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c Town of Southold 11/14/2019
a P.O.Box 1179
cm
53095 Main Rd
Southold,New York 11971
CERTIFICATE OF OCCUPANCY
No: 40855 Date: 11/14/2019
THIS CERTIFIES that the building BASEMENT ALTERATION
Location of Property: 53740 Route 25, Southold
SCTM#: 473889 Sec/Block/Lot: 61.4-6
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
10/9/2019 pursuant to which Building Permit No. 44301 dated 10/16/2019
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"foundation alterations to existing commercial building as applied for.
The certificate is issued to JKJ North Fork Realty Inc
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
c
A h ' d Signature
��FFnc�r TOWN OF SOUTHOLD
BUILDING DEPARTMENT
N TOWN CLERK'S OFFICE
oy • SOUTHOLD, NY
.}r01 � dao
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#: 44301 Date: 10/16/2019
Permission is hereby granted to:
JKJ North Fork Realty Inc
PO BOX 183
Cutchogue, NY 11935
To: legalize "as built" foundation alterations to existing commercial building as applied for.
Additional certification may be required.
At premises located at:
53740 Route 25, Southold
SCTM # 473889
Sec/Block/Lot# 61.-4-6
Pursuant to application dated 10/9/2019 and approved by the Building Inspector.
To expire on 4/16/2021.
Fees:
AS BUILT-COMMERCIAL ADDITIONS/ALTERATIONS $500.00
CO -COMMERCIAL $50.00
Total: $550.00
Buil ng nspector
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 $15.00
Date. 10 —
New Construction: Old or Pre-existing Building: (check one)
Location of Property: 5-3- Q I /or[a%(�_� A �6 l l-4, n
House No. (( Street Hamlet
Owner or Owners of Property: � k j N 6 C-{–k '�(
Suffolk County Tax Map No 1000, Section , Block r Lot
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: $
pplicant Signature
�D I OE 50UTyO - - -
# TOWN OF SOUTHOLD BUILDING DEPT. '
°`ycourrn��' 765-1802
INSPECTION ' '
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ]� SULATION/C AULKING
[ ] FRAMING /STRAPPING [ FINAL, k;
[ ]' FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT-CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
[ ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
[ ] CODE VIOLATION [ ] PRE C/O
REMARKS:
DATE 1 INSPECTOR.
FIELD INSpECTiON REPORT I -DATE COMMENTS �.
b
FOUNDATION (1ST) � y
------------------------------------
CIO
FOUNDATION (2ND)
z
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H
ROUGH FRAMING& y
PLUMBING
N
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INSULATION PER N.Y. H
STATE ENERGY CODE
Y �
FINAL
ADDITIONAL COMMENT
# 5
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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 4 sets of Budding Plans
TEL: (6.31)'765-1802Planning Board approval
4�
FAX: (631) 765-9502 Survey
Southoldtownny.gov ' PERMIT NO. Check
Septic Form
-C MY S D E.C.
,��•,r^ I i'{'�+,r y ,,.izr Trustees
a_ C.O.Application
Flood Permit
Examined loll" 20 �, Single&Separate
OCT 2019 Truss Identification Form
Storm-Water Assessment Form
�a 2l?3" I�T,,IT,c '„
I�',rII - .6�� Contact:
Approved 20 a Mail tom:mxq- C:7
Disapproved a/c
Phone:19_�
Expiration 120
Bui inInspector
APPLICATION FOR BUILDING PERMIT
Date OC$obPe- , 20104
INSTRUCTIONS
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 Pen-nit pursuant to the
Budding 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.
V 140
1 ature of applicant or name,if a corporation)
3 !
(Mailing address of applica )
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Name of owner of premises ale 1 ;l bxAm /f✓ .
(As on the tax roll or latest deed)
If pelican6is a orpor i n, signature of duly authorized officer
AtetX-A.
(Name and title of corporate officer)
Builders License No. E,I's h-C9 Se
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which proposed work will be done: k
X3'7-4d 14zec u o
House Number Street Hamlet
County Tax Map No. 1000 Section Block '4 ' Lot'
Subdivision fi t)4 Goo 1(G b(Q _, 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 Z ,fCrpS o n �rot4)2d -f Ico r -r 2 DJ:E i Ce S 2,0 of f(0 0
b. Intended use and occupancy 2 Sfio fy s o ✓1 G r D u ri c1 -�i'[b o r j 2 0 Gt?5 Z✓�G�"�c D 0 r'
3. Nature of work(check which applicable): New Building Addition Alteration
Repair Removal Demolition Other Work-- R(Oft)r emem Pf 5� -1
Lea yoL(A
O(u >)1De cription) vyl hAsPYmm
4. Estimated Cost ��ja U Fee i 1 $
(To,,be paid on filing this pplication)
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 eacli type of use "'°1a c o m m Prr 'ct
7. Dimensions of existing structures, if any: Front Lia•S 1 Rear Its. 9 Depth`55' I wesi~5�
Height Number of Stories
Dimensions of same structure with alterations or additions: Front n O Ch&lllne Rear (VO CIA40 j e.
Depth rvo C 12 At,=e Height n0 C Melyt9 e— Number of Stories N o r lea nc,Q
8. Dimensions of entire new construction: Front 0 16- Rear �� GL Depth K) Cho
Height Number of Stories R)(A
n o Change S
9. Size of lot: Front 30 Rear A5\.R Depth Is -Ofo
10. Date of Purchase �S"Z 0 X001 Name of Former Owner QGl vYl C-aS I• (�{ U `C +
11. Zone or use district in which premises are situated
to d< K_
12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO-1-
13. Will lot be re-graded? YES NOWill excess fill be removed from premises?YES NO
4.Names of Owner of premises JICS N 0!'1'h F0 f lkdress Fd .-A
n V /�3�"-�hoIdo. l�7 3`l'�`►� 5�
Name of Architect Address Phone No
Name of Contractorsbe I bA l y Address ,Q0.8 crf 3'6 Phone No. (v 3�
0V f-Ko fd
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 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__y_
* IF YES, PROVIDE A COPY.
STATE OF NEW YORK)
SS:
COUNTY OF,5 f-[C I _
YYl a irla fP+ m , Hoc I, s-fra-%e f being duly sworn, deposes and says that(s)he is the applicant
(Namd of individual signing contract) above named,
(S)He is the V )` (SL p reSi'Cby Of 'U KAT No r-('In Fo rle- jka (Ela ) 1A)(- -
(Contractor,
JUL -
(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.
Sworto before me this
day of 0(f+ LX.--- 20
Notary Put6aryPublic,State of New York Signature of Applicant
No.02G05024640-Suffolk County
Commission Expires March 14,20 2
S.C.T.M. NO. DISTRICT: 1000 SECTION: 61 BLOCK: 4 LOT(S):6
MAIN ROAD ( S .R. 25 )
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:V LOCATIONS SHOWN ARE FROM FIELD OBSERVATIONS
AND OR DATA OBTAINED FROM OTHERS.
AREA: 8,307.68 SQ.FT. or 0.19 ACRES ELEVATION DATUM- -------------------------
UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY IS A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY
MAP NOT BEARING THE LAND SURVEYORS EMBOSSED SEAL SHALL NOT BE CONSIDERED TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN
ONLY TO THE PERSON FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE TITLE COMPANY, GOVERNMENTAL AGENCY AND LENDING INSTITUTION
LISTED HEREON, AND TO THE ASSIGNEES OF THE LENDING INSTITUTION, GUARANTEES ARE NOT TRANSFERABLE.
THE OFFSETS OR DIMENSIONS SHOWN HEREON FROM THE PROPERTY LINES TO THE STRUCTURES ARE FOR A SPECIFIC PURPOSE AND USE 'THEREFORE THEY ARE
NOT INTENDED TO MONUMENT THE PROPERTY LINES OR TO GUIDE THE ERECTION OF FENCES, ADDITIONAL STRUCTURES OR AND OTHER IMPROVEMENTS. EASEMENTS
AND/OR SUBSURFACE STRUCTURES RECORDED OR UNRECORDED ARE NOT GUARANTEED UNLESS PHYSICALLY EVIDENT ON THE PREMISES AT THE TIME OF SURVEY
SURVEY OF: DESCRIBED PROPERTY CERTIFIED TO: JKJ NORTH FORK REALTY;
MAP OF: BRIDGEHAMPTON NATIONAL BANK;
BRIDGE 'ABSTRACT;
FILED:
SITUATED AT: SOUTHOLD 1
TOWN OF: SOUTHOLD KENNETH M. WOYCHUK L.S.
Surveying SUFFOLK COUNTY, NEW YORK � Land yang and Design
P.O. Boz 3, Mattituck, New York, 11952
FILE SCALE: " ' DATE: JULY 25 2012 PHONE (631) 298-1588 FAX (631) 298-1588
# 12—85 1 =20 N. Y. S. LIC N0. 50227 maintaining the records of Robert J. Hennessy
Kba-d
APPR
ED AS NOTED `
DATE: B.P.#
FEE: BY:
NOTIFY BUILDING DEPARTMENT AT
765-1802 8 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS:
1. FOUNDATION - TWO REQUIRED
FOR POURED CONCF.ETE
2. ROUGH - FRAMING & PLUMBING
3. INSULATION
4. FINAL - CONSTRUCTION MUST
BE COMPLETE FOR C 0.
ALL CONSTRUCTION SHALL MEET THE
REQUIREMENTS OF THE CODES OF NEW
YORK STATE. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS.
COMPLY WITH ALL CODES OF
NEW YORK STATE & TOWN CODES
AS REQUIRED AND CONDITIONS OF
V •
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SO�ni n TOMI�USTEES
N v s npc
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICATE=
OF OCCUPANCY
Additional
Certification
mdy Be Required.
SCTM #1000-61-4-6
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