HomeMy WebLinkAbout14497-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N,¥.
Certificate Of Occupancy
No. Zl6021 Date ...A.u.~u..s.t. 6, I987
THIS CERTIFIES that the building ...O.n..e..f.a.m..i .ly. dwe 11 ing
Location o f Property .... 1.3. A v e. S o u t h o 1 d
4. 5...A.r.s.h.a..m.o.m.a. ~ .ti.e .......'~'t/e~i ...................... ''''''Hamlet
House No.
County Tax Map No. 1000 Section .. 6. .6 ........ Block 3 ..... Lot 8
Subdivision Beixedon Estates .Filed Map No. !.4.72. LotNo. 17
conforms substantially to the Application for Building Permit heretofore filed in this office dated
·...N.o.v. :..2.5. ,. 1985 pursuant to which Building Permit No. 14497 z
dated..J.a,n.....9 ?..1.9. 8..6 .............. 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 fami,ly dwelling, garage and deck.
The certificate is issued to MARION AND EDWARD JABLONSKI
( owner,~v..~b~ ~'Xt~ X X X X
of the aforesaid building.
Suffolk County Department of Health Approval ......... 8..57.S.O. ~ ! .8.1.. J..u.l.y.. ! .4 .,.. ! .9 .8.7 ......
UNDERWRITERS CERTIFICATE NO. N819089 July 10, 1987
PLUMBERS CERTIFICATION DATED: K & K Plumbing 7/15/87 __
Rev. 1/81
FoJr. H ~0. ~
TOWN OF SOUTHOLD
BUILDING Dt:PARTMENT
TOWN HALL
$OUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
NB 14497 Z
Permission is hereby granted to:
.~.~&...~D ...... ..~.......~.....~..J~ ......
.... ...................
.... ~.~.~.~.~.~...~.~ ........
~ ......... ~.~.~~.......~ ....... ~.....~.~.....~~.~....
~ ~ ~ ~ ...... ~.~.....~.~.~..~..~~.~......~ ............
........................................................................................................ ~~.~ ..................
.......... ~i.~~...~~ .............. ~....~ ........................ ~.~.L~. ...........
~ .~ .........
~ ~ ~ ~. ~ooo s~ ...~.~ ......... ~ ....... ~ ........... ~ ~.
Building Inspector.
Rev. 6/30/80
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 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 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~$25.00, Accessory,~$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 $]0.00
4.Vacant Land C.O. $ 20.00
5.Updated C.O. $ 50.00 Date ..........................
NewConstruction ...... Old or Pre-existing Building ............ Vacant Land .............
Location of Property /~ ~,~"
House No. Street Ham/et
Owner or Owners of Property
County Tax Map No. 1000 Section ........... Block ............... Lot ..............
Subdivision../~.{~../.~,~/,).~#..~&/,/~-T~,~ ........ Filed Map No../.~.. ~)..2.....Lot No.../.? ........
Permit No. ,Z ¢.~/.~. '?.~-. Date of Permit . ././. .Applicant .~/~.¢:'.Z/$]~D... ~.~,H.J. .fi, /. .........
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 a?L~applicable codes and regulations.
A ant
pplic . .,. ...................
Rev. 10-10-78
........ ..~.. . ....
~~E D~P~AL AND WATER SU~PL~ACI~ITIES FOR THIS
LOgaN HAVE SEEN INSPE~ED BY~TH~ 'DE~MENT AND
~,o~-~.t~
THE NEW YORK BOARD OF FIRE UNDERWRITERS
100~07~
BUREAU OF ELECTRICITY
~ 85 JOHN STREET, NEW YORK, NEW YORK 10038
THIS CERTIFIES THAT
o~ly the e~ectrical equipment ~ d~seribed below and i~troduced by the applicant named on the above application number in the premises of
~d JaDlon~i~ Ar~amomO~lu~ Avenue, E/;~ ~/~don ~:e~, Southoid~ RY
~s examined on g~t~ 2~ ~9~7
FIXTURE FIXTURES
~ 2nd FI. Section Block Lot
Ou~id~
RANGES OVENS DiSH WASHERS EXHAUST FANS
DRYERS
NO. OF FEE'/
E R V I C
AWG
OF CC
2/0
AWG.
OF NEUTRA£
Sou%hold, NY 11971 ~1~578~,, t R
This certificate must not be altered in any monner~ return to the office of the Board if incorrect. Inspectors y ' y * edentials.
COPY FO~ BU LD NG DEPARTMENTi TH S COPY OF CERTIFICATE MUsT~ HOT BE ALTERED N ANY MANNER.
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. ]b/~?~
Owner t~ ~ck~ O~=S~ (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)
SworJa to before me this
~/~ .day of. ~L~/ /~
19 ~.
Notary Public~
J Notary Public
County ~~~
FIELD INSFECTION
FOUNDATION (1st)
FOUNDATION (2nd)
COMMENTS
~/e~ /--S -..C¢¢-~,,,¢o ~
INSULATION PER N, Y.
STATE ENERGY
CODE
FINAL
ADDITIONAL COMMENTS:
IELD IN~ECTION DATE COMMENTS
FOUNDATION .~ (1st)
FOUNDATION (~nd)
ROUGH FRAME &
PLUMBING '__
3.
iNSULATION PER N. Y.
C,ODE
4.
FINAL
ADDITIONAL COMMENTS:
NEW yORK STM[ Dt. PARIMI-NT OF ENVIRONMf-NTAL CONSERVATION
i PERMI f NO.
10-83-1597
UNDfR Iii[ IN'VIR()NttlENTAJ. CON$[RVATION LAW
EDWARD JABLONSKI
84 Raymond St.~ Hicksville, N. Y. 11801
Petty~s Pond
_~g~s~ruc~ a_ one faro, dwelling, de~k and s~[~a~ ~K~.~_~_.._a]_.~._.a~__%~as~__~O~ ftt_
from ~W and construct a 70 f~. timber bulkhead landward of ~W to avoid dest~
the exast~.ng boat baszn to a max~mu
iii-~--t~'-in{~itidal marsh present. Dredge ....... ~- ' ........... ~ ........ ' m
4 ft. bel~ MLW ~d use spoil as backfill.
sq~olk ...... I [ 6/30/85
GENERAL CONDIIlONS
8, Ihal Ihe State of New York shall in no case be liable for any damat
9, that ff the display of lights and signals on any work hereby authortz~
scribed by the U~ited States Coasl Guard shall be installed and mamtaine
~Ct. All work carried out under this permit shall be performed ~n acco
11. If granted under Articles 24 or ~5, the Department reserves Ihe
be just an0 equitable. H upon the expiration or revocation of this permit,
m~ificatJon of the wetland hereby a~lhorized has not been completed, U
(SE£ R£VERSE $IBE)
SPECIAL CONDITIONS
A through J
and K, M, N, P attached.
DJL:cg
c.c. file
attachments
Receipt
PE~IT ISSUE DATE
May 2~4, 1984
Stony Brook, N_.:_~Y
11794
The following conditio~s shall apply if checked as applic~ble by the
Regional Permit Administrator:
All dredging shall be conducted so as to leave a uniform bottom
elevation free of mounds or holes,
M.
All spoil material shall be disposed of either in the Atlantic
Ocean or at an approved U.S. Gevermnent Dumping Ground, as directed
by the District Engineer, U.S. Department of the Army, Corps of
Engineers. Any spoil material not intended for such water
disposal shal. 1 be removed from the site and disposed of at an approved
upland site. ~
All fill and spoil material shall be suitably contained at the work
sfte so as to prevent its eroding, leaching or othem~ise entering
into adjacent wetlands and waterways.
All peripheral rip-rap berms, cofferdams, rock revetments, gabions,
bulkheads, etc. shall be completed prior to placement of any fill
material behind such structures.
Ail repairs to existing structures shall be confined to replacement
of existing structural elements with no chance in design, dimension,
or materials~ unless specifically authorized herein.
The following Water Quality Certification shall apply if required
by one or more agencies of the United States Government and if
checked as applicable by the Regional Permit Administrators:
In accordance with Section 401(a)(1) of the Clean Waters Act of
1977 (PL 95-217) the New York State Department of Environmental
Conservation hereby certifies that the subject prelect proposal
will not contravene effluent limitations or other limitations or
standards under Sections 301, 302, 303, 306 or 307 of the Act.
Alternate Permit Administrator
Division of Regulatory Affairs
}ElS Department of Environmental
Conservation
Building 40, SUNY--Room 219
Stony Brook, NY 11794
(516) 751-7900
765-x8~2
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [~ROUGH PLBG.
FOUNDATION ZND I' ] INSULATION
[ ~'}/F/RAMING [ ] FINAL
REMARKS :~/~_
,,¢ ~" T~ '~
DATE
INSPECTOR
BUILDING DEPT.
INSPECTION
FOUNDATION IST £/] RO~GH~ PLBG.
FOUNDATION ZND [r-~INSULATION
[ ] FRAMING
REMARKS:
FINAL
T~E SI_adV',GE DI-~4a~SAL ;~D-WATER SUPPLY FA~CILITtES FOR THIS
~ATION HAVE BEEN INSPECTED ~BY~IS ~EPARTMENT AND
~UND TO BE ~T~FACT~Y.
~- ~- ~f ~.Wastewa~r ~anagement ~ction
BLDG. DEPT.
TOWN OF SOUTHOLD
m~tit~ti~r~ ~r ~'~ j
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N.Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted in duplicate 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 featu res.
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.
For existing buildings (prior to April 1957)~, Non-conforming uses, or buildings and "pre-exist!_n_g"
land uses:
1. Accurate survey of peoperty 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 ~r land use $/s-/$5.00
3. Copy of certificate of occupancy $1.00
Date .......
New Building ............. Old or Pre-existing Building(Z) ........... = fVacant Land .......... ,..
Location of Property ...'-~, ............. ~t ~. ~-..
House No. Street I! Hamlet
Owner or Owners of Property . i ~:b.e.~o.~ .e. Ade.m.s. qn' ._!_ .....................................
County Tax Map No. 1000 Section ,66 Block 3 Lot .~? '
Subdw s o . ~,-~.~--~.'. Map No ....................
Permit No ........... Date of Permit .......... Applicant .. .................................
Health Dept. Approval ........................ Labor Dept. Approval ...................... ,..
Underwriters Approval ................. Ptanning Board Approval .................. ~ .. ~
Request for Temporary Certificate ..................... Final Certificate ........ - ......... *
Fee Submitted $ .............................
Construction on above described building and perm}t~mee~s all app~cable_.codeS and regulations. APplicant .'('~.,~ J~ ~i~.. '~i~..
.., ......... ~ ...... ,.~ ...... ~ -// - ..... . .....
FORM NO, 6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N.Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted in duplicate 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
natura[ or topographic featu res.
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-e_xist!_n_g"
land uses:
1. Accurate survey of peoperty 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 er [and use $ (s-[ $5.00
3. Copy of certificate of occupancy $1.00 /
Date
New Building ............. Old or Pre-existing Building(X) ....... ~ ZVacant Land i ..... X
Location of Property ....... - .......................................... ~ ....... -,=-. ........
House No. Street Hamlet
Owner or Owners of Property Leno~e Adamsc~n
County Tax Map No. 1000 Section .... 66 Block 3 Lot .... 8
Subdivision .~. ~.; .Y,.P~..O, .~'...~.~.. ~.m.~..e,¢..~ ......... Filed Map No. '1.
Permit No ........... Date of Permit .......... Applicant., .................................
Health Dept. Approval ........................ Labor Dept. Approval ...................... ,..
Underwriters Approval ........................ Planning Board Approval ......... .. ........ ~ ~ .~
Request for Temporary Certificate ..................... Final Certificat~ ................. *
Fee Submitted $ .............................
Construction on above described building and permit' meets all app~cabte_,code~ and regulations,
~egion No,: _~
,e~e,p,,o.U 446985
Office: ,Re~e~q:_ ~.F~__~.~S~. ~3~ook ....
Applicant:
Amount'
Application Identification No,;
Permit Type:
Daniel
Check ~ Money Order []
Check or M,O. No.:
3Z4
Per.
NEW YOP~ STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
Regulatory Affairs Unit
Eullding 40, STONY--Room 219
Stony Brook~ New York 11794
(516) 751-7900
RE: Permit No., Location
· /O-~.~,..- -'"-,.~:l,'/_ __
Your recent request to extend the above permit has been reviewed pursuant
~ gNYCRR, Part 621. It has been determined that there has not been a material
change ~n environmental conditions, relevant technology or applicable law or
regulations since the issuance of the existing pe~it; therefore, the expiration
date is extended to
. ~ Your recent request to modify the above pe~it has been reviewed pursuant
to 6~CRR, Part 621. It has been dete~tned that the proposed modifications will
not substantially change the scope of the pe~itted actions or the existing
permit conditions.
~erefore, the pe~it is amended to authorize: O~~a~ ~
~is letter is an amendment to the original pemit and as such, ¢~all be posted
at the Job site,
All other terms and conditions remain as written in the origSnal permit.
Very truly yours,
Alternate Regional
Permit Administrator
CTH:DDR:co's
Sent to:
Approved .
'FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD, N.Y. 11971
TEL,: 765-1803
BLDG DEPT
1-",,, ¢* ,~F' SCIJI'HO.,D
ReceLved ........... ,19...
APPLICATION FOR BUILDING PERMIT
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.
e. 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 wl~,ole or in part for any purpose whatever until a Certificate of Occupancy
shall have been granted by the Building Inspector. '3
APPLICATION IS HEREBY MADE to the Bui;~ing Departmen~ for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold.,~uffolk 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, housin~ code, and regulations, and to
admit authorized inspectors on premises and in building for necessaryri'lCspections. /% / __ .
.. .......
(Signature 9f applic~t~ o~r name, if a corporation)
...... . .~.,.'.4 .< ~..//.~.,.//. ,)4,.../.<~?/ .............
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
(~cd D ~, t~ ..: .........................
Name of owner of premises . O.O.-B [x'k .)...m..~. .... .W'.... a n ......................
(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....~. · ~....~~
Electrician's License No. ~' / I~:.~ L ~
Other Trade's License No ......................
1. Location of land on which proposed work will be done ..................................................
............ e .... ............ ...................
House Nmnber Street Hamlet
County Tax Map No. 1000 Section .... {¢.~ ........... Block .... ~. ............. Lot...~ ...............
Subdivision... ~. >~.e. oyh, ~%~-c~sce% Filed Map No. .}.~..~.2, Lot
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy . ..~..~.q .%~...~. ........................................................
b. Intended use and occupanw . .~. );)~./.%.. (~q .03..l.,{...~. 9.k~ ~.~. ....................................
11.
Nature of work (check which applicable): New Building ....~.'..~... Addition ... i ...... Alteration ...........
Repair .............. Removal .............. Demolition ........... Other Work ...............
~ ~ .... - ~ (Description)
Estimated Cost. ~.~../. ~)oo, 77~
................................. Fee ..... . .... : ...........................
~ (to be paid on filing this application)
If dwelling, number of dwelT units ...O..~. ~ ....... Number of dwelling units,!on each floor .............
If garage, number of cars ;...~.o.c~ ...................................... I ................... , .........
If business, commercial or mixed occupancy, specify nature and extent of each type of use ........... ' ..........
Dknensions of existing structures, if any: Front ............... Rear ........ i ...... Depth ..... ~ ..........
Height ............... Number of Stories ............................. . ...........................
Dimensions of same structure with alterations or additions: Front ............. ! .... Rear ..................
Depth ...................... Height ...................... Number of Stories ......................
Dimensions of entire new construction: Front . .~0t. .......... Rear ...~.o.t ....i ...... Depth .-13.t. ..........
Height . .&.?. '. .......... Number of Stories . .../~'. ................. ' .....i ............................
Size of lot: Front ... ~..67..,..~.~ ........... Rear.. ?.9:..~.~. ...... Depth ~5 g. 0 ~ ~t~
7.11 6 ..... ' ..................
Da~e of Purchase /q .8.3....' .................. Nameof arm? wner ..~.%n.~e..e.A~m~p.~ ..... ' .....
Zone or use district in which premises are situated ..... ~t ~.e.n. ~.L~I ......
Do~s proposed construction violate any zoning law, ordinance or regulation: . ~.o. ~ ...........................
Will lot be regraded .. ~'.0.. ~,,~ ;~;'6 ;4 ~ ....... .....~.'...Will excess fill be removed, from Cremises:~ Yes No
Name of Owner of premises'~.a~v0r~ F.. ~.~.o.~, %k. ~. Address ~{ l{~.~ ?.~, lq c~,,tV.¢l~o~ne No ~ ~ ~5)~~'' ~.~! ~.
Name of Architect .~Ty.q ¢: ? .s ~ .&/~ Address ?.o ,j .r4. ? (4. ii."'~ .~$~/Phone No .... ~.
Name of Contractor .~.5~.~.~. C q(..~.<B. <o.%r. ~../. .....Address ~.f.,f..~./~ee/.,f/.///(/~. Phone No. ~'.'%'
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whetlier 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 YORK,
COUNTY OF .......... ....... S.S
................................................. being duly sworn, deposes
(Name of individual signing contract) ., ~
above named. ~,
and says that he is thee applicant
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 manner set forth in the ~pplication filed therewith. ,
Sworn to before me 'this
........... .d~..~. ........ day of...~'~ 0g~.'? ............. 19 ..~.5~- ,i
PL U]x~BE~' CF_, RT!F[CA TtON '
ON LEAD CO?,?T%¥T BEFORE
CERTIFICATE OF OCCUPANCY
SOLDER USED IN WATEI~
S UPPL Y S YS TEM CANNOT
]EXCEED 2/10 of 1% LEAD.
,w,cter dis~ribuJing
~,~§~m; piping shall be
types K or Lonly
t~ ,,
OF OCCU? 'C f
.:'i ' qJ:'¢"
0
/2. o.
-I