Loading...
HomeMy WebLinkAbout28379-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-29007 Date: 10/22/02 THIS CERTIFIES that the building ADDITION Location of Property: 105 SECOND AVE (HOUSE NO.) (STREET) County Tax Map No. 473889 Section 67 Block 2 Sutxiivision Filed Map No. __ Lot 17 Lot No. PECONIC (H3~MLET) conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 10, 2002 pursuant to which Building Permit No. 28379-Z dated MAY 13, 2002 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 SECOND STORY DECK ADDITION AND REPLACEMENT OF FIRST FLOOR DECK STEPS ON AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to STANLEY & SHIRLEY OFFICINA (OWNER) of the aforesaid building. SUFFOLK COUNTSf DEPARTMENT OF ~RALT~ APPROVAL ELEt-rKICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DA'r~3 Rev. 1/81 N/A N/A N/A 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. 28379 Z Date MAY 13, 2002 Permission is hereby granted to: STA/qLEY OFFICINA 19 SIMPOSON DRIVE OLD BETHPAGE,NY 11804 for : CONSTRUCTION OF A SECOND STORY DECK ADDITION AND REPLACEMEN'? OF EXISTING FIRST FLOOR DECK STEPS AS APPLIED FOR WITH FLOOD PERMIT at premises located at 105 County Tax Map No. 473889 Section 067 pursuant to application dated MAY Building Inspector. Fee $ 250.00 SECOND AVE SOUTH/PEC Block 0002 Lot No. 017 10, 2002 and approved by the Rev. 2/19/98 COPY 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 lbllowing: Bo 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. 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. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - $25.00 4. Updated Certificate of Occupancy- $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 / Date. New Construction: Old or Pre-existing Building: t/~ (check one) Location of Property: //d:L~'"- ,2. /~._o .ZCty.~/v'~ ~--_ House No. Street Hamlet Owner or Owners of Property: .--D~-w,~'~ c.-/ ~'( ~C'/,.'/.,~ L ~-~ O/~--/--/c~/,4//9 Suffolk County Tax Map No 1000, Section ~'~ '- 0(vT Block000 ~ · 00 Lot 0 I'7. Subdivision Permit No. ~t._'-~ 5 -/q '~.- Health Dept. Approval: Filed Map. Date of Permit. O ~ //~ ? )-oo -wApplicant: -..~?TY~'~ / , Underwriters Approval: Lot: Planning Board Approval: Request for: Temporary Certificate Fee Submitted: $ ~P ~. C~ c) Final Certificate: (check one) Appli~nature NATIONAL FLOOD INSURANCE PROGRAM ELEVATION CERTIFICATE Important: Read the instructions on pa~les 1- 7. SECTION A - PROPERTY OWNER INFORMATION O.M.B. No. 3067-0077 Expires July 31, 2002 BUILDING (~ER'S NAME Stanley Officina BUILDING STREETADDRESS (Including Apt., Unit, Suite, and/or Bldg. No.) OR P.O. ROUTE AND BOX NO. 105 Second Avenue CITY STATE ZIP CODE Peconic NY 11958 PROPERTY DESCRIPTION (Lot and Block Numbers, Tax Parcel Number, Legal Description, etc.) SCTM #1000-67-02-17 BUILDING USE (e.g., Residential, Non-residential, Addition, Accessory, etc. Use a Comments area, if necessary.) Residential LA 111UDE/LONGITUDE (OPTIONAL) ( ~e-~/'-f~.~¢' or ~..'.';.'.:'.'.':."') HORIZONTAL DATUM: [] NAD 1927 r-I NAD 1983 SOURCE: [] GPS (Type):__ [] USGS Quad Map [] Othec SECTION B - FLOOD INSURANCE RATE MAP (FIRM) INFORMATION B1. NFIP ~NITY NAME & COMMUNITY NUMBER Town of SoulhoU 360813 B2. COUNTY NAME Suffolk B4. MAP AND PANEL NUMBER 161 B5. SUffiX G B6. FIRM INDEX DATE 5/4/98 B7, RRM PANEL EFFECTiVE/REVISED DATE 5/4/98 BS, FLOOD ZONE(S) B9. BASE FLOOD ELEVATiON(S) {7.one AO, use depth of fl(xxthg) 11 B10. Indicate the source of ~e Base Flood Elevation (BFE) data or bese flood depth entemci in B9. [] FIS Profile [] FIRM [] ~nity De~ermined [] Olher (Desc~be):__ Bll. Indicate the eleva~on datum used forthe BFE in B9: [] NGVD 1929 [] NAVD 1988 [] Other (Describe): __ B12.~s~hebuildin~catedinaC~asta~Ba~erReenurcesS~tem~cBRS~area~r~th~wisePr~ectedArea~PA~? []Yes I--INo Desi~lnationDate SECTION C - BUILBING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building deva~ns are based on: [] Cons~n,::~n Drawings* [] Building Under ~* [] Finished C. x3nst~3n *A new Beva~on Cede will be required when const~on of ~3e building is compete. C2. Building Diagram Number 5 (Sdect the building diagram most similar to the building for which this ce'ifrx;ate is being completed - see pages 6 and 7. If no diagram accurataly represents the building, provide a ske~h or photograph.) C3. Elevalms- Zones Al-A30, AE, AH, A (w~ BFE), VE, V1-V30, V (with BFE), AR, AR/A, AR/AE, AR/A1 -A30, AR/AH, AR/AO Cornl~ete Items C3.-a-i below amording to the building diagram specified in Item C2. State the datum used. If t~ datum is different from the datum used for lhe BFE in ~ B, convert the datum to that used for the BFE. Show field measurements and datum conversion ~culaJon. Use the space provided or the Ccmrnents area of Sec~on D or Sed~)n G, as approp~ate, to decument the dalum conversion. Datum NGVD Conv~ments ElevaJonreferencemakused1929Deestheelevationreferencemakusedapbearon~eFIRM? []Yes [-INO o a) Top of bottom ~ (including basement or enclosure) 11.7ft.(m) o b) Top of next higher Ifoor 20.7 ff.(m) o c) Bottom of lowest horizontal structural member (V zones only) __ _~t.(m) o d) Attached garage (top of slab) . _fl,(m) o e) Lowest alevaJon of machinery and/or equipment savidng the building (Desc~be in a Comments area) __ _ft.(m) o f) Lowest edjscent {Itnish~d) grade (LAG) 4.3ft.(m) o g) Highest adjacent (finished} grade (HAG} _8. 9ft.(m) o h) No. of pamanent openings 01cod vents) within 1 ft. ~ove edjacent grade__ o i) Total area of all permanent openings (Ex~d vents) in C3.h __ .sq. in. (sq. cra) SECTION D - SUEVEYOR, 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. I certify that the information in Sections A, B, and C on this certificate 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 1001. CERTIFIER'S NAME Robed O'B~en P.E. LICENSE NUMBERO52714 TITLE President COMPANY NAME Rd~etO'BdenP. E. P. O. Box,~..4,~:~74 Main/J~ ....../ -~ CITY Laurel STATE ZIP CODE NY 11948-0456 DATE 10/17/02 TELEPHONE 631-298-5252 FEMA Form 81-31, JUL 00 SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS © © ©. j'[,~Jgf.TH T. T.E;-~RY TOWN C LETCK i~GiSTRI~d'~ OF V'IT/'d. ~TATIS~ICS ~^I2fllAG E OFFICIal2 IZI~COI~!)$ NCA~AGI~MENT OF`F'ICF~N oF' INF'OI2J~ATIOIN OF'I;ICEI~ 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)]. BLDG. DER?. TOWN OF S0"J~O~__.._.J: T. 'l;err¥ Southold Town Clerk August 25, 1993 '. ', APPLICATION PAGE I of 4 TOWN OF SOUTHOLD FLOODPLAIN DEVELOPMENT PERMIT APPLICATION This form is to be filled out in duplicate. ~_ECTIQN I: GENERAL PROVISIONS (APPLICANT to read and sikh]: 1. No work may start until a permit is issued. 7- The permit may be revoked if any false statements are made hcreba. 3. Il' revoked, all work must cease tmtil permit is re-issued. 4. Development shall not be used or occupied until a Certificate of Compliance i~ i_~sued. 5. The permit will exph-e if no work is commenced within six months of issuance. 6. Applicant is hereby informed that other permits may be required to fuffdl local, state &nd federal regulatory requircments. 7. Applicant hereby gives consent to the Local Adm;ni<trator or hi~/ber representative to make ica.sortable inspections required to verify compliance. 8. I, THE APPLICANT, C~RTII:'Y THAT ALL STATEMENTS HEREIN AND IN ATTACHMENTS TO _ THIS APPLICATION ARE, TO THE~GE, TRUE AND ACCUP,.ATE. SECTION 2: PROPOSED DEVELOPMENT (To be completed bv APPLICANT) NAME ADDRESS TELEPHONE APPLICANT BUll DER pROJECT LOCATION: To ,,void delay in prooe&4ag thc appllcadoa, please provide enough information to easily identify thc project Iocatiom Provide the ~treet addr~'-s% lot number or legal description (attach) =nd, outside urban ~reas, the distance to the ne. treat intersecting road or well-knoua~ [~dm~l'lG A sketch attached to th;< application showing the project location would be helpful. FOP(93) A.P PLICATtON ~ PAGE 2 OF ,~ DESCRIPTION OF WORK (Check all appticablc ,boxes): A. STRUCTURAL DEVELOPMENT ^CrIWTY [] New Structure ation [] Relocation [] Demolition [] Replaca:meat STRUCTURE T~PE ~Residential (1-4 Family) C] Residential (More than ,~ Family) [] Non-residential (Floodproo£mg? [] Yes) [] Combined Use (Residential & Commercial) [] Manufactttred (Mobile) Home (In Manu- factured Home Park? [] Yes) ESTIMATED COST OF PROJECT B. OTHER DEVELOPMENT ACTIVITIES: ~ [] Mining ~ Drilling O Grading [] Excavation (Except for Structural Development Checked Above) · [] Watercourse Alteration (Including Dredging and Channel ModLficadons) [] Drainage Improvementz (Including Culvert Work) [] Road, Street or Bridge Construcxion [] Subdivision (New or Expansion) [] Individual Water or Sewer System El Other (Please Specify). After completing SECTION 2, APPLICANT should submit form to Local Ad. mi-intrator for review. SECTION 3: FLOODPLAIN DETERMINATION (To be completed Ipv LOCAL ADMINISTRATOR) The proposed development is located on FI]R/vi Panel No. , Dated The Proposed Development: El Ia NOT located ia a Special Flood Hu~'urd Area (lqo6fy the applicant that the application review ia complete and NO FLOODPLAJ. N DEVELOPMENT P~ IS REQUrRED). ~ Iz located in a Spe. eial Flood H,?:*rd Are. a. FFR. M Zone de~'~i~nation is 100-Year flood elevation at the site i& Ft. NGVD (MSL) O Unavailable [] The proposed development is Ioca{ed in a floodway. FBFM Panel No. Dated DATE / × · A~t, PLICATION # PAGE 3 OF ,~ SECTION ,~: ADDITIONAL INFORMATION REQUIRED {'To be completed bv LQCAL ADMINISTRATOR] Thc applicant must submit thc documents checked below before the application ca~ be processed: [] A site plan sboWmg thc location of all cx~stmg structures, water bodies, adjacent roads, lot dimensions and proposed development. [] Development plans, drawn to scale, and speCificat~ns, including where applicable: details for anchoring structures, proposed elevation of lowest floor (indudLag basement), Iypes of water resistant materials used below the £trst floor, details of floodproo£mg of utilities located below the first floor and details of endosu.res below thc first floor. AJso, Subdivision or other development plane (If the subdivision or other development exceeds 50 lots or 5 a~es, whichever ks the lesser, the applicant must provide tOO-year flood elevations ff they are not othezwise available). Plans showing the extent of watercourse relocation and/or landform alterations. Top of new fill elevation Ft. NGVD (MSL). F'loodproofmg protection level (non-residential only) Ft.' NGVD (MSL). For floodproofed structures, applicant must attach certification from registered engineer or architect. Certification from a registered engineer that the proposed activity in a regulatory lloodway will not result La any increase in the height of the 100-year flood. A copy of all data and calculations supporting this findLag must also be submitted. Other: SECTION $: PERMIT DETERMINATION (To be comt~lcted by LOCAL, ADMINI$;TRATOR') I have determined that the proposed activity: A. V1 Is B. VI Is not La conformance with provisions of Local Law ~P __. 19 . The permit ks issued subject to the couditio~ attached to and ' · /-- APPLICATION PAGE 4 OF ~ APPfLAJ~: Appealed to Board of Appeals? I~] Y~:s [] No Hearing date: Appeals Board Decision --- Approved7 [] Yes Conckitions [] No SEC~]ON 6: AS-BUILT ELEVATIONS (To be submitted bv APPLICANT before CertLficate of Compliance is issued) The following information mnst be provided for project structures. This sec_~ion mu~t be completed by a registered professional engjneer or a licensed land surveyor (or attach a ccrtLficafion to tlxb application). Complete 1 or 2 below. Actual (As-Built) Elevation of the top of the lowest floor, including basement (in ..Coastal High .Hazard Areas, bottom of lowest structural member of the lowest floor, excluding piling and columns) i,:: FT. NGVD (MSL). 2. Actual (As-Built) Elevation of floodproo£mg protection is FT. NGVD (MSL). NOTE: Any work performed prior to submittal of the above information i~ at the risk of the Applicant. SECTION 7: COMPLIANCE ACTION (To be completed .by LOCAL ADMINISTRATOR) The LOCAL ADMINISTRATOR vKll complete this section as applicable based on inspection o£ the project to ensure compliance with the community's local law for flood damage prevention. INSP]~CTIONS: DATE BY DEFICIENCIES? [] YES El NO DATE BY DEFICIENCIES? [] YES [] NO DATE BY DEFICIENCIES7 E] YES E] NO SECTION 8: CERTIFICATE OF COMPLIANCECFo be comr~leted by LOCAL ADMINI~;TRATQR) · C~rtiiqcate of Compliance issued: DAx'~ 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 ~ AREA (O~q'qER MUST RETAIN THIS CERTIFICATE) PREMISES LOCATED AT: PERMIT NO. PERMIT DATE OWNERS NAME A/qD ADDRESS: CHECK ONE: El NEW BUILDING [] EXISTING BUILDING [3 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 # , I9__, AS MODIFIED BY VARIANCE # DATED SIGNED: DATED: C/C(93) BUILDING PERMIT EXAMINER CHECK LIST APPLICANT: C)~-.~,'c,'.,., ~ SCTM# DISTRICT: .1,000, SECTION: _ ~9 , BLOCK: 2 , LOT: ~'¢ STREET ADDRESS: lOT ~zco~,l'r~ ~___ CITY: ~ SUBDIVISION: PROJECTDESCRIPTION:~-~-cc_~-m'-~'~oa-'~-c_~ ~ID. ~ "~aa-r F~z-x~ 3 ESTIMATED PROJECT COST: <:~ ~'lc._ ARCHITECT / ~IxTGTi~R: ~l~-~ FAST TRACK? DATE ISSUED: / /02 DATE REVIEWED: ._6 / ~% /02 DATI~'SUBMITTED: 2.5 /~o/02 ,dc, SINGLE & SEPARATE CERT[FICATION-REQLIIRED? /Vo NOTES: ~ LOTS 40,000SF -100-24 Lot recognition (CIOZAq ED before June 30, 1983), UNDEP,.SIZED LOTS FROM JAN.1997 10%25 Me~ger.(A nonconforming at any time after 7/1/~: ZONING DISTRICT: ~t[O CONFORMING? Ho REQ. LOTSIZE:Dd~o00_ACT. LOTSIZE:~),qq~ REQ. LOTCOV. ~o~ ACT. LOTCOV. REQ. FRONT PROP. FRONT REQ SIDE ACT. SIDE REQ. REAR PROP. REAR ,~'o c ,~,',"~¢t~ /~, ~ ~',~ r- / WATER FRONT? A/° DESCRIPTION: PANEL #: ~=/_ FLOOD ZONE: /"4~--(,~d- APPROVALS REQUIRED SUFFOLK COUNTY HEALTH DEPT: YES or~.~ (BED #):__ DTE: / / PERMIT #:R10- TOWN SEPTIC RECEIPT: Y NEW YORK STATE DEC: rue-ucc 9/v?s YES or SOUTHOLD TOWN TRUSTEES: YES or TOWN ZONING BOARD APPROVAL: YES or TOWN PLAN. BOARD APPROVAL: YES or TOWN HISTORICAL PRE (SPLIA): YES or NYS ENERGY: YES OR NO : EGRESS (18 H min.? 4 sq total) ~., F't~ VENT (SQ. FT. x 4%). /~/r:3'-LIGHT (SQ. FT. x 8%). ,~,~ BUILDING PERMITS OPEN/E~D: BP& HAVE PRE CO'S: Y OR N BP -Z / C/0 Z- NOTES: FEE STRUCTURE: FOUNDATION: FIRST FLOOR: SECOND FLOOR: OTHER: TOTAL: 1. ( SF)- ( SF)= SF X $ 2. ( SF)- ( SF)= SF X $ SF SF SF SF INIT OTHER TOTAL SF FEE FEE FEE --$ +$ +$ --$ /Co 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION2ND [ ]INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY R£MAR~KS: - 6/ - ~/ - . 765-1802 BUILDING DEPT. INSPECTION [ ] ROUGH PLBG. [ ] FOUNDATION I ST [. ] I~TION [ ] FOUNDATION 2ND [ ] FRAMING ~ FINAL [ ] FIREP~A~C/~NEY REMARKS. ~ -'--"--, DATE ~~~INS FIELD /NSPECTION REPORT I DATE I COMMENTS FOUNDATION (2ND) ROUG~ F~ING & PLUMB~G ~ / ~ TOWN OF SOUTHOLD BUIL'DING DEPARTMENT TOWN HALL SOUTHOLD, NY 11971 TEL: 765-1802 Examined ,~/! Approved / Disapproved a/c ,20 ,20 ~ PERMIT NO. BUILDING PERMIT APPLICATION CHECKLIST Do you have or need the following, before applying: Board of Health 3 sets of Building Plans Survey. Check Septic Form N.Y.S.D.E.C. Trustees Contact: Mail to: Robert O'Brien P.E. _PO Box 456, Main Rd, Laurel, N Y. 11948 Phone: 631-298-§252 May 10, ,2002 Building Inspector LICATION FOR BUILDING PERMIT BLU'~ r ~,r Da~ ...................... ~STRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submiued to the Building Inspection 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 Permit. 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 a Certificate of Occupancy is issued by the building Inspector. 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, ad 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 remises and in building for necessary inspections. ~~eT if a P.O. Box 456, Main Road Laurel, New York 11948-0456 (Mailing address of applicant) corporation) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Engineer Name of owner of premises Stanley and Shirley Officina (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 proposed work will be done: 105 Second Avenue House Num0er Street County Tax Map No. 1000 Section 67 Subdivision N^w ,,~..~ Of~,J~AO A~.~IA, Peconic, ~ ..lJ~'lRa~t~ to ,~ ,:il~ 9 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 Single family residence b. Intended use and occupancy Same 3. Nature of work (check which applicable): New Building Repair Removal Demolition 4. Estimated Cost $5,000.00 5. If dwelling, number of dwelling units 1 If garage, number of cars Addition Alteration Other Work 2"a floor rear deck (Description) Fee $150 (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 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 §0 Depth 150 10. Date of Purchase 4/02 Name of Former Owner Barbara Kunen 11. Zone or use district in which premises are situated 12. Does proposed construction violate any zoning law, ordinance or regulation: No 13. Will lot be re-graded yo_.q 14. Names of Owner of premises Officina Name of Architect Name of Contractor Will excess fill be removed from premises: YES NO 19 Simpson Drive Address Old Bethpage, NY Phone No. 516-694-5777 Address Phone No. Address Phone No. 15. Is this property within 100 feet of a tidal wetland? *YES NO X · IF YES, SOUTHOLD TOWN TRUSTEES 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~) Robert O'Brien P.E. being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the Agent (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 me 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 /Dm dayof 20o ~.-- Notaxy Public Signature of Applicant ~~ OCCUPANCY OR ..~.__~[~ ~~ USE IS UNLAWFUL ~OT,. OUI~ING ~~ WITHOUT CERTIFICRTE 1. PUUNDAT . x ~ ~ , ~ -~l ~ ~~DE. NOT R ~ ~ -- ~ IBLE F ~ ~ L_,--~I - ,I |I : , ~,~ ..[.[ ' L . .,. '~~ -[ 1 / ~" ~:'.-2 .~.. .