The URL can be used to link to this page

Home My WebLink About14415-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy THIS CERTIFIES that the building ...S .e.c.q n..d..f. 1. 99.r ................................ Location I175 Great Peconic Bay Blvd. Laurel, N.Y. of Property/t~s~ County Tax Map No. 1000 Section 129 .Block 0 1 .Lot 006 Subdivision Laurelwood Estates .Filed Map No. 5595 .LotNo. 2 conforms substantially to the Application for Building Permit heretofore filed in this office dated 0 c t. 2 9, 1 9 8 5 pursuant to which Building Permit No. 14 4 1 5 z dated . .qt. ,t 9.b.e.r...3.1.,.. ! .9.8.5. ....... 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 ......... One family dwelling with attached garage "UPSTAIRS ONLY" The certificate is issued to JOHN & FLORENCE JACKOLSKI (owner, ~,~YOX l~14iioTdX X X X of the aforesaid building. Suffolk County Department of Health Approval ..... N../.A .................................. N781854 UNDERWRITERS CERTIFICATE NO .................................................. PLUMBERS CERTIFICATION DATED: January 29, 1987 Rev. 1/81 FORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy No. Z-15232 Date January 30, 19B7 THIS CERTIFIES that the building One family dwelling with attached garage ' 1!75 Great Peconic Bay Blvd. Laurel, N.Y. Location of Pro . House No. Street .............. h~t~/e~ 129 0 I 006 County Tax Map No. 1000 Section ............ Block ............... Lot ................. M/o Laurelwood Ests. 5595 2 Subdivision ............................... Filed Map No ......... Lot I'4o .............. conforms substantially to the Application for Building Permit heretofore filed in this office dated October 15, 1985 14415Z ..................... , .,. pursuant to which Building Permit No ...................... dated October 31, 1985 .............................. was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ......... ONE FAMILY DWELLING WITH ATTACHED GARAGE DOWNSTAIRS ONLY JOHN & FLORENCE JACKOLSKI The certificate is issued to ..................... [o~'n'e'r,'l~Z~'~:i$'~ ..................... of the aforesaid building. Suffolk County Department of Health Approval 85 - S O- 140 N781854 UNDERWRITERS CERTIFICATE NO .................................................. January 29, 1987 PLIIMBER$ CERTIFICATION DATED: Rev. 1/81 FO~M NO. f~ 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) N9 14415 Z Permission is hereby granted to: ............. ...~.~.~...~:....P..~.../..~..c.~ , - ~ ............. .......... ~z..;..Z~.~....~,z...Za-~..~ ........... ~.~.~.~zz-/z.z~.,....~:.:../......././..~o / - ~o,~/~-z~. ...~...~ ~.¢~. Z2.c~...~...~X~ ........... ......... ~.~....~.~,.~..z~xc .......... &..J.~....~xx.....¢..~,.//..-._ ..................... at premises located at ...... Z/....Z.S-~......'~' '~"'.Z.?~.~a-~-'Z~.C.....~.~...~.....~....~.; ....... ................................... .;, ............................................................................ Z--,,~.~.,~/z, L ~ ..Z~..... '../, ..4,~.~r~,...~. .......... ~,. ..~....~.~. ..... Z, az:.:...~... ............. County Tax Map No. 1000 Section ..... ~..~...~.. ..... Block ....(~...../. .......... Lot No....¢~..~ ....... Building Inspector. Fee $.. ,..':~...q....~.......~..~ Building Inspector Rev. 6/30/80 goal FORM NO. 6 TOWN OF $OUTHOLD 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 I~ 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 informe- tion required to prepare a certificate. C. Fees: Additions $25.00 1. Certificate of occupancy New Dwelling. S25.0.0, Accessory1$ ]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 $10.00 5.Updated C.O. $ 50.00 Date .............. NewCons truction ...... Old or Pre-existing Building ............ Vacant Land ............. Location of Property . ./~,/. Z~.... ~..2~..~.(~..~../'.C_,... ~...~.y,. ~/-,..V..~.: ............. /.-~.~. ~..~..~.L. House No. Street Ham/et Owner or Owners of Property .~..0../"~..~. ,~...~..Z~.,~.~. ~.-~. C~......~.,~.t~.~..~Z.~ ................. County Tax Map No. 1000 Section ..../?. ~. ....... Block O/ Lot. ~..~. Subdivision...~.f~.~..A~..~-.~..~.,.c¥.~.. ~..~.'.~./~,-.7~'.,~.-.~..Filed Map No, .'~. ,~.~..~...Lot No....2r ......... '... Permit No. /.-~'.~'..~. ~. Date of Permit .Applicant ..... ~/~..~.... Health Dept. Approval .... .~...~..~...~.O..'T../.¥~....Labor Dept. Approval ........................ Underwriters Approval . . . ~, .7..~ ............ Blanning Board Approva ...................... Request for Temporary Certificate ..................... Final Certificate ....................... Fee Submitted $ Construction on above described building and permit meets aIJ applicable codes and regulations. A' licantpp .............................. .'. Rev. 10-10-7S ~_, ~(~d ~_~ FORM NO. 6 TOWN OF SOUTHOLD Building Department 765 - [802 , ' APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. 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 ac, curate location of all buildings, property lines, streets, and unusual natural or topographic features.'V -- 2, Final approval of Health Dept. of water supply and sewerage disposalF(S-9 form or equal). ~ 3. Approval of electrical installation from Board of Fire Underwriters, V 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: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling $15.0 0 3. Copy of certificate of occupancy $1.00 4.Vacant Land C.O. $5.00 l[-0I--l~ l~-~ 5.Updated C.O. $15.00 Date ................... NewCOns %ruction ...... Old or Pre-existing Building ............ Vacant Land ............. LocationofProperty JlT.~. P~ez21~;c ~/. ~o[jL~v~P~ LI2C.LJ.~L Hou~ No, Street Hamlet Owner or Owners of Property ......... ~H~ ~ ................................................. ~O~EN~E ~[.OL3K~ co tv ooo so tio .. -t- a o,k .... Cot Subdivision ................................. Filed Map No ..... ~ .....Lot No .............. Permit No. Date of Permit /~/~../~.~.Applicant .AC.//// Health Dept. Approval ........................ Labor Dept. Approval ........................ Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate ....................... Fee Submitted $..,~¢ .C~0:..(~.~ ........... Construction on above ~ described building and permitP~eets a~'aQPlicable,eode~,a~f regulations. TOWN OF SOUTHOLD OFFICE OF BUILDING INSPECTOR P.O. BOX 728 TOWN HALL SOUTHOLD, N.Y. 11971 TEL. 765-1802 CERTIFICATION Building Permit No. Owner ~. ~',A/',,~-~', u/'"~///~' (please print) (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. ~lumber's signature) Sworn to before me this · ~ day of 19 ~?, . Notary Public, No, 4826~2 ,:ommisslon E~lr~ Mar~ County Notary Public FIELD I~l S ~'E~TI ON COMMENTS FOUNDATION (2nd) ROUGH FRAME & PLUMBING ADDITIONAL COMMENTS: ~Og~ ,,, o~_ ~ - ' ~ ' SCALE- T- , THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY s' R.E'r, r, EW ,,OR,<. NEW YORK 1003~ aO~U~ Jackalwski, P~conic Bay Boulevard, Laurel La.& La~relwood Dr., Lau~cel., ~.Y EXHAUST FANS 47 59 54 47 DRYERS MOTORS FUTURE APPLIANCE FEEDERS TIME CLOCKS UNIT HEATERS MULTI-OUTLET DIMMERS SYSTEMS NO. OF FEET SERVIC'~ DISCONNECT OTHER APPARATUS: Panelboards= 1-4cir., 125amps 2-G.F.C.~. 2 Smoke Detector S E R V I C E NO.O~ CC, COND. 4/~0~.o. 1 OF HI'LEG 4/O Guston Bartra . GENIAL MANAGER 227~ ~r~akwa~er Rd. '..~ / Matt~t~ck, N.¥11952 L/=#lS29E p¢~ <i,, This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their credentla(s, COPY FOR BUILD NG DEPARTMENT, THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY WANNER. 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND ~INS~TION FRAMING [ ] FINAL INSPECTOR~ 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL DATE '~/:;~ .~ '~ INSPECTOR 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL DATE INSPECTOR 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION ZST [ ] ROUGH PLBG. N FOUNDATION 2ND, [ ] INSULATION FRAMING [ ] FINAL REMARKs: .~/~ DATE iNSPECTOR ~,C L... 765-1802 BUILDING DEPT. INSPECTION ~)(~] FOUNDATION 1ST [ ] ROUGH PLBG, [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL DATE ..) !/~/~'" iNSPECTOR ~[/~'/-.~ r 765-'1802 BUILDING DEPT. INSPECTION [ ] FRAMING REMARKS: FOUNDATION lST [ ] ROUGH PLBG. FOUNDATION 2ND [] INSULATION [] FINAL 80-2,1 ~.~3t]3,$~reet Queens Village, April 15, 1986 Southold Building Department P.O. Box 1179 Southold, New York 11971 Dear Sirs: In order to proceed with completion of the second floor plan of~my residence at 1175 Peconic Bay Blvd., Laurel, New York, it is requested that extension be granted for t~e Building Permit No. 1~415Z issued to me by your Department on 10/31/85. Your attention to ~his request is greatly appreciated. John V. Jackolski TOWN OF SOUTHOLD OFFICE OF BUILDING INSPECTOR P.O. BOX 728 TOWN HALL SOUTHOLD, N.Y. 11971 January 5, 1987 TEL. 765-1802 RE: Mr. & Mrs. J. Jackolski,l175 Pec. Bay Blvd., Laurel To Whom This May Concern, We are unable to complete your Certificate of Occupancy because,of the following reasons. /~ An application for Certificate of Occupancy is not on file. (Enclosed) /~ No Underwriters Certificate on file. The check is(~v~l~ed/not on file.)~O No Health Dept. Approval on file. No final inspection has been made. Please con'act our office on this matter. Thank you for your cooperation. B il ing Permit / _4 / .5' z Building Dept. ***~/ No Plumber Solder Certificate on file. ( all permits involving plumbing being issued after April 1,1984 ) 'FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Received ........... ,19... Disapproved ........ .......... ........ . ' ................... ..... (Burl/ding Inspector) APPLICATION FOR BUILDING PERMIT Date . IO /t ~ 19 ~S INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 set~ 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/~'6'~e, housing code, and,,r-egulations, and to admit authorized inspectors on premises and in building for necessary ins~~ ~. ,.. )g~ (Si~ture.of applicant, Oa~ffmne, if a corporation) .././.., .'~..,>.v..m-z..~....................~..~.,, ..~. ,.y .... D.q. 97 .......... c/ ...... ihLili, g address of applicant) State whether applicant is owner, lessee, agent, architect, en~neer, general contractor, electrician, plumber or builder. ............................................. ", .......... , ~o'2 ! (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 .............. >~ ......... Plumber's License No..dP.....~..,~...~..~.~../.~.I<'. Electrician's License No. ~ Other Trade's License No ...................... 1. Location of land on which proposed work will be done ................................................... House Number Street Hamlet . County Tax Map No. 1000 Section .... I.."~..C~. ......... Block ....~ .............. Lot. ' ~.....[-9. ..... ,Subdivision [~ t~ ~ f'~' ~r~ ~- ~4 ¢> ~c:> ..................................... Filed Map No. '~ ~q ~ Lot ............... (Name) 2. State existing use and occupancy of premises and intende~e and occupancy of proposed construction: a. Existing use and occupancy ...... ./~. ?..~..../?~... ?....~. ........................... ' ............. b. Intended use and occupancy .... .~.I.M..c~..L:?- .... . .~...P,~x.. ).~..~.....~>...x~..~..k.~. ) .~..r,~ ........ ~ ............. 10. 11. 12. 13. 14. Nature ofwork (checkw /tpplicable): New Building ...v~.' ..... dition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work ............... '~P J ~,fla~ escripti n) Estimated Cost I .~. O, Oo o 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 If business, commercial or mix'ed occupancy, specify nature and extent of each type of use ..................... Dimensions of existing structures, if any: Front ............... Rear .............. Depth ............... Height ............... Nffmber of Stories ........................................................ Dimensions of same structure With alterations or additions: Front ................. Rear .................. Depth ~ Height Number of Stories Dimensions of entire new construchon: Front ~ .c/. x . Rear .... ~.~ ..... Depth ~8 · n~.h* .~ I ~ Number of Stories t .4 .o, .4 .c?. rth Size of lot: Front ................. Rear ...... I .............. De ................ Date of Purchase/~ .[?q.~.;.~,P.~. ~ ! .t. ) .~.?.2-. ......... Name of Former Owner ............................. Zone or use district in which plremises are situated ..................................................... Does proposed construction violate any zoning law, ordinance or regulation: . .1~[ .~. .......................... Will lot be regraded ...... i i~'~.~ ~-.~.~...~. · ~z~.,>.......... Will excess fill be re.moved from premises: Yes Name of Owner of premises 1~.~5 ~.~ .~P. ?~.~o~s.~l Address~.~.g.~. g!.~..r.qs..77~¢..~'~. Phone No.~.i~..~.4.~5..'..~...~ ....... ~ .............................. ~ ot*~n~'~r~ ......... one No. ~5. ............. marne o t:ontracmr ....... i .................. Address ........... Phone No PLOT DIAGRAM Locate clearly and distinctly a~l 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 show street names and indicate whether interior or corner lot. STATE OF NEW Y~I},K,,~ ~ i'~'N S.S COUNTY OF ...... ..... · ~. ~x~ .1~'.I~. -~ · . · .~'. · · ."~ · L'~ .t~.. ....... being duly sworn, deposes and says that he is the applicant (Name of individual sig~ing contract) above named. 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 conialned 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 me this ........ · ~. f~//~ ............. , 19 ..~'.~ 'Public ............... .~^N~ ~. srso~sglCOunty ~' ~ .. ~~~' Not~ Public, Sta~l~ o! New York ,' S~FFO LK COUNTY DEPT. OF I~EALTH A · SU~Y FOR ~UF~OLK COUNTY D~PARTM~NT OF' HEALTH SERV,C~: ~OHN V. ~ACKOLSKI ~ FLORENCE JACKOLSKI LOT NO.~,"LAURELWOOD ESTATES" 00: ~7, ~986 APRIL 17, ~986 FOR APPROVAL OF COb~STRUCTION ONlY AT LAUREL DATE APRIL 11,1986 ~WN ~ SOUTHOLD SCALE: DATE . , HS REF. NO.~~ SUFFOLK COUNTY~ NEW ~RK NO. 86-~90 ~ ~UTH~IZEO ALTERATION OR ADDITION m ~IS ~UARANT~y~F/.:~. ~ SURVEY ~ 4 VI~iTION ~ J[CTION 7~09 ~ THE ~OUT~L~~A~ APPROV~ ; ~ NEW YORK STAT~ [~CATION LAW YOUNG 8 YOUNG NOT[, m:~ ~ RIVER~AD, NEW YORK SUBDIVISION MAP FILED IN THE OFFICE OF THE CLERK OF ALDEN W. YOUNG~PROFESSIONAL ENGINEER SUFFOLK CO. ON MAY 17~ 1971 AS FILE NO. 5595 4ND LAND SURVEYOR N.Y.S. UCENSE N0.12845 HOWARD W. YOUNG~ LAND SURVEYOR J t J J: .I A~a'::P AS HOtEt) NOTIFY BUILDING DEp,'~RTMENT A 765-1802 9 AM TO 4 PM FOR THE FOLL~qING INSPECTIONS'. 1. FOUNOATION - ~0 REQUIRED FOR POURED CONCRETE ~. 'ROUGH - FRAMING & PLUMBING 3, INSULATION 4, FINAL ~ CONSTRUCTION MUST BE C~-ApI .RTE FOR C. O, ALL CONSTRUCTION SHALL ME~ THE REO1HREMENTS OF THE N,Y, STATE CONSTRUCTION & ENERGY CO~ES. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORE. i 14'-0" 4 FIRST .rLI Z':!- o" REAF-1 ELEV, ELEV, L '0 1 t,., I L z_-tq 40'- 0" ,i II I t I t I II I[ II ~C I I I II II III 0° I I 0® II I I I SECOND FLOOR LAN · II I I I