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HomeMy WebLinkAbout38334-Z 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#: 38334 Date: 9/18/2013 Permission is hereby granted to: Conklin, Michael & Conklin, Patrice 230 Old Shipyard Ln Southold, NY 11971 To: "As built" alterations to an existing single family dwelling as applied for. At premises located at: 230 Old Shipyard Rd, Southold SCTM # 473889 Sec/Block/Lot# 64.-2-50 Pursuant to application dated 9/11/2013 and approved by the Building Inspector. To expire on 3/20/2015. Fees: CO - ALTERATION TO DWELLING $50.00 AS BUILT - SINGLE FAMILY ADDITION/ALTERATION $810.40 Total: $860.40 i" Bw ding 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: I. 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. Swom 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 I. 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 $15.00 Dat/e. New Construction: Old or Pre-existing Building: L"", " (check one) Location of Property: 230 dliZ) 3,4 �lpylt&l) A—I%V£ SCV7eL,0 House No. Street Hamlet Owner or Owners of Property: 09A-7p /C't oeFUeL11"l Suffolk County Tax Map No 1000, Section_CZ4 Block Lot 5-0 Subdivision Filed Map. Lot: Permit No. $ Date of Permit. Applicant: Health Dept.Approval: Underwriters Approval: Planning Board Approval: / Request for: Temporary Certificate Final Certificate: ✓ (check one) Fee Submitted: $ Applic t Signature �o�apF SQ(/pho� Town Hall Annex Telephone(631)765-1%02 54375 Main Road Fax (631)765-9502 P.O.Box 1179 • �� Southold,New York 11971-0959 Cou BUILDING DEPARTMENT TOWN OF SOUTHOLD CERTIFICATION Date: Building Permit No. Owner: I�tGOUNt, `7 (CL CCk-y—t-I J j `(Please print) (y Plumber: (Please print) I certify that the solder used in the water supply system contains less than 2/10 of I% lead. (Plumbers Signature) Swornto before me this 115rz day of `®J 20 STEVEN J 613 CH Notary Public,State of New York No.01AN81401740173 Qualified in Suffolk County 1,/L ommission Expires January 23,20!I Notary Public, County *�zf S0V% TOWN OF SOUTHOLD BUILDING DEPT. 765.1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUG LEIG. [ ] FOUNDATION 2ND [ ] i LATION [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: DATE INSPECTOR • n c i ®■moi .moi r h , , . TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD, NY 11971 3 sets of Building Plans TEL: 765-1802Q Survey PERMIT NO. Check Septic Form N.Y.S.D.E.C. _ Trustees Examined 12043 Contact: Approved 20 Mail to: Disapproved a/c Phone: But tng nspe Lr APPLICATION FOR BUILDING PERMIT \ 145 8 U/ / (/ Date �d 20 /2 / 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 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, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions, or alterations or for removal or demolition as herein described. The appligant�grws to comp�y wable laws, ordinances, building code, housing code, and regulations, and to admit authorize�� tbrs n rebuilding for necessary inspections. I J L l SEP 1 0 2 (Signature of applicant or name, if a co poratio�)/��� (2d �dv /(72 11A- ix64r�1 ------7 (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder 14&Fy / � � �A /CF' 0,0 t1J �L/A-)Name of owner of premises I C rr�-/�}'L (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 prop ed wor will be don 2 '0 bU S1,4y�,0 AAti,9 AV House Number Street Hamlet County Tax Map No. 1000 SectionQ Block 2— Lot Subdivision Filed Map No. Lot (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy _ 04.1 F/49U1/Ly b. Intended use and occupancy 3. Nature of work (check: which applicable): New Building Addition Alteration _ Repair Removal Demolition Other Work (Description) 4. Estimated Cost 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 Rear Depth 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 10. Date of Purchase_ Name of Former Owner 11. Zone or use district in which premises are situated R — 1/_/0 12. Does proposed constriction violaate� Tany zoning law, ordinance or regulation: 13. Will lot be re-graded_ Will excess fill be removed from premises: YES Nb 14. Names of Owner of premises C OIVIZI—IA I Address ? 30 0Lb SV"% one No. �- Name of Architect_ Address Phone No Name of Contractor_ Address Phone No. 15. Is this property within 100 feet of a tidal wetland? *YES 0 • 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 ) {�_�being duly sworn, deposes and says that(s)he is the applicant (Name of individuhigning con t above na d, (S)He is the RlF/nI7_ (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. Sworn.tp before me this 1 b day of 20j_�_ v� Pt6UdN Notary Public S ature of Appli ant CONNIE D. BUNCH Nntary Public, Stat;of Nev,!Ycri( No. 01 81J61 Duan fled in S,Jsiolt c, aty commi"OnF:i,2�) OF SO�lyo� Town Hall Amex All Telephone(631)765-1802 co 54375 Main Road 61)�7.g6�5p-22� P.O.Box 1179 roner.riche rtldtONR S076UWO f1 nV us Southold,NY 11971-0959 BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: D J<lit/n�UZ7� �S� Date: Company Name: Name: License No.: Address: Phone No.: �p3� JOBSITE INFORMATION: (*Indicates required information) *Name: 0 e A4 IC ' eL/Aj *Address: Z 3 0 (J(_l SFl£ X Lff/�7S *Cross Street: *Phone No.: (/31 6FQ //C-:� Permit No.: Tax Map District: 1000 Section: Block: Lot: *BRIEF DESCRIPTION OF WORK(Please Print Clearly) tLILI P h l,t� (Please Circle All That Apply) *Is job ready for inspection: YE / NO Rough in Final *Do you need a Temp Certificate: YES /�O Temp Information(if needed) *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION 82-Request for Inspection Form s.. TOWN OF SOUTHOLD PROPERTY RECORD CARD OWNER STREET 2 �`�,' VILLA E DISTRICT SUB. LOT 7 y ! /, / b RMER OWNER //��,," N/ E ACREAGE Q o ac44n A J X Eugene shoer7 r^ S W TYPE OF BUILDING ( i RES. SEAS. VL. FARM COMA. IND. CB. MISC. �-io I I _ LAND IMP. TOTAL DATE REMARKS 67) hra/o o Dov 4 o v 0� .!�/v Zra Pao y6 00 Syo0 B N�i11 97 NEW NORMAL BELOW ABOVE �p „ S' Farm Ache Value Per Acre Value Tillable 1 Tillable 2 Tillable. 3 Woodland Swampland Brushlond House Plot n. ® a � ' ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ --------- ----- ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ Extension � m�' �C Both ® rIpExtension .. Ext. WallsInterior Finish te Extension Fire Place Heat ��� . . OI�iCr✓� PLUMSEi Cc TIFICATION toE V Pt1(lS F 001 L Ayo�� PLAT 'rEr., AS ON LEA DCONTENT BEFORE PL! ;'IABING --� APPV.. CU SHEET NO. Op I,` ' L RTIFICATE OF OCCUPAN ALL P'. � "!NG WASTE O _ g�(�ip..�R LINES NEED CALCULATED EY DATE DATE: 13 PP. _ � � SOLDER USED IN WATE' TESTING BEFORE COVERING EE SUPP Y SYSTEM CANS' CHECKED EY DATE _ NOTI Bu+t 4'c JT AT EXCEED 2110 OF1% LE 'r SCALE IJP' 1�2 765-1802 8 AM r. kGR THE FOLLOWING INSPEC f I ,'S: 20'-3° 1. FOUNDATION - Tit" ,FOUIRED FOP, POURED CCrJCHE1E rpLQn 2. ROUGH - FRAM NG & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCT!ON MUST BE COMPLETE FOR C.G. ALL CONSTRUCTION SHALL MEET THE u CL REQUIREMENTS OF THE CODES OF NEW YORK STATE. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. � ppM N TUB (r CON",--'y V11--H ALL CODES OF � NEW Y,-Jr-K S ( ^, rc & TOWN CODE AS REi�JIRED AM-, Cr S °Et fn CL _ LJ�DRCJOF�I 'i , dl r CL. )CCUPANCY OR ' USE IS UNLAWFUL WITHOUT CERTIFICATE OF OCCUPANCY - I T f 'tt� tIr'A}M�i /I �� Zn1D Fi.pc3SL LAYOJf QIFI� N L I Y>e #o� +342 ; 23� Ott S1-t1f�(ItLD L�ctl� So�St�ro�, �•1Y Ilgl l 9/o9/Zola �&'cEr�E2 q ?.a13 Town of Southold Annex 9/25/2013 P.O.Box 1179 54375 Main Road oy Southold,New York 11971 CERTIFICATE OF OCCUPANCY No: 36524 Date: 9/25/2013 TIIIS CERTIFIES that the building ALTERATION Location of Property: 230 Old Shipyard Rd, Southold, SCTM#: 473889 Sec/Block/Lot: 64.-2-50 Subdivision: Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this officed dated 9/11/2013 pursuant to which Building Permit No. 38334 dated 9/18/2013 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: "As built"alterations to an existing single family dwelling as applied for. The certificate is issued to Conklin,Michael&Conklin,Patrice (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL ELECTRICAL CERTIFICATE NO. PLUMBERS CERTIFICATION DATED 9/13/13 William Gremler Aut ed ignatur iyFFocx TOWN OF SOUTHOLD �ao�° copy BUILDING DEPARTMENT s TOWN CLERK'S OFFICE o • 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#: 38334 Date: 9/18/2013 Permission is hereby granted to: Conklin, Michael & Conklin, Patrice 230 Old Shipyard Ln Southold, NY 11971 To: "As built" alterations to an existing single family dwelling as applied for. At premises located at: 230 Old Shipyard Rd, Southold SCTM # 473889 Sec/Block/Lot# 64.-2-50 Pursuant to application dated 9/11/2013 and approved by the Building Inspector. To expire on 3/20/2015. Fees: CO -ALTERATION TO DWELLING $50.00 AS BUILT- SINGLE FAMILY ADDITION/ALTERATION $810.40 Total: $860.40 Bui ding 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: l. 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 io 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 $15.00 Date. New Construction: Old or Pre-existing Building: L111" (check one) Location of Property: �3� ��� �/����6��/J �/�-f�/ SO-U77-&Lb A-Y House No. Street Hamlet Owner or Owners of Property: Suffolk County Tax Map No I000,'Section ' . Block 2 Lot' 50 Subdivision Filed Map. Lot: Permit No. Date of Permit. ���' Applicant: Health Dept.Approval: Underwriters Approval: Planning Board-Approval- / Request for: Temporary.Certjficate• Final Certificate: ✓ (check one) Fee Submitted:$ n a4A Applic t Signature typF SO�T�QIo Town Hall Annex Telephone(631).765.180.2 7 54375 Main Road Fax(631).7G5-9502 P.O.Box 1179 G� Southold,New York 11971-0959 .cQly0 C4U011, BUILDING f)EPARTMENT TOWN OF SOUTHOLD _ 1 CERTIFICATION Date: Building Permit No. 1 � (Please print) Plumber: (Please print) I certify that the solder used in the water supply system contains lessthan 2/10 0£1%°. lead. (Plumbers Signature) " Sworn to before me this r3rz :. day-of �� ', 20 STEVEN J ANDRICH Notary Public,State of New York No.01AN6140173 Qualified in Suffolk County ommission Expires January 23,264 Notary Public, County Of SO�lyo�o Q couto,� TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION 1ST [ ] ROUG LEIG. [ ] FOUNDATION 2ND [ ] I LATION [ ] FRAMING /STRAPPING [ FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION [ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION [ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL) REMARKS: Ai DATE INSPECTOR FIELD IN3P$ N O1�T DATE couT�NTS • W FOUNDATTION(IST) (� (z (J\ FOUNDATION(2ND) • z 0 ROUGH FRAKWQ& PLUMING IWOULATION PDA N.Y. STATE ENERGY COM MAL , ADDITIONAL C6 TS u z TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST BUILDING DEPARTMENT Do you have or need the following,before applying? TOWN HALL Board of Health SOUTHOLD, NY 11971 3 sets of Building Plans TEL: 765-1802 Survey PERMIT NO. Check Septic Form N.Y.S.D.E.C. Trustees Examined 20 Contact: Approved_1y:,20 ' /J Mail to: Disapproved a/c 2d _� Phone: Bur frig nspe or APPLICATION FOR BUILDING PERMIT SU�(� r 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 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, and other applicable Laws, Ordinances or Regulations,for the construction of buildings, additions, or alterations or for removal or demolition as herein described.The appli i gr s�oc rnp w'I able laws, ordinances, building code, housing code, and regulations, and to admit autho �e . s!on -reil is a building for necessary inspections. :: S FP Q 2013 (Signature of applicant or name, if a co poration) 9 BLDG. DEPT. P6) PJ 61 TOWN OF.SOUTHOLD (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises IG(1<"1+L 4 PAIP/CL l®1t)ZZ-1 AJ (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 prop ed S wor• will be done,: 3o c�L sIy /9 � A),9 MTPd,,/ A4 House Number Street Hamlet County Tax Map No. 1000 Section Block 2 Lot Subdivision Filed Map No. Lot (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy 0/j2__ � b. Intended use and occupancy 0/1) )E- 14"/L 3. Nature of work(check which applicable): New Building Addition Alteration Repair Removal Demolition Other Work (Description) 4. Estimated Cost 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 Rear Depth 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 10. Date of Purchase Name of Former Owner 11. Zone or use district in which premises are situated 9 ^ 12. Does proposed construction violate any zoning law, ordinance or regulation: U�/Q 13. Will lot be re-graded Will excess fill be removed from premises: YES Cj 14. Names of Owner of premises (:�,011 1Z1_-1 j Address 2 30 OLh SN/N)*one No. �- Name of Architect Address Phone No Name of Contractor Address Phone No. 15. Is this property within 100 feet of a tidal wetland? *YES —(go • 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 OFn( a i_J LAU04. i) _being duly sworn, deposes and says that(s)lie is the applicant (Name of individu&Jigning contr t)jabove nay d, (S)He is the (Contractor, Agent, Corporate Officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this application are 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 Y e this i da of 20 Notary Public S ature of Appli ant CONNIE D. BUNCH Notagr Public, State of New York No.01 BU6185050 Qualified in Suffolk County Commission Expires April 14,2�� SOt,I�o{ 0 Town Hall Annex J Telephone(631)765-1802 54375 Main Road y �Io (631)768-95Q2 P.O.Box 1179 roger.rchertUwn.S0od ny us Southold,NY 11971-0959 'r BUILDING DEPARTMENT TOWN OF SOUTHOLD APPLICATION FOR ELECTRICAL INSPECTION REQUESTED BY: D J'4/t/yvU7-21 Date: p /3 Company Name: Name: License No.: Address: Phone No.: . JOBSITE INFORMATION: (*Indicates required information} *Name: ! +VP I I6 fo U, 4 � IC COWEI—//t/ *Address: Z3 Q OL�/ L4/lI5 GrI.T � *Cross Street: L / ��� �► r *Phone No.: Permit No.: Tax-Map District: 1000 Section: Block: Lot; *BRIEF DESCRIPTION OF WORK(Please Print Clearly) ZIL I Q64,1 a: (Please Circle All That Apply) *Is job ready for-inspection: YE / NO. Rough In Final *Do-you need a Temp Certificate: YES/�O Temp Information.(if needed) *Service Size: 1 Phase 3Phase 100 150 200 300 350 400 Other *New Service: Re-connect Underground Number of Meters Change of Service Overhead Additional Information: PAYMENT DUE WITH APPLICATION .82-Request for Inspection Form .,J TOWN OF SOUTHOLD PROPERTY RECORD CARD OWNER _ STREET VILLAGE DISTRICT SUB. LOT 7 �. ~ 14, eRM ER OWNER �� N E ACREAGE ^+ D G d azA M dd emu. Cn(f—c,-h peer- S W TYPE OF43UILDING 441L RES. i�o SEAS. VL. FARM COW. f IND. I CB. I MISC. LAND IMP. TOTAL DATE REMARKS -7e 47" o �� GAD7 A 5 � &-O �o 0 � ( 00 5Al00 3 s 'II qS^-L_ It 7 6 0 q -- C.Lea j �(617 11� 9 .��v B t�fTTt'! N NEW NORMAL BELOW ABOVE �-.� 6V 11 cv Farm Acre Value Per Acre Value Tillable 1 Tillable 2 Tillable. 3 Woodland Swampland Brushland House Plot r .:r=..:.:..`,:..,-x`..;� •PGA ;..:� tom"`--: .)_: ■■/.�.■.. now ,iy asl-i.�u�a��1i�i:JL"�SSS�'S�i� gym•..- ■■■/■/■■.■�///.■■.■■ on so MEN soe��������� Interior Finish 1 �� Rooms Ist .. QF-f=--ice PLUMBER CERTIFICATION JOB ��, NOTED LEAD CONTENT BEFORE PLUMBING _ SHEET NO. OF APPROVED °°S NO!ED CERTIFICATE OF OCCUPAN(' ALL PL-;,ABING WASTE &WA;ER LINES NEED CALCULATED BY DATE DATE: 3 B.P.; J 8�3 5 SOLDI RUSE®IN WA�TEI- TESTING BEFORE COVERING CHECKED BY DATE FEES . FO , ;�, � g�r — SURP Y SYSTEM CAN1`!� _ SCALE l a- or=�:�ffri.IEN .-_ T_. . . _ _F CE D?/10 OF-1�/ LEAD ; - - - - - - - -- - - - - - - - - - - -- -- --_.NOTIFiY--BUiLDI,t. T - _ T�j -- - ! ii --` i 0 I T0_.-4JPM FOR �FHE-- -I---_ 1 ! E--- —-f - - -- J;_ I �r I _ 765-1802 8-AM- - i �-- I t- i --i I '—T--� �- I ,I� � �—�V �_ , -�_T� � I �1.F.OLL6wiNG INS ECTIOiJS ; _._ I._.t ; I I i i f I I I I 1 20 I �I I I I I j t 1. �FO�.INDAT�01•P TWQ RFQUIRrD - ' FO F, _ , I , , 2.?ROIUGH=fFRFlMiI�GI� PLUMBING .i.. ' s:-klNsuLATION-�- _�._ . - - - - - t 1 I L__. I f L-- - .. _ f__1 _ - _ _l I -I----- --- -FOR,, -_ - _i 4:IFlt�IAL�--CONSTRUCTIOf�I MUST __ + _.._3__� ._.�_._, _.I_.. ,- ._.. ._.._-- __. ,. _..., _ __-- _ __�_J - iI. I, 1 _�_ �_� _�_.� --I- - f- -T I C 0 ! I 1 _ - - - , I Ii , I 1 , , AL�L CONSTRUCTION SHALL(MEET 1THE i P f I _ i REQU,IREMENTS OF THE CODES OF NEW I I . ._ . ._ _ . _ _ t r_ Y. . _ !_ _ -t_ _ _�. I 3 1 I I �-� 1 l _ i s ,I I � I , YORKI STATE. NOT RESP,ONSIB -E"FOR i � 3 I t�J DESIGN OR CONSTRUCTION E RQRS. I I � ! I' iI i I I t ,.. _ _1 _ _ _L_.I ' .J. i _ . I - - - - - -- q_ i _ .�_ � i '.. _� 4 I i Ii f i I i i I I I l_ COI�Fr�;LY�1"I-'I�{ ALL CODES I • , • � � i _'._ ' OF I _�_-. 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