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Home My WebLink About28341-Z FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No: Z-28843 Date: 11/27/02 THIS CERTIFIES that the building ADDITION & ALTERATIONS Location of Property: 1600 GIN LA SOUTHOLD (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 88 Block 3 Lot 18 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated APRIL 29, 2002 pursuant to which Building Permit No. 28341-Z dated APRIL 30, 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 ADDITION AND ALTERATION TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR. The certificate is issued to FRANCIS J KIERNAN JR & WF (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A ELECTRICAL CERTIFICATE NO. 1066620 11/18/02 PLUMBERS CERTIFICATION DATED 09/20/02 BURTS RELIABLE FUEL Authorized Signat e Rev. 1/81 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. 28341 Z Date APRIL 30, 2002 Permission is hereby granted to: FRANCIS J JR & WF KIERNAN GIN LA SOUTHOLD,NY 11971 for . ADDITIONS AND ALTERATIONS TO AN EXISTING SINGLE FAMILY DWELLING AS APPLIED FOR WITH FLOOD PERMIT at premises located at 1600 GIN LA SOUTHOLD County Tax Map No. 473889 Section 088 Block 0003 Lot No. 018 pursuant to application dated APRIL 29, 2002 and approved by the Building Inspector. Fee $ 250 . 00 Authori d S ' ture ORIGINAL Rev. 2/19/98 ,.,—F 7 Form No.6 t TOWN OF SOUTHOLD " BUILDING DEPARTMENT '' f 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 I%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$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. �� L New Construction: t/ Old or Pre-existing Building: (check one) �O Location of Property: /4 O House No. Street�/ Hamlet Owner or Owners of Property: r so Suffolk County Tax Map No 1000, Section Block Lot I r3 Subdivision Filed Map. Lot: Permit No. of?7 5�'l Date of Permit. Applicant: �- Health Dept. Approval: Underwriters Approval: Planning Board Approval: / Request for: Temporary Certificate Final Certificate: / (check one) Fee Submitted: $ oPs•.,r� 61, �,6 o 3 3 Applicant Signature Co -E 9$5-`/ suFFOL kUAoo y� Town Hall, 53095 Main Road y Z Fax (516)765-1823 P. O. Box 1179 v% Telephone (516) 765-1802 Southold, New York 11971 OFFICE OF THE BUILDING INSPECTOR TOWN OF SOUTHOLD C E R T I F I C A T I O N DATE: 9L40 Building Permit No. Owner: MIL FT. k:ea,rJAA (please print) Plumber: Pelf:Adle- F7%/C,( (please print) ZDsepH Kalle^l 22_ I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. l r2 lumbers Signature) Sworn to before me this day of 19 -ZUO.-�— Notary Public, County ANC A. ESTER Notary Publ cY State of New York CommissionExpi es Aug.ok 15,County Commission 15, _____ O cncrrJ�r1rJ��nrJ�cnr�r�rJ�rJ�rJrJ�rJ�rJ�rJ�rJ�rJ�cnrJ��ncn�P�rrJ��l�PrJ��ncncnrMPrJI rr nrJ�cnrr�Pr�rJ�cnrMULMr 0310dj�cnrrrcrJ�rJ�r�r�rJ�r�rrE rr� O 5 BY THIS CERTIFICATE OF COMPLIANCE THE 5 5 NEW YORK BOARD OF FIRE UNDERWRITERS 5 5 BUREAU OF ELECTRICITY 5 40 FULTON STREET -- NEW YORK, NY 10038 5 CERTIFIES THAT 7c 5 Upon the application of upon premises owned by 5 5 PAUL R. BURNS FRANCIS KIERNAN 5 C5� P.O. BOX 1061 1600 GIN LANE 5 5 SOUTHOLD, NY 11971-0932, SOUTHOLD, NY 11971 5 5 Located at 1600 GIN LANE SOUTHOLD, NY 11971 5 5 Application Number: 1066620 Certificate Number: 1066620 5 S 5 SSection: Block: Lot: Building Permit: BDC: NS11 S Described as a Residential occupancy,wherein the premises electrical system consisting of 5 electrical devices and wiring, described below, located in/on the premises at: 5 5 First Floor, Outside, 5 S 5 5 was inspected in accordance with the National Electrical Code and the detail of the installation, as set forth below, was 5 rj found to be in compliance therewith on the 18th Day of November, 2002. Ij 5 Name QTY Rate Rating Circuit Type 5 Appliances and Accessories 5 5 Dish Washer 1 0 1.2 KW 5 5 Range 1 0 13.9 KW 5 5 Wiring and Devices e� 5 Receptacle 9 0 General Purpose 5 5 Switch 5 0 General Purpose 5 5 Fixture 6 0 Incandescent r,5] Receptacle 1 0 20 amp Laundry 5 5 Receptacle 1 0 30 amp Dryer Receptacle 2 0 GFCI 5 S 5 5 5 5 5 seas 5 I of 1 5 5 This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. 5 5 D rrL1LPcnr�cn�P�Pr I�rJ�rJ�r�rJ�rJ�cPrJ�rJ�rJ�rJ��PcnrJ��n�rrJ�r rrJ�rJ@nrn�lr nr rcptnrJ�r�rJ��Pr�rPrJ�r�rJ�RIUff�LPLJ-r PLrL3rrrJ�L3J-L3 .nr3rJEuRri 023 Lei ENERGY COLIC CALCULATIONS (Lor Non-Electric Heat) Design Criteria G , 000 Degree'.Days O.A. 10°L I .A. 70Or• FOR: �rahC/ S K� erh4n 1400 4Qb e So fh /o/ DATED: Rev 2 � O� Aad , Irr, SUBSYSTEM AREA DESIGN THERMGL REMARKS 'fU" RA'Z'ING — t.xterioi: Walls (Opaque) 777 �bv Glazl:iy Doors ceiling/Root (Opaque) SkyliyhLs Floor roundaL•ion Walls I Slab Insulation TOTAL +S� Notes: Building Envelope Systems to meet requirements of 7915. 2 11VAC Equipement to meet requiremenL•s of-, 7915. 11 11VAC Systems to meet requirements of 7915. x2 Duct Systems to meeL• requiremeiiLs of 7915 . 13 VenL•1iaLions Systems to meet requiremienL-s of 7915 . 19 1nsulaLion of Yipiny .SysL•ems to meet requiremenL•s of 7915 . 15 Service Water Heating Systems & Equipment to meet requiremeliL's of 7915. 21 ElecL•rlcal & Lighting Systems & Equipment- to meet requirements of 7U15 . 31 To the best of my knowledge, of Nflyy0 belief, & professional y�P�Nce ju(lyemenL•, these plans are in compliance wiL•ii Lhe code. W C/ SFO 032254-1 �aV\ A9OFESSiON�� 0ti BUILDING PERMIT EXAMINER CHECK LIST DATE ISSUED: —/-/02 DATE REVIEWED: el /02 APPLICANT: �• 1-1EP�MJ DATE,SUBMITTED: W-/x/02 SCTM# DISTRICT: 1,000, SECTION: 8,g , BLOCK: _,I , LOT: I � N STREET ADDRESS: �,��',p kn,E CITY: SUBDIVISION: PROJECT DESCRIPTION: /.��a,i Za J iuc c wf,, ,a cy- ESTIMATED PROJECT COST: ARCHITECT/ERS :: FAST TRACK? SINGLE & SEPARATE CERTIFICATION-REQUIRED? A(o NOTES: LOTS 40,000SF-100-24.Lot recognition.(CREATED before June 30, 1983),UNDERSIZED LOTS/FROM JAN.1997 100-25.Merger.(A nonconforming at anytime after 7/1/83 ZONING DISTRICT: CONFORMING? REQ. LOT SIZE: �00o ACT. LOT SIZE: J�W REQ. LOT COV. .�7 ACT. LOT COV. REQ. FRONT A- PROP. FRONT /REQ SIDE ACT. SIDE REQ. REAR-----5$---PROP. REAR WATERFRONT? A1/0 DESCRIPTION: PANEL #: FLOOD ZONE: B, p Av, 7�Ow/ APPROVALS REQUIRED SUFFOLK COUNTY HEALTH WT: YES or I O (BED #): DTE:—/ /_ PERMIT #:R10- TOWN SEPTIC RECEIPT: Y or NEW YORK STATE DEC: PRE-DEC 9/1/75 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: 0OR NO : •{ ►.J EGRESS (18 H min.? 4 sq total) , VENT (SQ. FT. x 4%) N ''1' LIGHT (SQ. FT. x 8%) BUILDING PERMITS OPEN/EXPD: BP 530\ -Z/C/0 Z-' HAVE PRE CO'S : Y OR N BP -Z/C/o Z- NOTES: FEE STRUCTURE: FOUNDATION: SF FIRST FLOOR: .31J SF SECOND FLOOR: SF OTHER: SF INIT OTHER TOTAL j TOTAL: SF FEE FEE FEE q 1. ( ( SF)- ( SF)= SF X $ 2. ( SF)- ( SF)= SFX $ 765-1802 BUILDING DEPT. INSPECTION [ OUNDATION IST [ ] ROUGH PLBG. ] FOUNDATION 2ND [ J INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: _.1 DATE ' ASPECT M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ROUGH PLBG. [ ] NDATION 2ND [ ] INSULATION [ FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY REMARKS: JV- &J 4ea - DATE INSPECTOR 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] RO H PLBG. [ ] FOUNDATION 2ND [ INSULATION [ ] FRAMING [ ] FINAL [ ] FIREPLACE & CHIMNEY ,?:;jREMAR"mtso �._ r DATE INSPECTOR 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IN TION [ ] FRAMING [ INAL [ ] FIREPLACE & CHIMNEY 49 REMARKS DATE INSPE . _ l FIELD INSPECTION REPORT 6ATE COMMENTS Zoo �Z FOUNDATION(IS N ------------------------------------ 11 FOUNDATION (2ND) � O A ROUGH FRAMING& — PLUMBING INSULATION PER N.Y. P— y STATE ENERGY CODE �- FINAL ADDITIONAL COAMENTS 5 0 z n � W b `~ � O x x a b TOWN OF SOUTHOLD � BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL SOUTHOLD, NY 11971 sets of Building Plans TEL: (631) 765-1802 P °o a'1 FAX: (631) 765-9502 S y PERMIT NO. 0�834 ;R: heck N.Y. . .C. F^ (n: C Examined / '1, ,20 1 ' ' Contact: -approved_ __� �V 20 b D �� Mail to: Disapproved aicL — Phone: Xy;o �� [ Lxpiration /d -40 20 ck.1 J lo-4t'4 r�ara�ij Building Inspector 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 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 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. (Signature of applicant or name,if a corporation) 4602Gn�e, 5 al,41111,197/ (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder d[a2h 6Zr Name of owner of premises /7�i?GS �%, /LiErY9Ltrfy/`, w;A_ (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. W Plumbers License No. Electricians License No. Other Trade's License No. 1 . Location of land on which proposed work will be done: /t,/�2 a0 G,,lq zean e, O House Number Street Hamlet County Tax Map No. 1000 Section ff _Block C3 Lot 106, Subdivision ai ' Filed Map No. Lot (Name) 2. State existing use and occupancy of premises and . tended use and occupancy of proposed construction: a. Existing use and occupancy c b. Intended use and occupancy �,e� Nature of work (check which applicable): New Building Addition X Alteration Repair Removal Demolition Other Work (Description) 4. Estimated Cost Fee (To be paid on filing this application) 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 xtent of each type o use. Dimensions of existing structures, if any: Front rj5! 7 Rear </ Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front -.r--P�e Rear Depth Height Number of Stories Z 3. Dimensions of entire new construction: Front Rear 7 e;' Depth Height Number of Stories 17- 1). 9. Size of lot: Front 16zy Rear / O Depth 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situatedtczolo� 1-2. Does proposed construction violate any zoning law, ordinance or regulation? YES NOS 1;. Will lot be re-graded? YES NO-&-Will excess fill be removed from premises? YES NO 14. Names of Owner of premises Address Phone No. Name of Architect 'Z -( 2�1-0p� Address Phone No Name of Contractor , l-r -s Address 6� Gv� c:7 . -hone No 766 ,g?/y 1 5 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NO x _ * 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_'x/ * 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 ) / � -2W4'5 r being duly swom, deposes and says that(s)he is the applicant (Name of individual signing contract) above named, (S)He is the �ranP� (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 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. Swy�-p,to before me thi �j I day of 20 0.a� Notary Public S tore of Applicant JOYCE M.WILKINS Notary Public,State of New York No.4952246,Suffolk County Term Expires June 12, a o 0 3 FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0077 NATIONAL FLOOD INSURANCE PROGRAM Expires July 31, 2002 ELEVATION CERTIFICATE Important: Read the instructions on pages 1 -7. SECTION A-PROPERTY OWNER INFORMATION F`or Insueanco'Company Use: BUILDING OWNER'S NAME PpNtyNIUMger Francis J. Kiernan BUILDING STREET ADDRESS(Including Apt.,Unit,Suite,and/or Bldg.No.)OR P.O.ROUTE AND BOX NO. Grxnphny MAIC Ntmlber 1600 Gin Lane CITY STATE ZIP CODE Southold, NY 11971 PROPERTY DESCRIPTION(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.) 1000-88-03-18 BUILDING USE(e.g.,Residential,Non-residential,Addition,Accessory,etc. Use a Comments area,if necessary.) Residential LATITUDE/LONGITUDE(OPTIONAL) HORIZONTAL DATUM: SOURCE: 1_1 GPS(Type): or #p.#####°) 1_1 NAD 1927 1_1 NAD 1983 1_1 USGS Quad Map 1_1 Other: SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION B1.NFIP COMMUNITY NAME&COMMUNITY NUMBffff-7 B2.COUNTY NAME B3.STATE Town of Southold 360813 Suffolk 64.MAP AND PANEL I B5.SUFFIX I B6.FIRM INDEX I B7.FIRM PANEL B8.FLOOD B9.BASE FLOOD ELEVATION(S) NUMBER DATE EFFECTIVE/REVISED DATE ZONE(S) (Zone AO,use depth of flooding) B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in B9. 1-1 FIS Profile 1 XI FIRM 1J Community Determined 1-1 Other(Describe): B11. Indicate the elevation datum used for the BFE in B9: I)q NGVD 1929 iJ NAVD 1988 1-1 Other(Describe): B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? 1J Yes f 1 No Designation Date: SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) C1. Building elevations are based on: 1`1Construction Drawings* IJBuilding Under Construction* I X1Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Building Diagram Number 2 (Select the building diagram most similar to the building for which this certificate is being completed-see pages 6 and 7. If no diagram accurately represents the building,provide a sketch or photograph.) C3. Elevations—Zones Al-A30,AE,AH,A(with BFE),VE,V1 430,V(with BFE),AR,AR/A,ARAE,AR/A1-A30,AR/AH,AR/AO Complete Items C3.a-i below according to the building diagram specified in Item C2.State the datum used.If the datum is different from the datum used for the BFE in Section B,convert the datum to that used for the BFE.Show field measurements and datum conversion calculation. Use the space provided or the Comments area of Section D or Section G,as appropriate,to document the datum conversion. Datum Conversion/Comments Elevation reference mark used Does the elevation reference mark used appear on the FI Yes IX 1 No ❑ a)Top of bottom floor(including basement or enclosure) 4 4 ft.(m) NEIV ❑ b)Top of next higher floor 11 7 ft.(m) a . 1,MFr y4� ❑ c)Bottom of lowest horizontal structural member(V zones only) ---=ft.(m) G' oNk j0F ❑ d)Attached garage(top of slab) 9 8 ft.(m) E g "� p ❑ e)Lowest elevation of machinery and/or equipment -a servicing the building(Describe in a Comments area.) 4 4 ft.(m) E ❑ f)Lowest adjacent(finished)grade(LAG) 9 ft.(m) d n ��, LO ❑ g)Highest adjacent(finished)grade(HAG) 9 .�ft.(m) .0 '�� moo, 496*1 J� ❑ h)No.of permanent openings(flood vents)within 1 ft. above adjacent grade ----- 8 fG LAND L] i)Total area of all permanent openings(flood vents)in C3.h ———— sq. in.(sq.cm) 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. 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 LICENSE NUMBER John T- Met7�Pr, T.- S_ 4~9618 TITLE COMPANY NAME President ADDRESS CITY S ATE ZIP CODE P.O. Box 909 SIGNATURE DAT %PHONE 06 05 02 ( 631 ) 76S-1;020 FEMA Form 81-31,JUL SEE REVERSE SIDE FOR CONTINUATION REPLACES ALL PREVIOUS EDITIONS a ♦ T. TERRY IJ Y (-y;.'. �� I1,,,t1 I�:lll. S��NC MaIll TOWN CLERK H o • P O R(,S 117v $uullu,id. Nc„ 1 „rk I1'171 REGlsrRAR OF VITAL.STATISTICS Faz (5101 765-I R 1 MARRIAGE orFICER TcicPh<,.c 15I(,1 ?(,t_Ix(II RECORI)sMANAGEMENT OFFIceR Oj 4 r FREEDOM OF INFORMATION OFFICER �A 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) ] . cr TOWNOF SOJ71+01D udith T. /Terry Southold Town Clerk August 25, 1993 APPLICATION a PAGE I of 4 TOWN OF SOUTHOLD FLOODPLAIN DEVELOPMENT PERMIT APPLICATION This form is to be filled out in duplicate. SECTION 1• GENERAL PROVISIONS (APPLICANT to read and si¢n): 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 issuance. 6. Applicant is hereby informed that other permits may be required to fulfill local, state and federal regulatory requirements. 7. Applicant hereby gives consent to the Local Administrator or his/her representative to make reasonable inspections required to verify compliance. 8. I,THE APPLICANT, CERTIFY THAT ALL STATEMENTS HEREIN AND IN ATTACHMENTS TO THIS APPLICATION ARE,TO THE BEST OF MY KNOWLEDGE, TRUE AND ACCURATE. (APPLICANT'S SIGNATURE) DATE SECTION 2: PROPOSED DEVELOPMENT (To be completed by APPLICM'n t NAME ADDRESS TELEPHONE � ms` / sy�/t i �c1n► /�y 4 ;" / � oP ' 7'Gs-Js99 BUILD 2� 646,57 ENGINEER //�� .fir ry /zc rh PROJECT LOCATION: To avoid delay in processing the application, please provide enough information to easily identify the project Iocation. Provide the street address, lot 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. /�G� tJ'ih �'•yi ei FDP(93) APPLICATION PAGE 2 OF c DESCRIPTION OF WORK (Check all appbcablc boxes): A. STRUCTURAL DEVELOPMENT ACTIVITY STRUCTURE TYPL ❑ New Structure Residential (1-4 Family) Addition ❑ Residential (More than 4 Family) ❑ Alteration ❑ Noo-residential (Floodproofmg? ❑ Yes) ❑ Relocation ❑ Combined Use (Residential & Commercial) ❑ Demolition ! ❑ Manufactured (Mobile) Home (In Manu- ❑ Replacement factured Home Park? ❑ Yes) ESTIMATED COST OF PROJECT S,Z Z*50,6£� B. OTHER DEVELOPMENT ACTIVITIES: ❑ Fill ❑ Mining ❑ Drilling ❑ Grading ❑ Excavation (Except for Structural Development Checked Above) ❑ Watercourse Alteration (Including Dredging and Channel Modifications) ❑ Drainage Improvements (Including Culvert Work) ❑ Road, Street or Bridge Construction O Subdivision (New or Expansion) ❑ Individual Water or Sewer System ❑ Other (Please Specify) After completing SECTION Z APPLICANT should submit form to Local Administrator for review. SECTION 3• FLOODPLAIN DETERMINATION (To be completed by LOCAL ADMINISTRATOR) The proposed development is located on FIRM Panel No. . Dated The Proposed Development: U IsfM located in a Special Flood Hazard Area (Notify the applicant that the application review is complete and NO FLOODPLAIN DEVELOPMENT PERMIT IS REQUIRED). located in a Special Flood Hazard Area. FIRM zone designation is A E R 100-Year flood elevation at the site is: Ft. NGVD (MSL) ❑ Unavailable ❑ The proposed development is located in a floodway. FBFM Panel No. Dated ❑ Sec Section 4 for additional instructions. / SIGNED DATE f /Z APPLICATION PAGE 3OF4 SECTION 4• ADDITIONAL INFORMATION REQUIRED (To be completed by LOCAL ADMINISTRATOR) The applicant must submit the documents checked below before the application can be processed: U A site plan showing the location of all existing structures, water bodies, adjacent roads, lot dimensions and proposed development. ❑ Development plans, drawn to scale, and specifications,including where applicable:details for anchoring structures, proposed elevation of lowest floor (including basement), types of water resistant materials used below the first floor, details of floodproofing of utilities located below Che first floor and details of enclosures below the first floor. Also, ❑ Subdivision or other development plans (If the subdivision or other development exceeds 50 lots or 5 acres, whichever is the lesser, the applicant must provide 100-year flood elevations if they are not otherwise available). ❑ Plans showing the extent of watercourse relocation and/or landform alterations. ❑ Top of new fill elevation Ft. NGVD (MSL). ❑ Floodproofmg 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 fioodway will not result in any increase in the height of the 100-year Rood. A copy of all data and calculations supporting this finding must also be submitted. ❑ Other. SEEI'ION 5: PERMIT DETERMINATION (To be completed by LOCAL ADMINISTRATOR) I have determined that the proposed activity. A.O Is B.0 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 If BOX A is checked, the Local Administrator may issue a Development Permit upon payment of designated fee. If BOX B is checked, the Local Administrator will provide a written summary of deficiencies. Applicant may revise and resubmit an application to the Local Administrator or may request a bearing from the Board of Appeals. APPLICATION a PAGE 4 OF 4 APPEALS: Appealed to Board of Appeals? O Yes ❑ No Hearing date: Appeals Board Decision --- Approved? O Yes ❑ No Conditions SECTION 6: AS-BUILT ELEVATIONS (To be submitted by APPLICANT before Certificate of Compliance is issued The following information must be provided for project structures. This section must be completed by a registered professional engineer or a licensed land surveyor (or attach a certification to this application). Complete I or 2 below. I. 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-Built) Elevation of floodproofmg protection is FT. NGVD (MSL). NOTE: Any work performed prior to submittal of the above information is at the risk of the Applicant. SECTION 7• COMPLIANCE ACTION (To be completed by LOCAL ADMINISTRATE) The LOCAL ADMINISTRATOR will complete this section as applicable based on inspection of the project to ensure compliance with the community's local law for flood damage prevention. INSPECTIONS: DATE BY DEFICIENCIES? ❑ YES 0 NO DATE BY DEFICIENCIES? ❑ YES ❑ NO DATE BY DEFICIENCIES? O YES ❑ NO SECTION S• CERTIFICATE OF COMPLIANCE(To 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 (OWNER MUST RETAIN THIS CERTIFICATE) PREMISES LOCATED AT: PERMIT NO. PERMIT DATE OWNERS NAME AND ADDRESS: CHECK ONE: ❑ NEW BUILDING ❑ EXISTING BUILDING ❑ VACANT LAND THE LOCAL ADMINISTRATOR IS TO COMPLETE A. OR B. BELOW: 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 # , 19AS MODIFIED BY VARIANCE # - f DATED SIGNED: DATED: C/C(93) PROPERTY 'UTHOLD SOUTHOLD `' s COUNTY, N. Y. Ale o '� moo. CD 17, 2002 4% G ,a tie yam. s Z7J xo. ! %cl 00 t, OQ / w�E lei�1 ' BAY HAVEN OF SOUTHOLD' � NEW C SUFFOLK COUNTY CLERK ��69�i"�. ��Qt ME�r VO. 2910. PARCEL DESIGNATED t36103CO166 G MAY 4, 1998 WS SURVEY IS A VIOLATION FK STATE F_DLCATIOV LAW. N, G'AONVJ� W CQ�PES ThEWOF OPK Y ALL CERTF)CAF S RESSED SEAL OF THE SURVEYOR N.Y.S. LIC. NO. 49618 i OCCUPANCY OR USE IS UNLAWFUL PLUMBER CERT/F/CAT/O WITHOUT CERTIFICATE 4F:OCCUPANCY " ON LEAD CONTENTBEFOR Y °,. - , CERTIFICATE OF OCCUPANC �Q _ 1 w. ti 29 EXCEED SYSTEM of l/° LEAD. %��• _ - - - -- ----- - - - - - -- +`` ,ePROVED AS Nip SOLDER USED 1N WATER SUPPLY SYSTEM CANNOT DATE. z 1 ° / FES 2� / N NOTIFY BUILDING DEPARTMENT A 788. PLUMBING 1802 8 AM TO • FM FOR THE FOLLOWING INSPECTIONS: ALL PLUMBING WASTE i/ - a 1. FOUNDATION - TWO REQUIRED &WATER LINES NEED i �, \\ u 1 2 ROUGH- ppMCRETING & PWMEINQ TESTING BEFORE COVERING , �__�.� '- _..__ _ — m o $ 3 INSULATION •-_T f - — t FINAL - CONSTRUCTION MU&T 1 - .�2 - BE COMPLETE FOR C.O. 1 - ALL CONSTRUCTION SHALL MEET If copper tubing is used - - , THE REQUIREMENTS OF THE N.V. for water distributing I W STATE CONSTRUCTION & ENERGY system; piping shall be CODES. NOT RESPONSIBLE FOR of types K or L only DESIGN OR CONSTRUCTION ERRORE - UNDERWRITERS CERTIFICATE - g 7 REQUIRED _' 3 UNDERWRITERS CERTIFICATE REQUIRED 1' PROVIDE ANTI-SCALD AND/OR -1 r y tv tv f - THERMAL SHOCK PREVENTING // I 'u - PROVIDE DEVICES STATE BUILDING CODE. FLOOD Zion t't!✓ Com/\\ v AS TO PART. 721.1 COMPLEVENTION Y Wl CHAPTER„4gs N.Y.S BUILDING CODE. l OD DAMAGE PR — - -- - =Fr ---r SOUTHOLD' TOWN CODE - Q L / Y ¢ O Nil ------------- _. 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