HomeMy WebLinkAbout40277-Z Town of Southold 3/4/2018
P.O.Box 1179
_ 53095 Main Rd
O?' Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 39539 Date: 3/5/2018
THIS CERTIFIES that the building RESIDENTIAL REPAIRS
Location of Property: 65490 Route 25, Greenport
SCTM#: 473889 Sec/Block/Lot: 53.-5-12.6
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
11/12/2015 pursuant to which Building Permit No. 40277 dated 11/18/2015
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:
alterations and additions, including foundation, porch and two landings to an existing seasonal cottage(#3)as applied
for.
The certificate is issued to Breezy Shores Comnty Inc
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO. 40277 6/6/2017
PLUMBERS CERTIFICATION DATED
ut ed Signature
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#: 40277 Date: 11/18/2015
Permission is hereby granted to:
Breezy Shores Comnty Inc
PO BOX 925
Mattituck, NY 11952
To: make alterations/repairs to existing Cottage #3 as applied for with flood permit.
<�S b1n a.i
At premises located at:
65490 Route 25, Greenport
SCTM # 473889
Sec/Block/Lot# 53.-5-12.6
Pursuant to application dated 11/12/2015 and approved by the Building Inspector.
To expire on 5/19/2017.
Fees:
CO -ALTERATION TO DWELLING $50.00
SINGLE FAMILY DWELLING -ADDITION OR ALTERATION $200.00
Flood P $100.00
Total: $350.00
Building Inspector
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. Final survey of property with accurate location of all buildings, property lines, streets,and unusual natural or
topographic features.
2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 form).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead.
5. Commercial building, industrial building,multiple residences and similar buildings and installations, a certificate
of Code Compliance from architect or engineer responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
B. For 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$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00,
Swimming pool $50.00,Accessory building$50.00,Additions to accessory building$50.00, 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 $15.000
Date.
New Construction: Old or Pre-existing Building: (check one)
Location of Property: (�D $ 3 �i Z�( ,� c � B/I,� s6 kcr�
House No. Street Hamlet
Owner or Owners of Property: 6/1111— L.8m_A6
Suffolk County Tax Map No 1000, Section Block Lot
Subdivision Filed Map. —.Lot:
Permit No. 0/ Date of Permit. Applicant:
Health Dept. Approval. Underwriters Approval:
Planning Board Approval-
Request
Request for• Temporary Certificate Final Certificate: V (check one)
Fee Submitted: $ 5o '60
pplica t gnature
ho�"�'pF SOUryDlo
Town Hall Annex Telephone(631)765-1802
54375 Main Road Fax(631)765-9502
P.o Box 1179 o roper.richert( -town.southoId.ny.us
Southold,NY 11971-0959 Q
BUILDING DEPARTMENT
TOWN OF SOUTHOLD
CERTIFICATE OF ELECTRICIAL COMPLIANCE
SITE LOCATION
Issued To. Breezy Shores Community Inc. (Columbo)
Address: 65490 Route 25 (3-Sage Blvd.) City Greenport st: New York zip. 11944
Building Permit#: 40277 Section: 53 Block: 5 Lot: 12.6
Contractor: DBA. Custom Lighting of Suffolk License No: 38893-MA
SITE DETAILS
Office Use Only
Residential X Indoor X Basement Service Only
Commerical Outdoor X 1st Floor Pool
New Renovation 2nd Floor Hot Tub
Addition Survey Attic Garage
INVENTORY
Service 1 ph 200A Heat Duplec Recpt Ceiling Fixtures HID Fixtures
Service 3 ph Hot Water GFCI Recpt Wall Fixtures Smoke Detectors
Main Panel 200A A/C Condenser Single Recpt Recessed Fixtures CO Detectors
Sub Panel A/C Blower Range Recpt Fluorescent Fixture Pumps
Transformer Appliances Dryer Recpt Emergency Fixture Time Clocks
Disconnect 200A Switches Twist Lock Exit Fixtures tj TVSS
Other Equipment: 200A Underground Service.
Notes:
Inspector Signature: Date: June 6, 2017
0-Cert Electrical Compliance Form.xIs
�OY .000) ��OF SO(/jyo
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802 —
INSPECTION
[ ] FOUNDATION IST [ ] ROUGH PLEIG.
[ ] FOUNDATION 2ND [ ] I ULATION
[ ] FRAMING / STRAPPING FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
REMARKS: SkAf� it� i4ulm,�,
DATE wto ANSPECTOR
oy � oFso�lyo
TOWN OF SOUTHOLD BUJILDING DEPT.
765-1802
INSPECTION
[ ] FOUNDATION 1ST- [ ] ROUGH PLEIG.
[ ] FOUNDATION 2ND [ ] ULATION
[ ] FRAMING / STRAPPING [ FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ) ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
REMARKS:
DATE INSPECTOR
t: 1 1 0 . • . ��� s t !a
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STA TE RNEROY • t
P725
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TOWN OFAOUTHOLD BUILDING PERMIT APPLICATION 6HECKLIST
BUILDING DEPARTMENT Do you have or need the followi`ng,'bef&e applying?
TOWN HALL Board of Health
SOUTHOLD, NY 11971 4 sets of Buildmg Plans
TEL: (631) 765-1802 Planning Board approval
FAX: (631) 765-9502 Survey
SoutholdTown.NorthFork.net PERMIT NCheck
Septic Form
N.Y.S.D.E.C.
Trustees
(, r' C.O.Application
D '
Flood Permit
Examined ,20 Single& Separate
/�( ) <'n[ SEP 1 7 2015 Storm-Water Assessment Form
Contact:
Approved ,20 BLDG DEPT Mail to: T
Disapproved a/c T'!'f•0' Oc i i;.�i D
Phone: &?2) - 14 Z.
Expiration ,20
l I�; �<<� � � �� � � j::hs ec or _
PLICATION FOR BUILDING PERMIT .
NOV 1 2 2015 '
_ Date � , 20�
R; x;. �FP; INSTRUCTIONS
TOWN0f gri111110LD
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 will issue a Building Permit to the applicant. Such a permit.
shall be kept on the premises available for inspection throughout the work.
e.No building shall be occupied or used in whole or in part for any purpose what so ever until the Building Inspector
issues a Certificate of Occupancy.
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 construction of buildings, additions, or alterations or for removal or demolition as herein described. The
applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to admit
authorized inspectors on premises and in building for necessary inspections.
(Wknat6e o a is t or name, if a corporation)
ailing add ss of applicant)
pplicant) �—
State whether applicant is owner, lesse , age , architect engineer, general contractor, electrician,plumber or builder
Name of owner of premises
(As on i.he 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:
-AL,,E�3 "&g6z�Z D _
House Number Street Hamlet
County Tax Map No. 1000 Section C}2_2 Block (��' Lot �2.
Subdivisiori� 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 ;,R �F
b. Intended use and occupancy
3. Nature o£,work(check which applicable): New Building Addition Alteration i
Repair Removal Demolition Other Work T—
/�D�4Tio�1 ge:P'A-1P- s L Dr RapZAf' of -TT (Description)
4. Estimated Cost 4 2-L9, Czx�- Fee
(To be paid on filing this application)
5. If dwelling, number of dwelling units / Number of dwelling units on each floor
If garage, number of cars
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use. (�//�--
7. Dimensions of existing structures, if any: Front '/ g Rear Depth 2
Height Number of Stories
Dimensions of same structure with alterations or additions: Front Rear
Depth Height Number of Stories
8. Dimensions of entire new construction: Front Rear Depth
Height Number of Stories
9. Size of lot: Front Rear Depth �.(O L�
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 NOJZ�Will excess fill be removed from premises? YES NO
14. Names of Owner of remisesO-btyk,&D Address Phone No.2)2--.n4- 670/
Name of Architect Address Phone No 1p�- "FJ`L
Name of Contractor Address Phone No.
15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES /� NO
* IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED.
b. Is this property within 300 feet of a tidal wetland? * YES e"— 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.
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 OF5yffi V
being duly sworn, deposes and says that(s)he is the applicant
(Name of individual signing contract)above named,
(S)He is the k
(Contracto , 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 true 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
)7�' day of Se D+f'�� 2015 TRAC
T' NOTARY PUBLICC,,STATE
OOF F NEW
W YORK
d NO.01 DW6306900
au 14 - QUALIFIED IN SUFFOLK COUNTY
Notary Pu c COMMISSION EXPIRES J nature of Applicant
. r r: h. r •rk, .ti,rr•: h1• :: ". ,\.,moi' �� h rrr .; Vil..�r,_: '.
•l•�' � l- �� ;fes-, - _ ',.��-�' .,, � ,
s
`j BOARD.OF'SOUTHOLD TOWN TRUSTEES
SOUT�HOLD,NEW YORK �
PERMIT NO. 8687 DATE: OCTOBER 21,.2015
ISSUED TO ELENA COLOMBO
PROPERTY ADDRESS: 65490.ROUTE.25 .BREEZY SHORES COTTAGE #3
GREENP.ORT
SCTM# 1000=53-5-12.6
AUTHORIZATION r :i
Y �
Pursuant to the provisions of Chapter 275 of the Town Code of the Town of Southold and in
a ` accordance with the Resolution of the Board'bf Trustees adopted at the meeting held on October 21,2015,and
in consideration of application fee in the sum of$250.00 paid-by Elena.Colomboland subject-to the Terms and
Conditions as stated in the Resolution,the Southold Town Board•of`Trustees authonzes.and.permits the
following:
3
Iry
Wetland Permit to
'repai"r sections and replace sections of damaged-foundation•.of an 3
existing 1,045 sq.ft. cottage; and to replace the two existing cottage Iandings; and as
i
depicted on the site plan prepared by Robert I. Brown Architect, P.C. w/Fairweather
Design Associates, Inc., dated on October 20, 2015, and stamped approved'on October
21, 2015
h
IN WITNESS WHEREOF,the said Board of Trustees hereby causes its Corporate Seal to be affixed,
and these presents to be subscribed by a majority of the said Board as of this date. -
John M: 'B.redemeyer 1-1.1 - Absent ° r,
o�oOFe`o� =�
;- coo
rN, ,• ..;r I 1 :.• e:�/ 1 p �� .ir / 1 'l:rrl 1 � ,�.•S;irl� 1.::..•
.N r.. t-.�, r 4• ���r r rr• : ..lam r r::D�..
/ f
Michael J.Domino,President rjf SU(/TjyO Town Hall Annex
John M.Bredemeyer III,Vice-President ti0 lQ 54375 Route 25
P.O.Box 1179
Charles J.Sanders Southold,New York 11971
Glenn Goldsmith I • Telephone(631)765-1892
A.Nicholas KrupskiO Y Fag(631)765-6641
�y00UNT1,��
i
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
i
i
CERTIFICATE OF COMPLIANCE
# 1432C Date: December 8, 2017
THIS CERTIFIES that the repair of sections and replacement of sections of damaged
foundation of an existing 1,045 sq.ft. cottage; and to replace the two existing cottage landings-,
At 65490 Route 25i Breezy Shores Cottage#3,_Greenport
Suffolk CountylTax Map#1000-53-5-12.6
Conforms to the application for a Trustees Permit heretofore filed in this
office Dated September 24, 2015 pursuant to which Trustees Wetland Permit#8687
Dated October 21, 2015,was issued and conforms to all of the
requirements and conditions of the applicable provisions of law. The project
i
for which this certificate is being issued his for repair sections and replace sections of damaged
foundation of an existing 1,045 sq ft cottage• and to replace the two existing cottage landings.
The certificate is issued to ELENA COLOMBO owner of the
aforesaid property.
Authorized Signature
y
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BRF,EZY SHORE=S COMMUNITY INC
Sage Blvd.
Y
Greenport,NY 11944
i
August 31, 2015
f
Y
2
The Board of Directors of Breezy Shores Commune Inc. (BSCI) 2014/2015, consisting of
Elena Colombo. President (recused); Jim Sage, VP; E ob Welp, VP; David Nelson, Treasurer;
and Kathleen O'Neill, Secretary, hereby affirm that w have reviewed the repair and renovation
proposal for COLOMBO, cottage 3, which was prepare by:
t
a
c
Fairweather Design Associates,Inc. & Robert I.Brom,Architect P.C.
205 Bay Avenue
Greenport,New York 11944
Phone: 631-477-9752 1 Fax: 631-477-0973
and have no objections thereto, ft is-approved.
Thank you,
Kathleen O'Neill, Secretary.; on behalf of the Board of I' irectors
t
i
BREEZY SHORES COMMUNITY, INC. P.O. BOg 925 MATTITUCK, NY 11952
,boar_ reezshores om
peconiepaintinq@beilsc�ith.net
ROBERT I. BROWN, ARCHITECT P.0
205 Bay Avenue Greenport, NY 11944
631-477-9752 (fax)631-477-0973
info@ribrownarchitect.com
Transmittal
Date:
To:
Re:
Thank you, (�
Robert I Brown Architect PC
FEB 24 M
OBUMDMd DEPT.
TOWN OF SOUTHOLD
Scott A. Russell °SUl`Fq/r ST0]MMIWAT]ER,
SUPERVISOR ' AMIANAGIENIEN
SOUTHOLD TOWN HALL-P.O.Box 1179
53095 Main Road-SOUTHOLD,NEW YORK 11971
o Town of Southold
CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET
TO BE COMPLETED BY THE APPLICANT )
DOES THIS PROJECT INVOLVE AN�1Y OF THE FOLLOWING:
Yes No (CHECK ALL THAT APPLY)
❑[3\A. Clearing, grubbing, grading or stripping of land which affects more
than 5,000 square feet of ground surface.
El El B. Excavation or filling involving more than 200 cubic yards of material
within any parcel or any contiguous area.
❑Q C. Site preparation on slopes which exceed 10 feet vertical rise to
100 feet of horizontal distance.
❑❑ D. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
❑ E. Site preparation within the one-hundred-year f loodplain as depicted
-- - -on FIRM-Map of-any watercourse. -
❑� F. Installation of new or resurfaced impervious surfaces of 1,000 square
feet or more, unless prior approval of a Stormwater Management
Control Plan was received by the Town and the proposal includes
in-kind replacement of impervious surfaces.
If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name,
Signature, Contact Information, Date & County Tax Map Number! Chapter 236 does not apply to your project.
If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan
and a completed Check List Form to the Building Department with your Building Permit Application.
APPLICANT. Wroperty Owner Design Profess:oi I.Agent.C itractor 01 her! S.C..T.N1 1000 Date.
District
NA:,IE. 53 5 is
time Section Block Lot T
FOR, 13ULD'ItiG
Contact information:
Reviewed By
- - — — — — — — — — —
Dale:
Property- Address / Location of C.on.struction Work. — — — — — — — — — — — — — — — —
�ppro\ed for Nroces�tng Building Permit
�fcc2N SN r — — StormN�ater !`•tanagement Control Plan Not Required.
CA
��Jt'���► ❑ Stonii ater i•lanagement Coniml Plan is Regiiired.
(Fon\ard to Emlineeni), Department for Re%ie\\ i
FORNI k SNIC'P-TOS 'VI A Y 2011
APPt.1CATI()N a
PA(;E 1 of i
TOWN OF SOUTHOLD
FLOODPLAIN DEVELOPMENT PERMIT APPLICATION
This form is to be filled out in duplicate.
SECTION 1• GENERAL PROVISIONS (APPLICANT to read and stzn):
1. No work may start until a permit is issued.
2 The 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 issuancc.
6. Applicant is hereby informed that other permits may be required to fulf-riJ local, state and federal regulatory
re.quiremeats.
7. Applicant hereby gives consent to the Local Administrator or his/her representative to make reasonable
inspections required to verify compliance.
S. 1,THE APPLICANT, CERTIFY THAT ALL STATEMENTS HEREIN AND IN ATTACHMENTS TO
_ THIS APPLICATION ARE, TO TH BEST WO'VuLEDGI:,, TRUE AND ACCURATE.
(APPLICA
NT'S SS'*ATUR DATE `/�
SECTION 2: PROPOSED D LOPMENT (To be completed by APPLICANT)
NAME ADDRESS TELEPHONE
APPLICA1T4,',0,A
BUILDER I
ENGINEER yQ., .-(rl'�
-PRO= LOCATION:
• To avoid delay in processing the appficatioa, please provide enough information to easily identify the project
location. Provide the street address, Tot number or legal description (attach) and, outside urban areas, the
distance to the nearest intersecting road or well-known landmark. A sketch attached to this application showing
the project location would be helpful.
ADO- s
FDP(93)
APPLICATION 4 -
PAGE 2OF4
DESCRIPTION OF WORK (Check all applicable boxes)
A STRUCTURAL DEVELOPMENT
ACTIVTTY STRUCTURE. TYPE
❑ New Structure Residential (1-4 Family)
❑ Addition ❑ Residential (More than 4 Family)
❑ AJteration ❑ Non-residential (Flood proofing' ❑ Yes)
❑ Relocation ❑ Combined Use (Resldentlal & CommcraaJ)
❑ Demolition ❑ Manufactured (Mobile) Home (10 Manu-
�Repiacement factured Home Park) O Yes)
ESTIMATED COST OF PROJECTS 40
B. OTHER DEVELOPMENT AC 1VITIES.
❑ Fill ❑ Mining O Drilling ❑ Grading
❑ Excavation (Except for Structural Development Checked Above)
❑ Watercourse Alteration (Including Dredging and Channel Modifications)
❑ Drainage Improvements (Including Culvert Work)
❑ Road, Street or 13t 8ge Construction
❑ Subdivision (New or Expansion)
0 Individual Water or SaYET System
O Other (Please Specffy)'
After completing SECTION 2, APPLiCA14. T should submit form to Local Administrator for review.
SECTION 3. FLOODPLAIN DE'T'ERMINATION (To be comDlcic�v LOCAL ADMINISTRATOR)
The proposed development is located on FIRM Panel Dated
The Proposed Development:
❑ Is NQL located in a Special Flood Hazard Area (Notify the applicant that the application
review is complete and NO FLOODPLAIN DEVELOPMENT PERMIT IS REQUIRED).
❑ Is located in a Special Flood Hazard Arca.
FIRM zone designation is
100-Year flood elevation at the site is: Ft. NGVD (MSL)
❑ Unavailable
❑ The proposed development is located in a floodway
FBFM Panel No. Dated
O Sec Section 4 for additional instructioos
SIGNED DATE
APPLICATION +�
PAGE 3 OF a
SECTION 4 ADDITIONAL INFORMATION REQUIRED (To he completed by LOCAL ADMINISTRATOR)
The appbcant must submit the documents checked below before the app[icauon can be processed
O A site plan showuig the location of all costwg structulcs, water bodies, adjacent roads, lot
dimensions and proposed development
O Development plans, drawn to scale, and specifications, including wbere applicable: details for
anchoring structures, proposed elevation of lowest floor (including basement), types of water
resistant materials used below the First floor, details of floodprooftng of utibties located below
the fust 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 arc not otherwise available).
❑ Plans sbawing the extent of watercourse relocation and/or landform alterations.
O Top of new Fill elevation Ft. NGVD (MSL).
O Floodproofing protection level (non-residential only) FC NGVD (MSL). For
'Cr �.
floUproofed structures, applicant must attach certification from registered engineer or
architect.
❑ Certificatio from a registered engineer that the proposed activity in a regulatory flood-ay
will not result in any increase in the height of the 100-year flood. A copy of all data and
calculations supporting. his finding must also be submitted_
❑ Other:
!SECTION $:-PERMIT DETERMINATION (To be completed '�" LOCAL ADMINISTRATOR)
I have determined that the proposed activity. A. O Is
B.a Is not
• in conformance with provisions of Local Law . 19 The permit is issued subject to the conditions
attached to and made part of this permit.
SIGNED , DATE
U BOX A is chcEk d. the LocaJ Administrator may issue a Development Permit upon payment of designated
fee.
1�7: 8 is checked, the Local Administrator will provide a written summary of deficiencies. Applicant may
revise and resubmit an application to the Local Administrator or may request a bearing from the Board of
Appeals
APPLICATION a
PAGE a OF a
APPEALS Appealed to Board of Appeals? ❑ Yes ❑ No
Hearing date
Appeals Board Decision --- Approved' ❑ Yes ❑ No
COndltiOnS
SECTION G AS-BUILT ELEVATIONS (To be submitted by APPLICANT before erttficate of Compliance
is issued
The foUowwg information must be provided for project structures. Thus section must be completed by a
registered professional engmeer or a licensed land surveyor (or attach a certification to this application)
Complete t or 2 below.
1_ 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) is:
FT. NGVD (MSL).
2. Actual (As-Buil() Elevation of floodproofng protection is FT. NGVD (MSL).
<,.i
NOTE: Any work performed prior to submittal of the above information is at the risk of the Applicant.
SECTION 7• COMPLIANCE ACTIQN fTo be completed by LOCAL ADMINISTRATOR)
The LOCAL ADMINISTRATOR will complete this section as applicable based on inspection of the project to
ensure compliance with the communitys local law for flood damage prevention.
INSPECTIONS: DATE BY DEFICIENCIES? O YES ❑ NO
DATE BY DEFICIENCIES? OYES ONO
DATE BY DEFICIENCIES? OYES ONO
SECTION 8 CERTIFICATE OF COMPLIANCE L7o be completed 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
(0W`NER MUST RETAIN THIS CERTIFICATE)
PREMISES LOCATED AT: PERMIT NO.
PERMIT DATE
OWNERS NAME AND ADDRESS: CHECK ONE:
O NEW BUILDING
O EXISTING BUILDING
O VACANT LAND
THE LOCAL ADMINISTRATOR IS TO COMPLETE A. OR B. BELOW:
A. COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF
LOCAL LAW # , 19 .
SIGNED: DATED:
B. COMPLIANCE IS HEREBY CERTIFIED WITH THE REQUIREMENTS OF
LOCAL LAW # , 19-, AS MODIFIED BY VARIANCE # ,
DATED
SIGNED: DATED:
C/C(93)
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REPLACE 36" BELOW = i ON UNDISTURBED SOIL.
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REPAIRS i TO MATCH EEXI TIIN ONS
I
EXISTING OPENINGS • �� � � j f i w..
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i SITUA"rED ATCOTTAGE, 3, 'BREEZY ZY S�10RES'
0 .E'ENI 'IC)RT, T'O f q OF SOUTHOL17 �
S.C.T.I\,k 1(.)00-53-()5-P O 12.6 Q
t+¢✓ .. BY: Y0.,.NG & Y'ILJINO LAND SURVEYOR Lu
f DAT'IwsD JAN, 10,2013
COTTAGE #3 BREEZY SHORES
FEB 2 4 2016
S1T 'E PLAN
;'-V/ I_A\IDII+C BUUILDLNG DEPT.
TOWN OF SOUTHOLD
i l LL._J
4
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EX15TING
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DATE: VV L"x TOVM COD!L:-:S
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NOTIFY BU;l_'L)l:NG C!_Pjt�RTNIIENT lklr
W!, TO 4 PkIl FOFI, THE
705-1802 1) 13,
IN l, ft
4.
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CY E
ED CO'NCIRETE
FOR. POURcn
2. ROUGH -
0 F L U t�,4,R!N G
3. INSULATION
4. FINAL - COiNSTRUCTION! I`!UST
D-E COWLETE FOR. C.O.
ALL CONSTRU'_-,Tl`.)N 10"Hi"ll V,_71-T THE OCCUPANCY OR F3ASED ON MAP OF LU
-fl-E CODES OF NE_�,%/ SITUATED ATCO`TTAGE 3, 'BREEZY SHORES'
REQUIREMENTS OF I, USE IS UNLAWFUL
YORK STATE. NOT RESPOIN!SIRLE FOR DT G REEN PORT. TO'WN OF SOUTHOI-D
DESIGN OR CONSTRUCTION ERRORS. S,CT.M. 1006-"53-05�P/O 12.6
WITHOUT CERTIFICATE IFIDATIE
Y,
V BY: YOUNG & QUNG LAND SURVEYOR
OF OCCUPANCY DATED JAN. 10,2013
RETAIN STORM WATER RUNOFF
PURSUANT TO CHr"IFTER 236
f #3 DREf-ZY 5HORE5
K" F'AdIR
OF THE TOWN CODE.
COTTA ,
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SHELTER ISLAND SOUND
7
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0
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UNI.At-J". CY15TWC, FUI
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