HomeMy WebLinkAbout14417-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. Z-15988 Date ,July 23 1987
THIS CERTIFIES that the building ...O.N.E.. ?.A.M.I. ,Ly..D..W.E.L.L.I..N.G .......................
Location of Property ....4.7,0..D..o.g.w.o.o..d .L.a.n..e East Marion, New York
House IVo. Street Ham/et
County Tax Map No. 1000 Section 038 .Block 05 .Lot 002
Subdivision M/o Gardiner Bay Ests.Sec. 3 .Filed Map No. 5083 .LotNo. 180
conforms substantially to the Application for Building Permit heretofore filed in this office dated
October 29, 1985 pursuant to which Building Pennit No. 14417z
dated .. O..c.t.o.b.e..r..3. ! ,...I.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 SCREENED PORCH AS APPLIED FOR
The certificate is issued to EDWARD & CAROL ANN PEARCE
..................... ?o;,;n'e'r, X ....................
of the aforesaid building.
Suffolk County Department of Health Approval 85- $ O- 176
UNDERWRITERS CERTIFICATE NO. N 803327
November 25, 1986
PLUMBERS CERTIFICATION DATED:
Building Inspector
Rev. 1/81
FOW, M' NO. ,s
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. ¥.
BUILDING pI=R~IT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
CC~PLETION OF THE WORK AUTHORIZED)
NM 14417 Z
Dote ~ 19.~.*[*~
Permission is hereby granted to:
../..Z ~..~.~,~.~/~:~.~'~...~.. ............
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,o ......... ~.®~,~....~. . .~.........oz~z~....~. .~/..~.~....~/,z,~(,~..~ .....................
~,~,~,,,,=,~, ..... ~.za ......... ~.~.~ ........ ~., .................................................
........................................................ ~. ........................................... ~z~ac<,~e: ~'
.~~....~.e...~:~..~z~~ ~ ~ ............. ~:~ ........... ~.~ .......... ~z.~/~
~..~ m~ ~ No. lo0o s,¢,,o, ....~.~.....~ ..~.~. ....... ~o, No..~.~ ......
Building Inspector.
Fee $.....~..~....~.....~.'......~.'~
Building Inspector
Rev. 6/30/80
FORM NO. 6
TOWN OF $OUTHOLD
Building Department
Town Hall
Southold, N.Y. 11971
765- 1802
TOWN OF SOU ~,HOLD
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 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-
lions, 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 pz~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 informa-
tion required to prepare a certificate.
C. Fees: Additions $25.00 1. Certificate of occupancy New Dwelling,S25.0.0, Acc~ssory,1$10.00 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
4.wc nt c.o. $ 2o.o0
5.Updated C.O. $ 50.00 Date ...........
NewC°nstruction ...... Old or Pre-existing Building ............ Vacant Land
Location of Property /Y/7~ ~ o(,~ ~. ~
House No, Street Ham/et
Owner or Owners of Property ~ L ~-- ~-~-'~
County Tax Map No. 1000 Section ~ ~ Block J.. . Lot
Subdivision ................................. Filed Map No ........... Lot No.
Permit No..~.¥¢(.~ .~. Date of Permit ./~: ?./..'~?..Applicant ..................................
Health Dept. Approval ........................ Labor Dept. Approval ........................
Underwriters Approval ........................ Planning Board Approval .................... ..
Request for Temporary Certificate ..................... Final Certificate .......................
Fee Submitted $ .............................
Construction on above described building and permit meets all,a~plicable codes and regulations.
App cant ........................
Rev. I0-10-78
FIELD INSPECTPON COMMENTS
FOUNDATION (1st)
FOUNDATION (2nd)
I~OtJGH FRAME &
PLUMBING
INSULATION PER N.
STATE ENERGY
G,ODE
FINAL
ADDITIONAL COMMENTS
THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
[~ A'p~]. 13, ]~987 85 JOHN STREET, NEW YORK, NEW YORK 10038
404132/86
"~" ~'"'""~" ~"' "" ~"~ N 803327
THIS CERTIFIES THAT
only the electrical equipment ~ ~serlbed belo~ a~ in*mduc~ by the applicant ~med on the a~e a~pllcation number in the premises of
Edward Pe~rce, 470 Dogw~d Lane, Eas~ ~ar~on, N,Y
was examined on attd found to be in contpllance with the require.tents qf this Board
FIXTURE FIXTURES RANGES C~KING DECKS OVENS
OUTLETS I SWITCHES
19 34 23 19
DRYERS FURNACE
FUTURE APPUANCR FEEDERS
EXHAUST FANS
TIME CLOCKS UNIT HEATERS MULTI-OUTLET DIMMERS
SYSTEMS
NO~ OF FEET
SERVICE DISCONNEC~
OTHER APPARATUS:
~Otors: 1-1bp
3-G.F.C.I. 1.--b~oke Detector
Track Llghtin~ 16' 0" 11 Lites
S E R I C E
NO OF CC CONO A, W G
pER ~' OF CC COND
V
NO OF HI-LEG
Dennis Cler±e , Jr.
P. O. Box 284
Laurel, N.¥.11948 Lic. 2342E
Per .
This certificate must not be ol~ered in on~ manner; re~vrn ~o the office o~ ~he 8o~rd i~ incorrect Inspecfors m~y be identified b~ ~hek credentials.
COPY FOR BO LDING DEPARTMENT THIS COPY OF GERT F GATE MUST NOT BE ALTERED IH ANY
TOWN OF SOUTHOLD
OFFICE OF BUILDING INSPECTOR
P.O. BOX 728
TOWN HALL
SOIJTHOLD, N.Y. 11971
TEL. 765-1802
CERTIFICATION
Building Permit No._~_~
Owner
(please print)
Plumber N~l~om ~bl,~
(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
Notary Public, ,.~/~,~ I];, County
Notary Publ ic~7~
NorARY PUDL?,, S~t! of e~ee' York
[~o 4834804, Suffo~ Coun~
T~rm Ezpu~ March 30,
765-180Z
BUILDING DEPT,.
INSPECTION
[ ] FOUNDATION 1ST [~ROUGH PLBG.
FOUNDATION 2ND [ ] INSULATION
~ FRAMING
[ ] FINAL
REMARKS:
BUILDING DEPT.
~,~ INSPECTION
FOUNDATION IST [ ] ROUGH PLBG, .-.Z"/~.~,~,,.,.,~
FOUNDATION 2ND £~INsuLATIo~
F~MINQ [ ] FINAL
.
.... NSPECTOR ~
'FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
9OUTHOLD, N.Y. 11971
TEL.: 765-1802
Examined ............... 19 Received ........... ,1 9.. ·
Approved ....... t9 Permit No ......... ~ ~.
Disapproved a/c ............... .~.~. ....... O ........ / ~L ~
....
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
....... 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, hous,~g code, and regulations, and to
admit, authorized inspectors on premises and in building for necessary ij~oe.~ctions.
(Signature of applicant, or name, if a corporation)
·
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
,
Nme of owner of premises..~.. ~.. :~Q-&d .d~ ............................
(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. /.~.O...~..~...~../.~..~.~..~.~._:A ....
Electrician's License No. ~.~..ff~....~./.c.{~..;~.fi. ....
Other Trade's License No. ~..~(...Z./.~..~..~.~..
1. Location of land on which proposed work will be done ..................................................
House Number Street Hamlet
County Tax Map No. 1000 Section ..... ~.~.~ ........ Block . ..~ ........... Lot. ~
Subdivision .~.~ ~&]~}~. Filed Map No. ~ Lot / ~
(
2. State existing use and occupancy of premises and intended use and occupancy of proposed constructi°n:
a. Existing usc and occupancy .... u~. ¢~.'y/ ......... ' ..................... ~s.~d.~,0.,,f ..................
b. i~te~ed use and occupancy .......................... ..... ~ 2~', ~¢ '""~¢,,~=~ ..... ,~,, ..............
:3'., Nature of work (check which applicable): New Building .......... 'Addition .......... Alteration ..........
Rep,.ir: ~'.':i i Remb al Demolitio Othe Work
~. Estimated Cost o ~. Fee
'~' (to be paid on filing this application)
5. If dwelling, number of dwellingl units... ! ........... Number of dwelling units on each floor ................
If garage, number of cars .... ~ ...................................................................
6. If business, commercial or mix6d occupancy, specify nature and extent of each type of use ..... .-7. ..............
7. Dimensions of existing structures, if any: Front ...... .~. ....... Rear ......... Y.... Depth .... '7. ..........
Height ............... Number of Stories ........................................................
Dimensions of same structure With alterations or additions: Front ................. Rear .................
h
Dept ................... ?.. Height ...................... Number of Stones .............. ~. .....j..
Dimensions of~entire~new construction: Front... ~;~...t~...~.<~. Rear .... ~ff.~.. ~./..~. Depth ~/~...~..~....~'./.~....
Height ... ~..~.'.~. ..... Number of Stories ..... Z~ ................................ z '~ ...... ~ .......
Size of lot: Front .... Zo..~..F-.~....., ....... Rear ....~...~. ~?. ........... Depth . .~.. 7: .?./.../.-.-'~. .......
Date of Purchase ....... ~.~.~.7.~.~.. ......... k..~,.N~m~of~nnerOwner .~.~.~t.~.q..('.~.~.~'..~. ............
Zone or use district in which p~emises are situated ~,.'. :.~q. ..... *.~ ......................................
.Does proposed construction violate any zoning law, ordinance or regnlation: . ~..o. .................
Will lot be regraded ...... .2~....~jo. .............. Will excess fill be removed from premises: (Y~s~ No
Name of Owner of premises .~.i?..~..~..~. o.~ ff~..~f..~.. Address/?.~./.~.~?.~?.?.~. ~.~'?.{Phone No.¢/.~.~. .'~.. .....
Name of Architectt~.~..~.&4.~.~? ~ ~fg.°.C.~ .B'~... .... Addrass~.~..~..~,~ ?q/.~.C..~.w..~Phone No. ff..~/...~r?.
Name of Contractor ........ ~ .................. Address ................... Phone No ................
9.
10.
I1.
12.
13.
14.
Locate clearly and distinctly al
property lines. Give street and bloclq
interior or corner lot.
STATE OF NEW YORK, S.S
COUNTY OF ................
PLOT DIAGRAM
buildings, whether existing or proposed, and, indicate all set-back dimensions from
number or description according to deed, and show street names and indicate whether
............ being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named, j
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 manger set forth in the application filed therewith.
Sworn to before me this
'
............ ?.....~. .... day ~f .................... 19
Notary Public, ..... ' ! ........ County
(Signature of applicant)
SUFFOLK CO. HEALTH DEPT. APPROVAL
H.S. NO.
.... _ ~'~.0 5LJ~.',/~'?~.~'=L~ ~0~ STATEMENT OF INTENT
~ ~ ~i ~ ~~,~ ~ ~ ~ ~ ~ ~ ~ .~'~- ~ ...... ~, r'~ .... .~ , ,-.~ ~ ~- THE WATER SUPPLY AND SEWAGE DIS~SAL
.. ~..~.~,__~ ~ ~ _.~ ( ~ . . SYSTEMS FOR THIS RESIDENCE WILL
--~' ~ .~ CONFORM TO THE STAND. DS OF THE
~ ~ SUFFOLK COUNTY DEPT. OF HEALTH
~ ;INGLE FAMILY m~,~ I V,~:';~ ~'~, ~,'
[ ~ < /. , SUFFOLK CO, TAX MAP DESIGNATION:
~ '~ ~c~[~; ~O '~ 1" DIST. SECT. BL~K
/,~0~ '~ ~ // ~o~e~?~ OWNERS ADDRESS:
-... ~ ~ ........ : /.
: TEST HOLE STAMP
's ':¢~ ~" - SEAL
~ ('pc:v~ ~,~;, ~ ~,~ ~-c,/4
' RODERICK VAN TUYL, P.C.
I ~ LICENSED LAND SURVEYORS
~ou~) GREEN~RT NEW YORK
SUFFOLK CO. HEALTH DEPT. AII~Pll'OvAL
H.S. NO.
STATEMENT ~ INTENT
C~ TO T~ STAND~ ~ THE
~FF~ CO. ~, OF HEALTH ~RVIC~.
~IC~T
.. s..~. ~.:
~F~ ~. TAX MAP ~~ ~
~~
VAN T~YL, P.C.
~ N~ Y~K
SUFFO[
?
ONL?
H.D. REF .......
DATE
THE SEWAGE.~DISPOSAL AND WATER 'SUPPLY FACILITIES FOR THIS
LOC/~!,O,~4~AVE BEEN INSPECTED BY THIS DEPARTMENT AND
FOU{~ TO B~A ~ I.S F A ~T 0 i:~_~.A~..
Chlef-'of Wastewater Management Section
GREEN~RT NEW YORK
SUFFOLK CO. HEALTH DEPT. APff~OVAL
H.S. NO.
STATEMENT OF' INTENT
THE WATER SUPPLY AND SEWAGE DI.~aO~AL
SYSTEMS FOR THIS RESIDENCE VlflLL
CONFORM TO THE STANDARDS OF THE
SUFFOLK CO. DEPT. OF HEALTH ~ERVlCr~.
(SI ,~
APPLICANT
SUFFOLK COUNTY D~PT. OF HEALTH
SERVICES -- FOR APPROVAL OF
CONSTRUCTION ONLY
DATE:
H. S. REF. NO.: <~- $O - 1'7~=~
APPROVED:
SUFFOLK CO. TAX MAP DE~GNATION:
DIST. SECT, BLOCK PCL.
OWNERS ADDRESS:
DEED:
TEST HOLE
IL~NG DEPARTME~ AT
~ AM TO 4 PM FOR TH~
FOLLOWING INSpECTiONS:
1. FOUNDATION - ~ R~U[RE~
FOR POURED CONCR~
ROUGH- FRAMING & FE~IR~
INSULATION
FINAL - CONSTRUCTIO~ ~
B~ GOMPLET~ FOR C ~
ALL CONSTRUCTION '$HAEE ~E~
'STATE CONST~UCTI'O~ ~' ~E~ '
:CODES, NOT RESPON~I~E~ ~
DESIGN OR CONST~U~I'ON E~O~5,
L
IO'.- o"
lB- G
.I
If copper tubing is used
for water distributing
sys em; piping shall be
of types K or __L only_
SOLDER USED IN WATER
SUPPLY SYSTEM CANNOT
EXCEED 2/10 of 1% LEAD.
pLUMBER CERTIFICATIOn.
ON LEAD coNTENT BEFOR~
CE}2TIFICATE OF OCCUPANCY
,t
I
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