HomeMy WebLinkAbout15386-zFORM NO. 4
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
$outhold, N.Y.
Certificate Of Occupancy
No. z-15989 Date July 23, 1987
THIS CERTIFIES that the building ONE FAMILY DWELLING WITH ATTACHED GARAGE
" i66b' ¥gCi('s ..................................
Location of Property 1200 Rosewood Drive Mattituck, New York
Ifl/~JS'o '~iO: ........................................................ Streot Hamlet
County Tax Map No. 1000 Section ...I. 1.3. ...... Block 02 .Lot 23
S hd' '' M/O Rosewood Ests. 20
U~_lVlSlOn ............................... Filed Map No. 5240 .Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
October 2, 1986 . pnrsuant to which Building Permit No. 15386z
dated October 2, 1986 wasissued, and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is .........
ONE FAMILY DWELLING WITH ATTACHED GARAGE & WOOD DECKS AS APPLIED FOR
The certificate is issued to ... DONALD J. WILCENSKI
.................. .....................
of the aforesaid building.
Suffolk County Department of Health Approval 8 6- S O- 1 2 0
UNDERWRITERS CERTIFICATE NO. P E N D I N G
PLUMBERS CERTIFICATION DATED: July 20, 1987
Rev. 1/81
Building Inspector
TOWN OF SOUTHOLD
BUILDING DEPARTMEN'r
TOWN HALL
SOUTHOLD, N. Y.
BUILDiHG PERi, IT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N~ ~53Sg
Z
Permission is hereby granted to: ~
...... ~,,,× ~ ................................................. ~
.... ..c,,,,~.~~....~.....~.,.....~.~.~..~. .......
~ ............................................ ~ ........................... ;:::: ....... ~.....~ ................. ; ......... ~. ..............
at premises located at ...(..~:'...°..~......~.. ~~....~...~.-...~- .......... -,....~.~ ...........
County Tax Map No. 1000 Section ...... .\.~...'~ ........ Block ...~..~ .............. Lot No....~....~. · ............
pursuant to application dated ..... .(~..C~..'~...~......~.. .................. , 19..~.~., and approved by the
Building Inspector.
Building Inspector
Rev. 6/30/80
FoRM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N,Y, 11971
765 - 1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
This application must be filled in typewriter OR ink, and submitted 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-g 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 featu res.
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 inform+
t/on requ ired to prepare a certificate.
C. Fees: Additions $25.00
1. Certificate of occupancy New Dwelling $25.00, Accessory ,,$]0.00 Business $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.wo nt L nd c.o. 20.00 1 £7
5. Updated C.O. $ 50.00 Date . ..cP.°..( ............
NewConstruc%ion ...... Old or Pre-existing Building ............ Vacant Land .............
Location of Property O 5¢¢~,ro-z~ ~ ~)~-¢~- ~ ~
House No. Street Ham/et
Owner or Owners of Property ....... ~ .............................
County Tax Map No. 1000 Section ..... /~ .~. ...... Block ..... O..~. ....... Lot .... . .c~.~ .......
Subdivision....~..~V~.v',)..~. . .~..~.T..A:%~.5, ....... Filed Map No..~'?q.g'~ .Lot No. .~. O
Permit No. .I ....... Date of Permit ....... Applicant ... ~-c/~ o, E'~j~
· App
Health Dept. Approval ..................... Labor Dept. royal .......................
Underwriters Approval . :'~/.~p./.~.7. .............. Planning Board Approval .....................
Request for Temporary Certificate ..................... Final Certificate ,~,,, .................
Fee Submitted $ ...........................
Rev. 10-10-78
765-1802
BUILDING DEPT.
INSPECTION
FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION ZND [ ] INSULATION
[//~FRAMING [ ] FINAL
DATE
INSPECTOR
TOWN OF SOUTHOLD
OFFICE OF BUILDING INSPECTOR
P.O. BOX 728
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL. 765-1802
CERTIFICATION
Date
Building Permit NO. 1~
(please print)
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.
(plumber's signature)
Sworn to before me this
Pub 1 ic, County
Notary ~
Join, [,~glres ~'~aicD 30, 19~
J Notary Pub linc ~
FOUNDATION ~(lst)
FOUNDATION
2.
ROUGH FRAME &
.FLUMBING
INSULATION PER N.
STATE ENERGY
CODE
FINAL
ADDITIONAL COMMENTS:
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING
REMARKS:
FINAL
DATE iNSPECTOR
7GS-1802
BUILDING DEPT.
INSPECTION
FOUNDATION ZST [ ] ROUGH PLBG.
[~J~OUNDATION 2ND [ ] INSULATION
FRAMING £ ] FINAL
765-t802
BUILDING DEPT.
INSPECTION
FOUNDATION ZST [ ] ROUGH PLBG.
FOUNDATION 2ND [ ] INSULATION
INSPECTOR
7GS.1802
BUILDING DEPT.
INSPECTION
[ ] FRAMING
REMARKS:
FOUNDATION 1ST []ROUGH PLBG.
FOUNDATION 2ND []INSULATION
[]FINAL
INSPECTOR /~~ ~
.4/0/¢
and sewage disposal
Suffolk
FOR APPROVAL 0~: CONST~?JC'fION OF
$in~ Family Re~nce Only
EXPJRES ~O YEARS F~TE OF AP~L ~
,, n~r~n~n~[~, ,
FILED JAIV.
· AVMIO$ BANK
,I. WILCENSKI
S~GLE FAMILY DWELLING ONLY
./0/ F JOHN ~ ROSE KOROLESK!
DATE ...............
LOCATION HAVE BEEN INGPECTED fly THIS DEPARTMENT AN]
FOUND TO BE ~ATtS~ACTO~Y.
O~ief of ~astewater Management ~ctlon
i ,ll~~' ,I
S.67°55'10"W. 167. 05
LOT 18
' L G°t
bJ
CERTIFIED TO ·
AMERICAN TITLE INSURANCE
SOUTHOLD SAVINGS BANK
DONALD J. WILCENSKI
CO.
"MAP
FILED
S,URVE Y OF
LOT 20
OF ROSEWOOD ESTATES
JAN. 2Zl~ 1969 FILE N0.5240
AT MA TTITIJCK
TOWN OF $OUTHOLD
SUFFOLK COUNTY , N.Y.
[000 ' II 3 02 23
SCALE I" = ;50'
NOV. 20,198 6
MAIN ROAD
SOUTHOLD, N.Y.
LIC. NO. 49 668
RS ~ ENGINEERS ,P.C .
11971
the LLA~[~o ~d ~pproved ~nd adop~d
for ~c~ ~se ~ T~ N~W Var~ $~e Land
86 685
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1803
Approved O.~.X~..I..0.., 19~.(~. Perrait No.]. .~'7..~..~.~...~.
Disapproved a/c .....................................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Received ........... ,19...
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 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 neces~-a~nspecti~qs~,x ,~, t, ('~ '
...'~b,.,,~../'~.~-,..,..~.~ .... ; ......
(Signature bf"gpplicant, or_name, if a corporat'on)
...~..~. ~ ~.,,, .~...~. .... .v?..g.o.?., ~.~..o .......
owctq-o~t~ ,/J~ ~/~s . ..
· '~ ................... -~: ......
(maii±hg addresg of app )loUld~-i~er.
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or
..... .o.~ ~ ...............................................................................
Name of owner of premises..'~ .&.U.~ .... .~.... L/~; .! .q--~..B.~..~.i ...................................
(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 ..... ~. .................
Plmnber's License No..~ ....................
Electrician's License No...~ ~00 ~
Other Trade's License No ......................
I. Location of land on which proposed work will be done..~.o.T'. ............ ~.0 ....... ~'.~..'~. ...........
.............. ~, I.tqru
.... ............... ...... ;t .....
Itouse Number Street Hamlet
County Tax Map No. 1000 Section ..... i.\3 ......... Block .... a,.O ......... ~ot .... ~.3 ............
Subdivision..~..~'.~-~..tO..O..O..~....~..,g.~.,~,.~.t~. ........ Filed Map No.. ~.Z .~o. ....... Lot .l~ ............
(Name)
2. State existing use and occupancy of premises and intended us0 and occupancy of proposed construction:
a. Existing use and occupancy. .~..O-.~4~...~. ..... .~..~.'~' ..................................
b. Intended use and occupancy . .[ ......................................
3. Nature of work (check which appli,cable): New Building.........V .'Addition ..~..-I .. Alteration ...... , ....
Repair Removal Demolition ' Other Work
.~. ?.O..O. (Description)
4. Estimated Cost... ¢.0~..~ ..................... Fee .......................................
(to be ~aid on filing this application)
5. If dwelling, number of dwelling units ..... ~ ......... Number 9f dwelling un:is on each floor.. ~ ...........
If garage, number of cars ...... o~ CIX~... ~ :r~...~.~..d~..~,. ....... j ............................
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 ofi Stories ..............
8. Dimensions of ehtire new constrnctlon Front ' ~ . Rear ~ n~,,+h ~'.
· .r [ '' '..h ............... i ......... ~ ..................
Height . [kY ........ Number, of Stories t~. .
9. Size of lot: Front ...... [.~/~1..Q.o .... Rear IZI. ,O~ rDenth ~l^.'~, ~
10. Date of Purchase o.C--~..g~ .... j0~, .'7.. ?~.~.. ~i ~a~_~ o['F,'o'r~ir'~)~v~;;' .i~..~ .t. i ' ~4~.'~ l~.-4.~'/' ' ' i i .....
11. Zone or use district in which premises are situated .~:.... ~z ~e~.~...2 ............................
12. Does proposed construction violate any zoning law, ordinance or regulation:
13. Will'lot be regraded ...kIx~. ~:. ............ , ...... ~. Will excess fill be removed from premises: Yes
14. Name of Owner of premiSes . ~)or~.~,/.. ~... b~.~..~..~*Address tq~qt~ (2o~D ! Phone No .'7].~76~6~
Name of Architect ..... ~,,,~.,-/ .... /~...,~o.~...~,. ..... Address ~..~,~ i .~.'~o.' i ~xY-.~ .' .~."./'Phone Nol
Name of Contractor . .~.u.t.c3 q~...(4o...,~...°..oky'. ?y>. ,. Address Cw~ .q'f~...~.. ~0t~ht~. Phone No..~.$ .1. ~. ~..~."/ ....
15. Is this property located within 1.00 feet of a tidal wetland? *iYes ..... No .....
· If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from
property lines. Give street and block number or description according to deed, and showy street names and indicate whether
interior or corner lot. ~o~t>O~ ~$'r~'F~-~ ~ ~ ZO
2,0
........................ being duly sworn, dep( scs and says that he is the applicant
(Name of individual signing contract)
above named.
(Contractor, agent, corporate officer, etcJ
of said owner or owners, and is duly authorized to perform or have performed the shid work and to make and file this
application; that all statements contained in this application are true to the best of hi~ 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
..... ~9,,y_~.. ............. day of.. ~ ......... , 19 .'~..
$otaryPublic, ..~ ........ :...; .... :.'County _
USE iS' UNLAWFUE ~ . ,,: r
:WITHOUT CERTIFICATE
OF OCCUPANCY'
CELL/k ~,-~t~ ~E MEN].