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FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
Date SEPTEMBER 15r 1988
THIS CERTIFIES that the building
Location of Propert~ 100
House No.
County Tax Map No. 1000 Section 37
Subdivision GARDINERS BAY EST.IFiled Map No.
ADDITION & ALTERATION
KNOLL CIRCLE EAST MARION
Street Hamlet
Block 5 Lot 20
255 Lot No. 36-38
conforms substantially to the Application for Building Permit heretofore
filed in this office dated OCTOBER 5, 1987 .pursuant to which
Building Permit No. 16511Z dated OCTOBER 11, 1987
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 A SECOND STORY ADDITION & REMODELING OF EXISTING PORCH TO AN
F~XISITNG ONE FAMILY DWELLING,
The certificate is issued to
~ORDON & MADELINE SCHLAEFER
(owner,
N014227
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
UNDERWRITERS CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
HENRY J. SMITH & SON, INC. 7/1/88
BuildingOInspector
Rev. 1/81
FOR~ NO. S
TOV~N OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N° 16511 z
Permission is hereby granted to:
~,~.._~.~,.....u.%.~..~:.......:... ~
,o .~.~..~..~..~.~...~..~...~...~~..~.~0...~
............................
at premises located at .I..,.L~.,........~....~.*.-'w~A~M'~..~L'~.......I'JC3.'iM"D'/'c43'r~-....A'J'...'L~· ...........
County Tax Map No. 1000 Section ..... ..0,.."~,~ ........ Block ..... .(~..~.. ...... Lot No, ...~..,.~.. .............
pursuant to application dated .....~..~.'-.~.~...~.. ...................... , 19.~.7/.., and approved by the
Building Inspector,
Fee $...~.~...:.. ~...
Building Inspector
Rev. 6/30/80
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N.Y, 11971
765- t802~
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
This application must be filled in typewriter OR i6k, and submitted I m,,,~-~ to the Building Inspec-
tor with the following; for new buildings 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 of Health Dept. of water supply and sewerage disposal-(S~9 form or equal).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa-
tions, a certificate of Code compliance from the Architect or Engineer responsible for the building.
5. Submit Planning Board approval of completed site plan requirements where applicable.
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing"
land uses:
1. Accurate survey of p~operty showing all property lines, streets, buildings and unusual natural or
topographic features.
2.Sworn statement of owner or previous owner as to use, occupancy and condition of buildings.
3. Date of any housing code or safety inspection of buildings or premises, or other pertinent informa-
tion required to prepare a certificate.
C. Fees: Additions $25.00 POOLS $25.00 ALTERATION $25.00
1. Certiflcate of occupancy New Dwelling $25.00, Accessory.~$]O.00 BuShiness $50.00
2. Certificate of occupancy on pre-existing dwelling $ 50.00
3. Copy of certificate of occupancy $ 5.00, over 5 years $]0.00
4.Vacant Land C.O. $ 20.00 .-~,~_j. .......... l.~_~__~-
5.Updated C.O. $ 50.00 Date .~l...!~
Newc°nstruction ...... Old or Pre-existing Building ............ Vacant Land .............
Location of Property . .).~.C? ..... Jf~..Q. [./'., .~.! .~¢~. l(~. .... ,~,-~.~. ,'~. ~.tD' .Y~. ............
House No. Street Ham/et
Owner or Owners of Property .~t~'~¢ .~ Co~l.~-r...~..~..~.~..{!.~.L .~..~../..0-~..'~.~-
County Tax Map No. 1000 Section ...3.9 ......... Block ..... .~. ........ Lot... ,~,, .O. ........
Subdivision, .~, .~L..r~. j.~..~,F~.,,, ~.~..,. ~-~..'~...Jrt/., .Filed Map No....~..~.~."...Lot No...
](.¢~-//'Z~ Date of Perm~ it /O./3~ A licant
Health Dept. Approval ........................ Labor Dept. Approval ........................
Underwriters Approval ~ Planning Board Approval
Request for Temporary Certificate .............. Final Certificate
Construction on above described building and permit meets all applicable codes and regulations.
(~'qbP~k- ~l-~ ~'j Applicant .(~.~ .~.4~....~..~.. , ,~~~,
%,!>0,
Rev. 10-10-78
FOUNDATION
FOUNDATION ( 2nd )
2.
ROUGH FRAME ~///
.?LUMBI~
INSULATION PER N.~.
STATE ENERGY
CODE
FINAL
ADDITION A'L COMMENTS
THE NEW YORK BOARD OF FIRE UNDERWRITERS
1001071
BUI~EAU OF ELECTRICITY
[--- 85 JOHN STREET, NEW YORK, NEW YORK 10038
27,
54,,~' 588188 N ~]422~
~ppl~a~ion No. on ~l~
~O~DO~ SC~I,~EYFg~ K~Ohh C~RChg, E~T ~AR~O~
~ examin~ on andf~nd to be in co~pllance with the r~ui~ments of th~ ~rd.
~TU~ RXTUI~S ~NGES OVENS FANS
O4JTLETS SWITCHES
SERVICE ~SC:O~INECT S E R V I C E
SO~WHOhD, N{, '1
this certificate mu~ not be altered in any manner; return to the office of the_Boo_rd if_incorrect.. Inspectors may be identified by theirs' ~e~entials.
C:Q~Y I~R BUII,INNG DEPARTMENT. T~IIS ~ OF CERTIFICATE MUST HOT BE ALTERED IH ANY M~4HER.
HENRY J. SMITH & SON,
PLUMBING, HEATING & FUEL OIL
MAIN ROAD
SOUTHOLD, N,Y, 11971
(516) 765,-3690
Inc.
CERTIFICATION
Building Permit No._~ .......
Owner Gordon Schlafer.~a_~_~_M~_N~
Plumber Henr. x J. Smith &
I
system
certify that the solder used in the water supply
contains less than 2/10 of 1% lead.
Sworn to before me this
_~s_~_day of Jul~ ...... ,
19 88
Notary Public, Suffolk County
765:~.802
BUILDING DEPT.
INSPECTION
FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING ,r.~"~INAL
REMARKS:
?GS-JS02
BUILDING DEPT.
INSPEC N
FOUNDATION 1ST ~P~ ROUGH PLBG.
[ J FOUNDATION 2ND [ ] INSULATION
[ ]FRAMING [ ]FINAL
REMARKS:
DATE
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ],ROUGH PLBG.
/
[ ] FOUNDATION 2ND d INSULATION
DATE
_INSPECTOR ,,~
765-~LSOZ
BUILDING DEPT.
INSPECTION
FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION 2ND [ ~SULATION
FRAMING
~r ] FINAL
INSPECTOR
'FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
~OUTHOLD, N.Y. 11971
TEL.: 765-1803
Examined~...~....o~...l.I ..... , 19~. 7.
Approve~..<~. ~ .I. I ..... , 19~..?. Permit No..I..IP.~.-~.}.I .'".~.'.
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Received ........... ,19...
Date ................... 19...
INSTRUCTIONS
a. Tkis 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 giving a detailed description of layout of property must be drawn on the diagram which is part of this appli-
cation.
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 issued a Building Permit to the applicant. Such 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 whatever until a Certificate of Occupancy
shall have been granted 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 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.~.d.~, c .,~.~:. ........
(Signature of applicant, or name, if a corporation)
· ./..~¢.. ~¢.~.~ ~../). ~,..~. !.~...x/.~.,,
(Mailing address of applicant) //¢~ /
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
.............................. D. ~. t. !4 .~..~. .......................................................
Name of owner of premises .... ~. c.~yg.. ?....~. CLC~.~/~.O ~.. ~..~C~L.[.Cce~.-/~ ~ ..............................
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
..... ....
(Name and title of corporate officer)
Builder's License No ..... i~=~)..~.~'.~. · ._ ~
Plumber's License No.. ~: ~../D.~..}~.. ............
Electrician's License No ..... .~.}: .~ ..............
Other Trade's License No ...... .'~././¢
1. Location of land on which proposed work will be done ..................................................
.... ! .0o. ...................... l<~.~ Lc .... Cl ~ ..... ~r.~../..
House Number Street Hamlet
County Tax Map No. 1000 Section ...~ .~. ........... Block ...~ ............. Lot..~.0 ..............
Subdivision Je~..~.. g~f. Map ..... ......
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy .......... J...'~LD0..~. .. I ................................
.......... ...............
b. Intended use and occupancy
Repair .............. Removal ......
4. Estimated Cost . . .l~b~l)7~...i .........
5. If dwelling, number of dweilin~ units ......
Nature of work (check which applicable): New Building ' Addition Alteration .'
....... Demolition ............ Other Work ...............
(Description)
............... Fee .....................................
*, (to be paid on filing this application)
/ ....... Number of dwelling units on each floor ................
If garage number of cars ' ........ .....
6. If business commercial or mix,.cE occupancy, specify nature and extent of each type of use
, ~f any: Front .... ~.-~. ....... Rear ...
7. D~ensmns~o f,e~astmg.~ '
Height .. Z~.~: ~: ~.~ ~'~.:;t2~er of Stohes ..... Z ...................................... t ...........
' S' ; J ' ''
D~en ~onsfi~e s~ur~i~ alteratmns or addmons: Front ... ~ ~. ......... Rear..~> .............
Depth .... ~.~..'.~.. [~1. HeiSt ~.~ r . . . Number of Sto~es... ~.~ ...........
8. Dime~sipns of entire ne tion: Front .... ~..[~.. Rear .. ~¢ .......... Depth .. ~ .......
~g t ..... ~.a ,~.,,la~l~er of Stones ....... ~ ...... ~ ......................... ~ ..............
9. S~z~ of 1~: ~f6ht~:L'.Yg2~.~. Rear ... I ~ ............. Depth ... joo
10. Date of Purchase .............................. Name of Fomer Owner ,.~. ~.g~'... ~o.~.~.~..
1 1. Zone or use district in which p~emises are situated ....... ~.~
12. Does proposed construction vi01ate any zoning law, ordinance or regulation: .... ~.~ ........................
13. Will lot be regraded ........ .~. · ..............Willexcess fillbe removed from premises: Yes ~ No
14. Nme of Owner of premises ~g¢.~..~, ~ddress ~mo~g.O~.., .... Phone No ................
Nme of Architect ......... [ ............. Address K~T ~t~. Phone No.
' ........................
Nme of Contractor .~ff~l. · .~. · ~ Address ~ ~. ~.&. Phone No. Z&~q~. .
PLOT DIAG~
Locate cle~ly ~d distinctly ~1 bufld~gs, whether existing or proposed, ~d. indicate ~1 set-back d~ensions from
property ~nes. Give street and block number or description according to deed, ~d show street nines and indicate whether
interior or corner lot.
STATE OF NEW YORK, - S.S
............. .... ............. being duly sworn, deposes and says that he is the applicant
(Name of individual sigfiing contract)
above named.
He is the ........... ~,iC~ ......................................................
, (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 manngr set forth in the application filed therewith.
Sworn to before me this
................. ~.....day of .... ~:? ~..~-. i ............19 ~.7.
Notary Public,
· . . ounty
- : 8B.t*FII{.DEVOE ...................
NOTA~ PUBtlC, Sine ~ ~w ~
~. 4707878,,Surfak C~o (Signature of applicant)
Terml Expires M~rch ~, 1
i
,/
%.
ti copper tubidg is used
for water distributing
system; piping shell be
o! typei~
suPPLY sYSTEM cANNOT
ExcEED 2/10 of 1% LEAD.
PLUMBER CERTIFICATION
ON LEAD CONTENT BEFORE
cERTIFICATE OF OCCUPANCY
OCCU?^NC¥ OR
USE JS UNLAWFUL
,,~4 ~hOUT C~RT~FJCA~
CJ