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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
No Z-23775 Date JULY 17, 1995
THIS CERTIFIES that the building ALTERATION
Location of Property 1015 KINBERLY LANE SOUTHOLD, NEW YORK
House No. Street Hamlet
County Tax Map No. 1000 Section 70 Block 13 Lot 20.6
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated FEBRUARY 21, 1995 pursuant to which
Building Permit No. 22612-Z dated MARCH 3, 1995
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 ALTERATION TO 2ND FLOOR OF EXISTING ONE FAMILY DWELLING
AS APPLIED FOR.
The certificate is issued to ANNA MARIE BAGNATO
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N-355764 - JUNE 21, 1995
PLUMBERS CERTIFICATION DATED MAY 17, 1995 - JOHN BORRELLI
/X'y/
"'Z t ui ding Inspector
Rev. 1/B1
FORM NO.3
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)
9q
NP 22612 Z Date 19.....!.~
Permission Is hereby granted to:
...3.~....... .1rr........ efkl tl'` xlV
tv..S ../..~ff.J.. / ........:..~~.Ae..
Ttt~Cd......../?...... /f..9...7..f
to.... d i4°.......... i-..........S~- ~c9G? c1,r............
......e,...
a.....','
...-..^....K/`............../..~.....................................................
at premises located at......../...1. ...........'./1~~~Cf! "
~rwo.............................................................................
County Tax Map No. 1000 Section Block ..........1.5....... Lot No. ~t. [rp.........
pursuant to application dated 19......f.. and approved by the
Building Inspector,
Fee 5..x/..6,0....,.
Building Inspector
Rev. 6/30/80
Form No. 6~
TOIJN OF SOUTHOLD
lr-" BUILDING UCPART11LNT
TOfdN HALL
JUL 1 41995 765-1802
APPLICATION FOR CCRTIFICATIi OF OCCUPANCY
A. This application must be filled in by typewriter OR ink and submitted to the building
inspector with the following: for new building 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 from Health Dept. of water supply and sewerage-disposal(S-4 form).
3. Approval of electricanl installation from Board of Fire Underwriters.
4. Sworn statement from'plumber certifying that the solder used in system contairs
less than 2/10 of 1% lead.
5. Commercial building, industrial building, multiple residences and similar buildings
and installations, ha certificate of Code Compliance--from architect or engineer
r responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and
"pre-existing" land uses:
1. Accurate survey of property showing all property lines, streets, building and
unusual natural or topographic features.
2. A properly completed application and a consent to inspect signed by the applicant.
If a Certificate of Occupancy is denied, the Building Inspector shall state the
reasons therefor in writing to the applicant.
C. Fees
1. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00,
Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $25.00,
Additions to accessory building $25.00. Businesses $50.00.
2. Certificate of Occupancy on Pre-existing Buildinc - $100.00
3. Copy of Certificate of Occupancy - $20.00
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
Date f YJ
New Construction....... Old Or Pre-existing Building......
Location of Property k7!it/3rEa..&y Lo.r~
r~ 7W-q
House No. Street Hamlet
Onwer or Owners of Property... /qVV A?!t...... /../J _ (ti~~ • • .
County Tax Map No 1000, Section .7.q...... Block ..........Lot.... Zd:.lf............
Subdivision.........
..........Filed P1np............ Lot........
Permit No. Z 2~',l? Date Of Permit. Sib 14( -
• • ........Applicant.FJNV1t.. M A2{t, • - •1,~j4G~;a-70
Health Dept. Approval
• • • • • • • -...Underwriters Approval.. !z°'s 1 .14 ~
:Tanning Board Approval
Zequest for: Temporary Certificate........... Final Certicate...........
=ee Submitted: $ „
.....:__.,(a p~ ' ~Q~`t•. ; : , ~~l.A•.i.liti• •"!./Y.~..........
~cU"~~a3\ 7V2.5 T
MRY 17 195 12:32PM SOUTHOLD TOWN HRLL 516 765 1823 P.1
'r1
Town Hall, 88095 Maln Flood Fax (518) 765.1829
P. 0. Box 1179 Telephone (518) 785.1802
Southold, New VOrk 11971
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
C E R T I F X CAT I O N
• DATE
Building Permit No. F•
Owner: A41 A A 6 NA N L7 _ JUL .I A 1995
(please print)
plumber:d/ f-
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.,
lumbers Signature)
sworn to before me this
L , U day of 19Y3-
Notary Public, County
MARIA C. BORRELU
Notary Public, State of New York
/ e No. 5008189
Qualified in Suffolk County
Commission Expires Feb 16, 19
CA Fax (516) 765-1823
Town Hall, 53095 Main Road Cz
P. 0. Box 1179 Telephone (516) 765-1802
Southold, New York 11971
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
April 28, 1995
Mr. Joseph Fischetti
1725 Hobart Road
Southold, NY 11971
Re: Anna Marie Bagnato
Prem: 1015 Kimberly Lane, Southold NY
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
XX An application for Certificate of Occupancy is
not on file. (Enclosed)
XX No Underwriters Certificate on file.
XX The check is not on file. $25.00
No Health Department Approval on file.
No final inspection has been made.
XX No Plumber Solder Certificate on file.
(All permits involving plumbing being
issued after April 1, 1984).
BUILDING PERMIT # 22612-Z
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
l]?L$ YNSPECTION REPORT IRATE n COMMENTS
ii--
FOUNDATION (SST) 11 II II
II II
11 -11-
11 II
II~~ C
FOUNDATION OND) _ u I l~
1~0
I -
a~ ii ii o d
ROUGH FRAME & II
PLUMBING c'
II it yy
II It
S
0 91 ~ ~C4 ~ y~
IIT I
INSULATION PER N. Y. n n of
STATE ENERGY II II y
CODE
ii
n I C
n
n n
n u
FINAL
ii
ADDITIONAL-COMMENTS
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M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ INAL
_ : `
REMARKS:
DATE INSPECTOR
r.
X
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST ( I ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
REMARKS: `
6
DATE 5~ INSPECTO l
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ GH PLBG.
[ ] FOUNDATION 2ND [ INSULATION
[ ] FRAMING i [ ] FINAL
REMARKS:
DATE INSPECTOR
765-1802
BUILDING DEPT.
NSPECTIO
[ ]FOUNDATION 1ST 'ROUGH PLBG.
[ ] FO DATION 2ND [ ] INSULATION
[ FRAMING [ ] FINAL
REMARKS: ~v
DAT INSPECTOR
'70-13--2-0
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1000061 BUREAU OF ELECTRICITY
83 JOHN STREET, NEW YORK, NEW YORK 10038
bate' JUNE 21,1995 Application No. on file 87501295/95 N 355769
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises, of
ANNA MARIE BAGNATO,~t1015 KIMBERLY LANE, SOUTHOLD, N.Y.
in thefollowing location; ZI Basement X lst FL ® 2nd Fl. GAR/OUT Section Block Lot
was examined on NNE 16,1995 andfound to be in compliance with the National Electrical Code.
FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISHWASHERS EXHAUST FANS
OUTLETS ECEPTACLES SWITCHES INCANDESCENT.fwORESCENi OTHER AMT. K W. AMT. K W. AMT. K.W. AMT K. W. AMT H P.
6 15 17 6 1 F
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL RECPT TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET DIMMERS
AMT. K. W. OIL H. P. GAS H. P AMi NO. A. W G AML AMP. AMT. AMPS. TRANS. MT. H. P SYSTEMS AMT. WAIIS
NO. OF FEET
1 20
SERVICE DISCONNECT NO. OF S E R V - I C E
AMT. AMP. TYPE METER 3W 3,e 3W 3,e 4W NO.OF CC COND A. W. 0. NO. Of HI-LEG A W LEG 6 OF NEUTRALS A. W. G.
EQUIP. PER d Of CC. C ND. Of HbIEG OF NEUTRAL
OTHER APPARATUS:
MOTORSt2-F H.P.,1-1 H.P.
G.F.C.It-1
HARTO ELECTRIC LIC.#1478E G//ice
40 SEABRO AVE.
P. BOX 607 GENERAL MANAGER
AMITYVILLE, NY, 11701 11
Per
This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their credentials.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
F (5 rI np ' I $OARD OF HEeLTH
.u) -U k FORMNO.1 3 SETS OF PCA-US
TOWN OF SOUTHOLD SURVEY
n a
FEB BUILDING DEPARTMENT CHECK . , .
1. TOWN HALL SEPTIC FORM _ .
BLDG. DEPT. t SOUTHOLD, N.Y. 11971
TOWN OFSOUTHOLD 1 TEL.: 765.1802 NOTIFY'< \
? Q1~ CALL .
Examined ...3 19./.Y MAIL TO:
Approved . , d.. 19~J . Permit No..d~o2 .
.
Disapproved a/c
/ns............. . .dingctor) '
APPLICATION FOR BUILDING PERMIT
~2i /9S
Date 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 stieets
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, o f rem al dem*ar ein described.
The applicant agrees to comply with all applicable laws, ordinances, bu ' g cod k, hou ing cations, and to
admitauthorized inspectors on premises anal in building for necessary insp io
JOSEPH PISCHETTI, JR.
PROFESSIONAL E'NTTI GINEER (Sign t re of applicant, or name, if a corporation)
Hobart Road 2S/>a62ao 7` ~jgtJ SOdJ'T>~~
Southold, N. D(..119711
(Mailing address of applicant)
State whether applicant is owner, lessee, 'agent, architect, engineer, general contractor, electrician, plumber or builder.
P ti
Ll ~c.1...~Q.......7.............
Name of owner of premises
(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 .
Other Trade's License No .
I. Location of land on which proposed work will be done. S ~LveM t7~ L/ry
SOU /'2p.0.....................
House Number Street / z Hamlet
County Tax Map No. 1000 Section ~.Q........... Block ` J.......:.. , Lot
Subdivision Filed Map No. , Lot
(Name)
2: State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy S~ /t FA0"1 `?klelth!
b. Intended use and occupancy
3. Nature of work (check which applicable): New Building , Addition Alteration v : .
Repair Remo:val. . . , , , . , , Demolition Other Work
(Description)
4. Estimated Cost .....1.2,e ~ I Fee . . . .
(to be paid on filing this application)
5. If dwelling, number of dwelling units Number of dwelling units on each floor .
garage, number of b If business, commercial cars or mix es) • ,
occupancy, specify nature and extent of.each type of use .
Dimensions o existing structures, if any: Front Rear Depth
Hem ht Dimensions of same structure Ha tber of Stories . . , , ,
pay /
g Numh alterations or additions: Front • 'R~eaf y G~........ .
Depth . . Height Number of Stories . Q
8. Dimensions of entire new construction: Front • Rear Depth . re*4„5*
,
Height Number of Stories •
9. Size of lot: Front Rear , Depth .
10. Date of Purchase Name of Former Owner .
11. Zone or use district in which premises are situated . .
12. Does proposed construction viola Se any zoning law, ordinance or regulation: .
13. Will lot be regraded . r~, 0 Will excess fill be removed from premises: Yes No
14. Name of Ow er o~~f, pprenU&es ~ h~. ~ , , Address . Phone No. . .
, 1D.
Name of Mir ~Sa 7, , , , , , , , , , , , Address , Nebnv..~r . Phone N0.76S,-Z9S~i ,
Name of Contractor Address . Phone No........
15. Is this property within 390 feet of a tidal wetland? Yes...? No..
*If yes, Southold Town Trustees Permit maybe 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 show street names and indicate whether
interior or corner lot.
STATE OF NEW YORK, S .S
COUNTY OF.
. .
• •7• • • • • • • • • • . • • • being duly sworn, deposes and says that•he is the applicant
Name of individual signing contract)
above named. 1~7 1,
3e is the.... .
(Contractor, agent, corporate officer, etc.)
)f 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
vork will be performed in the manner set forth in the application filed therewith.
iworn to before me this
? d y of . . . 19
lotary Public,:...... County
JOYCE M. WILKINS
52246 State of Suffolk Cowi1 York . . .
(Signature of No applicant)
Term Expires June 12;18Y
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1. ~ ' i CnLy{.'~.I.y~'YCSLMG9.tiG-FN:-JOM^+a~sC~_. ~wfv~.t7
DATE:
FEE:~JlL=-BY: r r NOTIFY 'BUILDING DEP RT ,6NT'AT- - YSI
'r 765-1802.5 AMTO 4 PM" POR THE OF N +ta^ "s`
FOLLOWING INSPECTIONS: gPSE Ek'p - a
i I ~ ' _ _ _ _ ....r m ' 1. FOUNDATION - REQUIRED
I ~ ~ FOR 2. ROUGH - FRAMING_ &PLUMBING' M J"I,t 4 I
3. INSULATION
~p (I ~a..~ ~ _ ~ T' MUST 4. FINAL - CONSTFi UCTION
1 ~ 'i ~ ~ ' ~ _ Alfi.~.. ,BE COMPLETE FORC.O: " @y + F i?'~r,a
- "-S',4,T 1,-4?' _ ALL CONSTRUCTION SHALL MEET n"~O o523~0 -rah i ' I' 4 T1,-4" THE REOUIREMENTS"OF THE WY, i0h~ f ^ yY .
STATE CONSTRUCTION & ENER0Y. 6q no>-AY `l i t ti,
I _ - ~ - -~1 . _ _ CODCS, NOT RESPONSISLE. FOR
DESIGN OR CONSTRUCTION ERRORS
' dOSEPFI".'F.15CHETTlF~JRy r- gROF,Pn5510MAG ENCIHBER'rn
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EMERGENCY ESCAPE AS',L'
REQUIRED BY PART, 714
1111 STATE BUILDING COD'E'
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H PART. 717.3 (f) (1) OF I p PL'l1MBR CERT~FIC~171QN
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