plans indicate that exterior entry to the Accessory Apartment of the existing one-family dwelling will retain the existing appearance of a one-family dwelling, REASONS FOR BOARD ACTION, DESCRIBED BELOW: Based on the testimony, documentation, and other evidence, the Zoning Board determined the following Findings of Fact to be true and relevant: 1) The Accessory Apadment, as applied for, is reasonable in relation to the District in which it is located, adjacent use districts, and nearby adjacent residential uses. 2) This Accessory Apartment shall be in conjunction with the owner's residence in the principal single- family dwelling unit, and as proposed will not prevent the orderly and reasonable use of adjacent properties, 3) This accessory use will not prevent orderly and reasonable uses proposed or existing in adjacent use districts. 4) No evidence has been submitted to show that the safety, health, welfare, comfort, conve,*,ience, order of the Town would be adversely affected. 5) This zoning use is authorized by the Zoning Code through the Board of Appeals, as noted herein, and a Certificate for Occupancy (or Certificate of Compliance) from the Building Inspector is a code requirement before an Accessory Apartment may be occupied. 6) No adverse conditions were found after considering items listed under Sections 280-143 and 280-144 of the Zoning Code. 7) A Certificate of Compliance or similar document will be necessary for issuance by the Building Inspector certifying that the premises conforms to Ch. 280 of Zoning for an Accessory Apartment use. BOARD RESOLUTION: On motion by Member Weisman, seconded by Chairwoman Oliva, it was RESOLVED, to GRANT a Special Exception for an Accessory Apartment in conjunction with applicant's single-family residence, as applied for, SUBJECT TO THE FOLLOWING CONDITIONS: 1. The owner shall occupy the dwelling as her residence. 2. There shall be no backing out of vehicles onto the street. 3. A Certificate of Occupancy or written compliance document shall be.obtained from the Building Department before occupancy of the Accessory Apartment. 4. A chain ladder or other emergency equipment shall be installed on the second floor area which meets the requirements of the Building Codes. Vote of the Board: Ayes: Members Oliva (Chairwoman), Goehringer and Weisman. (Members Simon and Dinizio were absent.) This Resolution was duly adopted (3-0). RUTH D. OLIVA, CHAIRWOMAN 9/¢.,,1./06 Approved for Filing ×o ~ o - ??- P~ z. o TOWN OF SOUTHOLD PROPERIMt~_~ORD CARD ~/,,,.~ · OWNER STREET ~ 7~ VILLAGE DIST. i SUB. LOT FO~AEI~, OWNER , E '~ ACR. I ,/ ~ ,*-.v, ' ~ ~ ~ ~, ~ ,~:.~, S W ~PE OF BUILDING R~/~ ' S~S. VL J FARM CO~. CB. MICS. Mkt. Value ~ND IMP. TOTAL DATE R~RKS '///, /~/ 7cI I~ ~ :. ~-~r - .,,, ~ /2~1~7, o~er/~,~)~, - p_/s~ ~ rill~bl~ , FRONTAGE ON WATER ~1~ FRONTAGE ON ROAD / ~ ~ ~ DEPTH 3 ~ o ' t~ P~t BULKH~D 78.-8-20 10/06 Po~ch ~-~ Breezeway Patio ,~'~al Foundation ,7>4 Both Floors Basement ~ ~ T~xt. Wells Fire Ploce ~',, ~ ~[5~ r~ ~f Interior Finish Heat Rooms 1st Floor Rooms 2nd Floor inette 'DR. BR. FIN. B Driveway COLOR TRIM II Extension Extension Foundation Basement Walls Both Floors Interior CERTIFICATE OF LIABILITY INSURANCE 08-01-2007 .~oDuc~ THIS CERTIFICATE IS I~ED ~ A ~ER OF INFORMATION & ~ [n;~nce B~oke~a~e, ~nc. ONLY AND CONFERS NO RIGHTS UPON THE CE~IFICATE S6-15 Fresh Pond Road HOLDER. THIS CERTIFICATE DOES NOT ~END, EXTEND OR ALTER THE CO~GE ~FO~D BY THE POLICIES BELOW. ]~e~oo~ ~~385 (718) 456-4670 IN SUERS ~FORDING CO~GE N~C~ ............................................................................................................................................s~. i~'~ffC~*g'~X~*'"~'~'O~XffE~""~'~ ~ .................................. 3IMENSIONAL CONCEPTS, INC. - ...................................................................................................................................... ?~ZNVZEW NY 11803 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THiS CERTIFICATE MAy BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. A X iO~.~P~CL~.Ln~ CLS1368248 )3-18-07 03-18~08 {EACHOCCURRENCE $1000080 500 PD [ .E~sc~&~v~mu~¥ $1000000 i~ DEDUCTIBLE i O~.NEF~ AC43 F~OAT~ $2000000 [ GEN'L AGGREGATE LIMIT APPU ES P ER: IpRODUCTS.CO~PIOPAGG $2000000 [ i NON*OWNEOAU?O8 [ (per ecc~ent) i i ANYAUTO ! OTHF~TH~N . ..~..A...C?. .$. ................................. i'"'"j J AUTO ONLY: AGG S B NYS DISABILITY DBL123104 12-31-06 12-31-07 ~TATUTORY ;ONTRACTOR CERTIFICATE HOLDER CANCELLATION FOWN OF SOUTHOLD P.O. BOX 1179 SOUTBOLD, NY 11971 ACORD 25 (2001108) IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not censtitate a contract between the issuing insurer(s), aulhorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001108) New York State Insurance Fund Workers' Compensation & DisabiliO: Benefits Specialists Since 1914 8 CORPORATE CENTER DR, 2ND FLR, MELVILLE, NEW YORK 11747-3166 Phone: (631) 756~1000 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE DIMENSIONAL CONCEPTS INC 25 HOFSTRA DR PLAINVIEW NY 11803 POLICYHOLDER DIMENSIONAL CONCEPTS INC 25 HOFSTRA DR PLAINVIEW NY 11803 ;ERTIFICATE HOLDER TOWN OF SOUTHOLD PO BOX 1179 SOUTHOLD NY 11971 POLICY NUMBER H 1443 116-7 I' (~TiFICATE NUMBI::R 874?9 PERIOD COVERED BY THIS CERTIFICATE DATE 02/23/2007 TO 02/23/2008 8/1/2007 THIS IS TO CERTIFY THAT THE POLICYHOLDER NAMED ABOVE IS INSURED WITH THE NEW YORK STATE INSURANCE FUND UNDER POLICY NO. 1443 116-7 UNTIL 02/23/2008, COVERING THE ENTIRE OBLIGATION OF THIS POLICYHOLDER FOR WORKERS' COMPENSATION UNDER THE NEW YORK WORKERS' COMPENSATION LAW WITH RESPECT TO ALL OPERATIONS IN THE STATE OF NEW YORK, EXCEPT AS INDICATED BELOW, AND, WITH RESPECT TO OPERATIONS OUTSIDE OF NEW YORK, TO THE POLICYHOLDER'S REGULAR NEW YORK STATE EMPLOYEES ONLY. IF SAID POLICY IS CANCELLED, OR CHANGED PRIOR TO 02/23/2008 IN SUCH MANNER AS TO AFFECT THIS CERTIFICATE, 18 DAYS WRR-I'EN NOTICE OF SUCH CANCELLATION WILL BE GIVEN TO THE CERTIFICATE HOLDER ABOVE. NOTICE BY REGULAR MAIL SO ADDRESSED SHALL BE SUFFICIENT COMPLIANCE WITH THIS PROVISION. THE NEW YORK STATE INSURANCE FUND DOES NOT ASSUME ANY LIABILITY IN THE EVENT OF FAILURE TO GIVE SUCH NOTICE. THIS CERTIFICATE DOES NOT APPLY TO BUILDING DEMOLITION. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYANDCONFERS NO RIGHTS NOR INSURANCE COVERAGE UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICY. NEW YORK STATE INSURANCE FUND DIRECTOR,INSURANCE FUND UNDERWRITING This certificate can be validated on oar web site at https:l/www.nysif, comlcert/certvat.asp or by calling (888) 875-5790 VALIDATION NUMBER: 827956931 HOME iMPROVEMENT CONTRACTOR UCENSE PINO UCUL ,~., ,.~ ~ 273~H ~ ~ ~m 07~1~ TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ]FOUNDATION 1ST [ ]FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ] ROUGH_pLBG. [ ] IN/gU~TION [ i~l NAL REMARKS: FIREPLACE & CHIMNEY ] [ ] FIRE SAFETY INSPECTION ] FIRE RESISTANT CONSTRUCTION []FIRE RESISTANT PENETRATION DATE INSPECTOR [ ] FOUNDATION 2ND [ ]FRAMING / STRAPPING [ ]FIREPLACE & CHIMNEY [ ]FIRE RESISTANT CONSTRUCTION REMARKS: [ ] INSULATION [ ] FINAL [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT PENETRATION DATE I N SPECTO R ~}1~ , ~/~-~./~ / FIELD INSPECTION REPORT [ DATE ! COMMENTS FOUNDATION (1ST) FO~DATION (2ND) -- ROUGH F~G & pL~G ~'S~ATION PER N. Y. STATE ENERGY CODE ~DITION~ COUNTS TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 www. northfork.net/Southold/ Approved Disapproved a/c Expiration ,20__ BUILDING PERMIT APPLICATION CHECKLIST PERMIT NO. ~,,~_~ ,2o Do you have or need the following, before applying? Board of Health · ~ 4 sets of Building Plans Planning Board approval Survey Check/'~ Septic Form N.Y.S.D.E.C. Trustees Contact: ,20__ Mail to: -~Ins, p_~e~ ~ Phone:'765 - APPLICATION FOR BUILDING PERMIT Date ,20 INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and waterways. · c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector wilI issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector issues a Certificate of Occupancy. f. Every building permit shall expire if the work authorized has not commenced within 12 months after the date of issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an addition six months. Thereafter, a new permit shall be required. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the constmction 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. G/~signature of applicant or name, ifa corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises T~/- I ~ '~ ! _~ d /-- ~ C ~ (As on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. 1. Location of land on which propo~d work will be do~:~, House Number Street Hamlet County Tax Map No. 1000 Section '7 Subdivision (Name) Block ~' Lot ..7 0 Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing usc and occupancy b. Intended use and occupancy ~Xl.-'&'xL.d-'L.x 3. Nature of work (check which applicable): New Building Repair Removal Demolition Addition Other Work 4. Estimated Cost Fee 5. If dwelling, number of dwelling units If garage, number of cars Alteration (Description) (To be paid on filing this application) Number of dwelling units on each floor 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front Height. Number of Stories Rear Depth Dimensions of same structure with alterations or additions: Front Rear Depth. Height Number of Stories 8. Dimensions of entire new construction: Front Height Number of Stories Rear Depth 9. Size of lot: Front Rear .Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation? YES__ NO __ 13. Will lot be re-graded? YES NO__Will excess fill be removed fi.om premises? YES__ NO 14. Names of Owner of premises Name of Architect Name of Contractor Address Phone No. Address Phone No Address Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a fi.eshwater 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 MAY BE REQUIRED. 16. Provide survey, to scale, with accurate foundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey. STATE OF NEW YORK) SS: COUNTY OF <~ot't:.lk ) '~ o I:~,~ ~/x cI ,o i _* ck being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the (Contractor, Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are tree to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this dayof P,J,.s,t~,..,-,to~,,. 20~6 Public (,~ (,3 '~ John M. Judge NOTARY PUI~LIC, State of New York No. 01JU6059400 Qualified In Suffolk County Commission Expires May 29, 20(> ~t~ d Signature of Applicant ~ SURVEY OF PROPERTY i 51TUAT'E~ ' TOI~ i .eUFF-OLK GOUNT'T', JOHN C. EHLERS LAND SURVEYOR 6 EAST MAIN STREET N.Y.8. LIC. NO. 50202 SUI~VE~ OF PROPERTY' SITUATE: TOI~Xl.. 5bITOLK COUNT~, Ih' SUFFOLK COIJNT~ TAX # 1000-11~-8-20 NOTE~: o PIPE FOUND AREA = tq,qqq SF OR 0.46 A~.RES GF;~-~PHIC 5CALF I"= ~O' N JOHN C. EHLERS LAND SURVEYOR 6 EAST MAIN STREET N.Y.S. LIC. NO. 50202 RIVERHEAD, N.Y. I 1901 369-8288 Fax 369-8287 REF.-\ta'-Ip servefidXPROS\03-236.pro UNDERWRITERS CERTIFICATE REQUIRED OF OCCUPANCY 32'-7' 18'-3" SECOND FLOOR PLAN , SCALE Y4" = 1'-0" ~' Z 0 n Z ~z~