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Home My WebLink About36559-ZTown of Southold Annex 54375 Main Road Southold, New York 11971 8/3/2011 CERTIFICATE OF OCCUPANCY No: 35111 Date: 8/3/2011 THIS CERTIFIES that the building Location of Property: SCTM #: 473889 Subdivision: AS BUILT ALTERATION 670 Cedar Birch Road, Orient, NY, 15.-8-27 Filed Map No. Sec/Block/Lot: conforms substantially to the Application for Building Permit heretofore Lot No. filed in this officed dated 7/14/2011 pursuant to which Building Permit No. 36559 dated 7/14/2011 was issued, and conforms to all of the requirements of thc applicable provisions of the law. Thc occupancy for which this certificate is issued is: Alteration to a Single Family Dwelling; 2 Car Garage Conversion to Living Space (Art Studio), Furnace Room & Washer/Dryer, as applied for. The certificate is issued to Robinson, Janice (OWNER) of thc aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 3/29/l ! 36559 7/25/11 ,~rts Reliable Inc TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, NY BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permit #: 36559 Date: 7/1412011 Permission is hereby granted to: Robinson, Janice PO BOX 46 Orient, NY 1~957 To: Alteration to a Single Family Dwelling; 2 Car Garage Conversion to Living Space (Art Studio), Furnace Room & Washer/Dryer, as applied for. At premises located at: 670 Cedar Birch Road, Orient, NY SCTM # 473889 Sec/Block/Lot # 15.-8-27 Pursuant to application dated To expire on 1/1212013. Fees: 7/14/2011 and approved bythe Building Inspector. CO - ALTERATION TO DWELLING SINGLE FAMILY DWELLING - ADDITION OR ALTERATION $50.00 $701.60 Total: $751.60 · 'gn p Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY 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. Finnl survey ° f 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 (8-9 form). 3. Approval o f 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. (~) 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 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 accessory building $25.00, Businesses $50.00. Certificate of Occupancy on Pre-existing Building - $100.00 Copy of Certificate of Occupancy - $.25 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 New Construction: Location of Property: "[louse No. Owner or Owners of Property: ~'~¢~-~O Suffolk County Tax Map No 1000, Section Subdivision Permit No. ~.~, '~ ~" tS~ Health Dept. Approval: Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ _~-0 - ~9~9/ Date. Old or Pre-existing Building: Street Date of Permit. Underwriters Approval: Block Filed Map. Applicant: Final Certificate: (check one) 0 Lot: (check one) Applic '.~nt Signature Town Hall Annex 54375 Main Road P.O. Box 1179 Southold. New York 11971-0959 Telephonc (631) 765- 1802 Fax (631 ) 765-9502 ro.qer, dchert~town.southold.n¥.us BUILDING DEPARTMENT TOWN OF 8OUTHOLD CERTIFICATE OF ELECTRICIAL COMPLIANCE SITE LOCATION Issued To: Janice Robinson Address: 670 Birch Lane City: Orient St: NY Zip: 11957 Building Permit #: ~;)~,l;~ ~--,~ Section: I ~ Block: ~ Lot: ~ '7 WAS EXAMINED AND FOUND TO BE IN COMPLIANCE WITH THE NATIONAL ELECTRIC CODE Contractor: as built DBA: License No: SITE DETAILS Office Use Only Residential R Ind°°r Ix~ BasemeBt Ix~ Service Only [~ Commerical Outdoor 1st Floor Pool New Renovation 2nd Floor Hot Tub Addition Survey Attic Garage INVENTORY Service 3 ph Hot Water GFCI Recpt Main Panel A/C Condenser Single Recpt Sub Panel A/C Blower Range Recpt Transformer Appliances Dryer Recpt Disconnect Switches Twist Lock Other Equipment: Ceiling Fixtures ~ HID Fixtures Wall Fixtures ~ Smoke Detectors Recessed Fixtures ~.~ CO Detectors Fluorescent Fixtun~[~ Pumps Emergency Fixture Time Clocks Exit Fixtures U TVSS convert garage to art studio--out building converted to accessory apartment 2-paddle fans, 70ft of lighting track, 2-exhaust fans Notes: Inspector Signature: Date: July 25 2011 81-Cert Electrical Compliance Form [owq Hml. 53095 Mare !~oad P O. 8o): 1179 $outhold, New Yolk 1'~971 Fax (5161 765 Telephone 1516) 76E OFFICE OF 'THE BUILDING INSPECTOR TOWN OFSOUTHOLD CERTIFICATION Date: Building Permit No. -~ ~ ~--~ Owner: ~,~:)i ('~-.%~'~rl, ~.~¢tf'~', CC ' (please pant) Plumber: "~2b ',,) (please print) I certify that the solder used in the Water supply system contains less than 2/10 of 1% lead. (plumbers signature) Sworn to before me this ¢~q'P" day of h r*zrrA. 201 / Notary Public, .~O-,C~\<-- County [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSerTION [ ] FRAMING/STRAPPING [,.,,,]'TINAL INSPECTION DATE [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTA~I' CONSTRUCTION[ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: /,~-'--,-x~. _~//~. /-~ c~_~-~* INSPECTOR TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 TO~iN OF SOUTHOLD --BUILDING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: (631) 765-1802 FAX: (631) 765-9502 SoutholdTown. NorthFork.net PERMIT NO. Examined Approved _ 7~ /I.~ ,20 E×piration BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying? Board of Health 4 sets of Building Plans Planning Board approval Survey Check ,]~ ~'-Ot ~ t'-) Septic Form N.Y.S.DE.C. Trustees Flood Permit Single & Separate Storm-Water Assessment Form Contact: Mail to: Building Inspector CATION FOR BUILDING PERMIT Date ,20 INSTRUCTIONS ly filled m by typewriter or in ink and submitted to tile Building Inspector with 4 sets of plans, accnrate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings oil premises, relationship to adjoining premises or public streets or areas, and waterways. c. The work covered by this application may not be commenced before issoance of Building Permit. d. Upon approval of this application, tile Building Inspector will issue a Building Permit to the applicant. Such a permit shall be kept on the premises available for inspection throughout tile work. e. No building shall be occnpied or used itl 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 i£the work attthorized has not commenced within 12 months after tile date of issuance or has not been completed within 18 months fi'om such date. If no zoning amendnrents 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 ora Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk Connty, New York, and other applicable Laws, Ordinances or Regulatious, for the construction of buildings, additions, or alterations or tbr removal or demolition as herein described. Tile applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit attthorized inspectors on premises and ill building for necessary inspections. ~ //~ ~ 1 C~nature ofapplicant'or r~e, if'a co~offat[o6) (Mailing address of applicant) ,/ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of o f premises %.~%/Z,/(~ ~ ~/ (Al on the tax ,'t~' Imst dee~ If applicant is a corporation, s~re of duly authorized officer (Name and title of corporate officer) Builders License No. Plumbers License No. Electricians License No. Other Trade's License No. Location ~1' land on whichoorav, osechwark will/be, done' House N'umber Street ~ County Tax Map No. 1000 Section } 'D~ Block Subdivision Hamlet Lot Filed Map No. Lot 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ,~57~-/~ i/r) ~[ )~'~ '" '"" b. Intended use and occupancy ~[=_~' 1/~) .~ ~)t'", ~ 3. Nature of work (check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work If dwelling, number of dwelling units If garage, number of cars /, I .Z~ Fee (Description) (To be paid on filing this application) Number of dwelling units on each floor I 4. Estimated Cost } ~9 t o c~ O 5. 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. 7. Dimensions of existing structures, if any: Front ~,'~'~ / Rear .,fi' 7 [Depth Height ~ / Number of Stories -"2 ,~ DimensJons~of same structure with altera~ens or additions: Front Depth ~¢'/~ Height ~txg//¢--¢_/ Numbe-r of Stories 8. DimensionjCofentire new construction: Front /zC.,'~-q~ Real: ~ Height..?..,¢¢'.~¢~/ Number of Stories 9. Size of lot: Front Rear Depth Depth 10. Date of Purchase Name of Former Owner 14. Names of Owner of premises Name of Architect Nanqe of Contractor 15 a. Is this property within 100 feet of a tidal wetland or a ti'eshwater wetland? *YES * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY [}E R~51~I~. b. Is this property within 300 feet of a tidal wetland? * YES NO ~ * IF YES, D.E.C. PERMITS MAY BE REQUIRED. Address Phone No. Address Phone No Address Phone No. ~ b// 16. Provide survey, to scale, with accurate tbundation plan and distances to property lines. 17. If elevation at any point on property is at 10 feet or below, must prov,ide topographical data onsu/ 18. Are there any covenants and restrictions with respect to this property ? * YES NO · IF YES, PROVIDE A COPY. STATE OF NEW YORK) SS: COUNTY OF ) being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, OONNIE D. BUNCH Notary Public, State of New York (S)He is the No. 01BU6~185050 (Contractor, Agent, Corporate Officer, etc.) Oommi~slon .................... Expir~ ,~ri114,~__2(~)~ of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are true to the best of bis knowledge and belief: and that the work will be performed in the manner set forth in the application filed therewith. Notary Public U.S. DEPARTMENT OF HOMELAND SECURITY Federal Emergency Management Agency National Flood Insurance Program ELEVATION CERTIFICATE Important: Read the instructions on pages 1-8. OMB No. 1660-0008 Expires February 28.20 A!. Building Owner's Name Janice Robinson SECTION A - PROPERTY INFORMATION IFor Insurance Company Use: Policy Number Company NAIC Number A2. Building Street Address (including Apt., Unit, Suite, and/or Bldg. No.) or P.O. Route and Box No. 670 Cedar Birch Lane City Odent State NY ZlPCode 11957 A3. Property Description (Lot and Blcok Numbers, Tax Parcel Number, Legal DesonPtion, etc.) 1000-15-08-27 A4. Building Use (e.g., Residential, Non-Residential, Addition, Accessory, etc.) RESIDENTIAL A5. Latitude/Longitude: Lat. 41desrees 09minutes 07.5seconds Long. 72def:lrees 14minutes 53seconds Horizontal Datum: [] NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number _4 AS. For a building with a crawl space or enclosure(s), provide A9. For a building with an attached garage, provide: a) Square footage of crawl space or enclosure(s) 1391sq ff a) Square footage of attached garage b) No. of permanent flood openiogs ld the craw~ spaca or enclosure(s) walls within 1.0 foot above adjacent grade c) Total net area of flood openings in AS.b -- sq in b) No. of permanent flood openings in the attached garage wails within 1.0 foot above adjacent grade c) Zota~netaraaoffloodopeningsinAg.b z SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION B1. NFIP Community Name & Community Number I B2. County Name Southoid, Town of 360813 j SUFFOLK IB3. State NY B4. Map/Panel Number B5. Suffix B6. FIRM Index B7. FIRM Panel BS. Flood B9 Base Flood Elevation(s) ( Date Efta;rive/Revised Date Zone(s) AO, use base flood deptt' 36103C0088 G 5/04/98 AE ell 0 B10. Indicate the source of the Base Flood Elevation (BFE) data or base flood depth entered in Item Bg. [] FIS Profile [] FIRM [] Community Determined [] Other (Describe) Bll. Indicate elevation datum used for BFE in Item Bg: [] NGVD 1929 [] NAVD 1988 [] Other (Describe) B12. is the building located in a Coastal Barrier Resources System (CBRS) araa or Otherwise Protected Aroa (OPA)? Designation Date __ [] CBRS [] OPA []Yes []No SECTION C - BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1 Building elevations ara based on: [] Construction Drawings* [] Building Under Construction* [] Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations - Zones Al-A30, AE, AH, A (with BFE), VE, V1-V30, V (with BFE), AR, AR/A, AR/AE, AR/Al-A30, AR/AH, AR/AO. Complete items C2.a- below according to the building diagram specified in Item A7. Benchmark Utilized Vertical Datum NGVD Conversion/Comments a) Top of bottom floor (including basement, crawl space, or enclosure floor)_ b) Top of the next higher floor 9.3 c) Bottom of the lowest horizontal structural member (V Zones only) d) Attached garage (top of slab) e) Lowest elevation of machinery or equipment sen/icing the building _5._5 (Describe type of equipment in Comments) f) Lowest adjacent (finished) grade (LAG) _5.2 g) Highest adjacent (finished) grade (HAG) _8.3 Check the measurement used. [] feet [] meters (Puerto Rico only) [] feet [] meters (Puerto Rico only) [] feet [] meters (Puerto Rico only) [] feet [] meters (Puerte Rico on[y) [] feet [] meters (Puerto Rico only) [] feet [] meters (Puerto Rico only) [] feet [] meters (Puerto Rico only) SECTION D - SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information, t codify that the information on this CedJficate represents my best efforts to interpret the data available. I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section f O01. [] Check here if comments are provided on back of form. Certitier's Name JOHN T. METZGER License Number 49618 T/tie SURVEYOR Company Name PECONIC SURVEYORS, P.C Address 1230 TRAVELER ST. (P.O. BOX 909) City SOUTHOLD State NY ZIP Code 11935 Signature ~ ~~ Date 02f26/09 Telephone (631)765-5020 FEMA Form 81-31, February 2006 See reverse side for continuation. Replaces all previous ec TOWN OF SOUTHOLD PROPERTY REpO..RD CARD OWNER STREET ~7 C) VILLAGE DIST. SUB. LOT FORME.R_OWNER'~'~--~z-~ N E k (-"w'~v. 'r~) ACR. S W ~PE OF BUILDING ~' ~ / ~ s~s. VL ~ ~ CO~. C~. ~CS. ~. ~ND IMP. TOTAL DATE R~RKS ~ill~l~ FRONTAGE ON WATER ~1o~ FRONTAGE ON ROAD ~ DEPTH ~ ~ BULKH~D ~o~1 CO'OR ~ ,~--~ M. Extemion ' Extensim Rorch ~, ,~ / Patio O. B. ~c~ ~ 2o'~ ~o ~al Foundation Basement Ext. Walls Fire Place Recreation Room Both Interior Finish Heat Rooms 1st Floor Rooms 2nd Floor Driveway jlnette FIN. 8 PECONIC CESSPOOL INC. January24,2011 Main Road P.O. Box 487 Laurel N.Y. 11948 Phone (631) 727-0115 (631) 298-9658 Fax (631) 727-7564 Janice Robinson 670 Cedar Birch Lane Orient Point, NY 11957 This is to certify that the above mentioned has a cesspool system consisting of cement blocks main cesspool, cement blocks overflow cesspool and precast cement overflow, with a capacity of more than 3 000 gallons. System in good working condition. Very truly yo~frs (-~, PECONICXTESS~OOL in'~ ': Lesz'ekqVIa~iorowsk~. President Suffolk County License Number 43857-LW GENERAL AFFIDAVIT STATE OF COUNTY OF · PERSONALL. Y came and appeared before me, the undersigned Notary, the within named 'x _~. ~ ! ~ _~_L")b/.l~. ~ , who is a resident of GO~---C)L{'~ County, State of ~,)~'A/x-J ~bQ,~--x_ , and makes this his/her statement and General Affidavit upon oath / and affirmation of belief and personal knowledge that the following matters, facts and things set forth are true and correct to the best of his/her knowledge: Signature of Affiant SWORN to and subscribed before me, this thed~day of "~/.~J'~k ~ 20//. CHRISTINA VOLINSKI NOTARY PUBLIC-STATE OF NEW YORK NO. Ol-V06105050 Qualified In Suffolk COunty PUBLIC - BUILDING PERMIT EXAMINER CHECKLIST *Date Submitted: ~ ~-~1 Date Reviewed: A'rchitee~ngineer: ~ ~ Estimated Cost: SCTM#1000-- I-~'--- ~- ~-7 Subdivision: ~ Property Address: ~ 7 0 ~ ~C~ ~ City: Zone: ~-~00 Conforming? 0 ~ Pre COs? Building Permits (Open/Expired): BP__-Z / C/0 Z-__, Info: BP -Z / C/0 Z- ., Info: Single & Separate Search Required? Y o/N~etermination: STog t~,'s~tAqr!~R.. Rtt td~,F-~,, REQ. Lot Size: c'Z°0 ~ ACT. Lot Size: &% ~2-a (, ~,~',~_~ REQ. Lot Coy. ACT: Lot Coy. R.EQ. Front ACT. Front REQ Side ACT. Side REQ. Rear PROP· Rear REQ. Height. ACT. Height RE~. $oT8 $10~'5 ,ti ~'F If yes, water body: Panel# Flood Zon~ ' ' Bulkhffa~'/Bluff Dis{~ance: ~ ADDITIONAL APPROVALS REQUIRED pla a/._q' (%) ,,cl6W~-D, S~-,~/..~I~ Ot~$u¢ve.¥ ~ Suffolk County Health: Y 0 If yes, *BedO: *Date: / / *Permit~ Town Septic: - If no, certification required: Y or N Received: Y or N By: ~S D~C: PR~DEcg/I/7~ Y O~- Date: / / Permit ~: or NJ Le~ter- Notes: Southold Trustees: Y 0r~- Date: / / Permit ~: or NJ Letter - Notes: Southold ZBA: Y or~- Date: / Permit ~: - Notes: Southold Planning: Y o~- Date: / /__ Permit ~: - Notes: Town Landmark C of A: Y ~TE: / / *~S CODE ~ompliance ~age 2~r N Fee Structure: Calculation: Foundation:SF 77 X;. 4 /.xv , g o First Floor: .~ 7'7 SF + hfitial Fee: $ ~ 0 , ~t9 Second Floor: SF + Additiongl Fee ( ): $ Other: SF SF X $, --$ Total: SF + Initial Fee: $ ):$ 3 .~, y'o 7or, 60 NEW YORK STATE CODE COMPLIANCE CItECICLIST CLIMATIC/GEOGRAPHIC DESIGN CRITERIA: Oroumt Snow Load: ~0 Weathering: Severe__ .'Fr°st Depth: 36"__ Design Temp: 11 ' Ice Shield Underlay: YES USE/OCCUPANCY CLASSIFICATION: HBIGIilT/FIRE AREA: TYPE OF CONSTRUCTION: DESIGN CRITERIA: ENGINEERED/pREscRIPTIVE FULL FR/AMING DESIGN ELEMENTS: Y/N HEADERS: YfN WALL STUDS: YfN CEILING JOISTS: Y/N FLOOR JOISTS: LUI~BER SPECIES A-ND GRADE: YIN Wind Speed: 120MPH Seismic Design Category." B Termite: M-H ' Decay: S-M Flo~d Hazabds: GII2:D ERS: YfN ROOF IL&FTERS: YfN WINDOW AND DOOR SCHEDULE: MISSLE TEST REQUIREMENTS: Y/N EGRESS 5.7 S.F.: Y/N LIGHT 8%: Y/N lrENT 4%: Yffq NAILING/CONSTRUCTION SCHEDULE: Y/N MEANS OF EGRESS: Y/N PLUMBING RISER DIAGRAM: Y/N LOCATION OF FIRE PROTECTION EQUIPMENT: Y/N TRUSS DESIGN: ¥/N CERTIFICATION: Y/N ENERGY CALCS: Y/N (R~$¢}IECK) TOTAL COMPLIENCE7 Y/N (RETURN TO PACE ONE) CONSENT TO INSPECTION Owner(s)Name(s) , the undersigned, do(es) hereby state: That the undersigned (is) (are) the owner(s) of the premises in the Town of Southold, located at which is shown and designated on the Suffolk County Tax Map as District 1000, Section /~- ,Block ~ ,Lot ~"~ That the undersigned (has) (have) filed, or cause to be filed, an application in the Southold Town Building Inspector's Office for the following: _ That the undersigned do(es) hereby give consent to the Building Inspectors of the Town of Southold to enter upon the above described property, including any and all buildings located thereon, to conduct such inspections as they may deem necessary with respect to the aforesaid application, including inspections to determine that said premises comply with all of the laws, ordinances, roles and regulations of the Town of Southold. The undersigned, in consenting to such inspections, do(es) so with the knowledge and understanding that any information obtained in the conduct of such inspections may be used in subsequent prosecutions for violations of the laws, ordinances, roles or regulations of the Town of Southold. Dated: ~ ~ (Signature)_ . t~-rlnt IN ame) (Signamre) (Print Name) Town Hall Annex 54375 Main Road P.O. Box 1179 Sou~old, NY 11971-0959 7 o BUII.I~ING DEPARTMENT TOWN OF $OUTHOLD APPLICATION FOR ELECTRICAL INSPECTION BY: Company Name: Date: Name: License No.: Address: Phone No.: JOBSITE INFORMATION: *Name: *Address: *Cross Street: *Phone No.: Permit No.: Tax Map District: (*Indicates required information) 1000 Section: /'~ Block:, *BRIEF DESCRIPTION OF WOR~ (Please Pdnt Clearly) ' (Please Circle All That Apply) *Is job ready for inspection: *Do you need a Temp Certificate: / NO NO Temp Information (If. needed] *Service Size: 1 Phase 3Phase 100 *New Service: Re-connect Underground Additional Information: Rough In Final 150 200 300 350 400 Other Number of Meters Change of Service Overhead PAYMENT DUE WITH APPLICATION 82-Request for Inspection Form N/o/F cATHERINE SEEwALD A T ORIENT TO ~N OF SOUTHOLD SUFFOLK COUNTY, N.Y. I000-15-08-P? SCALE. 1'--30' AUOUST 20, 200~ I~ARCN I0, 2010 JANICE ROBI NSONi 670 CEDAR BIRCH LANE ORIENT NY GARAGE CONVERTED TO ART STUDIO , I ELECTRICAL INSPECTION REQUIRED COiV]PLY WITH ALL CODES OF NEW YORK STATE & TOWN CODEE AS REQUIRED ~THOLD TOWN ZBA~-' ,~-/~%-~ SOU~NING BOARD · (~ J $OU/g,T~OLDTOWNTRU~I'r~S~ ,,.4'q.¥,S, DEC ,~ ~PROVED AS NOTED r~,. ,~ , .~ ,',u DEPARTMENT AT :,,, , '1 r,) 4 FM FOR THE 1 ~' ,II~I~A] i% i~voR~QUiRED ~LECTRICAL & aAUkKING 4 ' ',AL CONSTRUCTION ~ ELEOT~IgAL Mo ~ T B~ COMPLETE FOR C,O, ALL CONSTRUCTION 8HALL MEET THE' R~OUlREMENT8 OF THE O00E8 OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN O~ CONSTEU~TIONERROR~, J/ NICE ROBINSONi 670 CEDAR BIRCH LANE ORIENT NY GARAGE CONVERTED TO ART STUDIO YU ~USE % ~,,,,f -T-,Cp. ii