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Home My WebLink About22804-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. ~ERTIFICATE OF OC~3PAN~Y No Z-23690 Date JUNE 8, 1995 THIS CERTIFIES that the building. Location of Property 1150 SMITH ROAD House No. County Tax Map No. 1000 Section 98 Subdivision ADDITION PECONIC, N.Y. Street Hamlet Block 3 Lot 27 Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated MAY 30, 1995 ~ursuant to which Building Permit No. 22804-Z dated JUNE 6, 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 DE~K ADDITION TO EXISTING ONE FAMILY DWELLING AS APPLIED FOR "~ BUILT". The certificate is issued to of the aforesaid building. DONALD A. DOHRMAN SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A UNDERWRITERS CERTIFICATE NO. N/A PLUMBERS CERTIFICATION DATED Rev. 1/81 N/A FOI~M NO,3 TOWN OF $OUTHOLO BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N.Y. BUILDING PERMIT N~ (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK A~. ~ ~,~ ......... ~ .................... ~..?" 22804 Z ~'"~'""'~ CountyTax MaP No. 1000 Section .......... . ,.~..~...,,,, Block ........... ~ .........Lot No, ..,,,~......~.. .............. Building Inspecto,~¢.~ Fee $....'~.. ,~,, ...,~, ,~,.. Rev. 6/30/80 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 65-1802 . APPLICATION FOR.CERTIFICATE OF 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-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2/10 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurat~ survey of property showing all property lines, streets, building and unusual natural o= 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 Building - $100.00 3. Copy of Certificate of Occupancy - $5.00 over 5 years - $10.00 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 February ~ 1995 for foundation Date ....................................... New Construction.~ ......... Old Or Pre-existing Building ................. Location of Property ........ 5~j%b. Road Peconic, NY House No. Street Hamlet Onwer Owners of Property P99A¥ ^' Dohrman Cosnty Tax Map No 1000, Se tion...¥. ......... Bloe .. ............. Lot.. .................. Subdivision .................................... Filed Map ............ Lot .................. 22804-Z ' June 6,1995 ~ Donald Dohrm~n Permit No..- .............. Date Of Permit ............. Appxicant ........ Health Dept. Approval .......................... Underwriters Approval ......................... Planning Board Approval ........................ Request for: Temporary Certificate ........... Final Certicate ........... $ APP ICA FIELD INSPECTION REPORT DATE COMMENTS FOUndATION (IS~) ROUGH FRAHE & PLUMBING INSUlaTION PER N.Y. ~___ Il STATE ENERGY co~ {[ " FINAL I~ ADDITIONAL COI~iENTS: 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION2ND [ ] INSULATION [ ] FRAMING [/~FINAL [ ] FIREPLACE & CHIMNEY DATE i N S PECTOR ~--f_--,.~//~ , FORM NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.; 765-1803 BOARO OF ItEAL¥11 ......... 3 sETs OF PLANS .......... suRvEY ................... C,IECK .................. CALL ~ .................. I'IAIL 'FO; Date ....... : ........... 19... INSTRUCTIONS a, This apl~lication must'be completely filled in by typewriter erin ink and submitted to the Building Inspector, wilh 3 sets of plans, accurate plot plan to scale. Fee acco[ding to schedule. , b. Plot plan showing 19cation 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 mu~t 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 i~sued a Building Permit to the applicant. Such permit shall be kept on the premises available for inspection throughout the work. e. No buildiRg shall be occupied or used in whole or in part for any purpose whatever until a Certificate'of Occupancy sball bare been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Betiding Permit pursuant to tile Building Zone Ordinance of the Town of Sonthald, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal ~[ demolition, as herein described. The applicant agrees to cmnply with all applicable laws, ordinances~ building code, housing code, and regulations, and to admit authorized iuspectors on premises and in building for necessary inspections. (Signatur9 of applicant, or name, if a corporation) (Mailing address of applicant) State wbetlmr applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ~,,,e o~ow~,er of premises...........~ 0 ~-~ ~.~..'D.. ... .0. .~. A.~., (as ou tile tax roll or latest deed If applicant is a corporation, siguatnre of duly authorized officer. (Name and title of corporate officer) Builder's I.icense No .......................... Plumber's License No ......................... Electrician's License No ....................... Other Trade's Lieeuse No... .................... Locatiou of land on which proposed work will be done ......................... ' o. .... r .q..,,' .......... ............. l louse Number Street ~11o3c '"~'7 ltamlet Cou'nty Tax Map No. lOO0Section .~.q:.~...~..?.q.q.~Bl k .............. :... Lot..Z~. ............ Subdivision ..................................... Filed Map No, : .............. Lot ............... (NaLne) - ' 2. State existing use and occU'pancy O(premises and inteuded use and occupancy, ofp[o )osed constructiom a. Existihg use and' ~Ccupan'cy ........... ' ............ ¢'.~ ~'~ .4~ ~ ,~)i.~:, ~ ~ ~A~O[{ . . ~ , ~j ~:~L~J ',~%~;~2~'~: :o~ ..................... b, Intended use and occupancy ........ ~*-:~ ~ ~{u[ ' ............. ~ ................ !.vm.,,mc): Prow ~3unUmg ......... Addition Alteration Repair Renlpval Demolition ............... ; ..... .............. ' ............. ' Other Work Estmlate os[ ..... '. 5. If dwelling, number of dwellingl malts (Descrip fion) .................... Fee ....................., ...... , ........... (to be paid on filing this application) ............ . ,. Number Of dwelling milts on each floor... .............. · If garage, number of cars .... 6 If business cmmnercial or mixe ............ ' .............. ' ................................... ' , . .occupancy, specify nature aud extent ofeach, typeol~use'...,,. ........... 7 D ' I ' ' if F · ue is o is o exlstulg stn, ctur s, ally: font ...... , ........ Rear ............... Depth ........... Height Nut berofStorles ' " ' Dinle.sions of shine stmotur, e w' th alterations or addlhons:' ' Front .................. Rear ................ Depth ' .'.. lleigbt Nnmber of Stories . Dullenslons ofeutlre leW CoUStlllCtlOI1; Front ' Rear , ............................. Depth ............ Height ... ..... Nuniber of Stories . . .' ................................ ,. Sizeof 0t, rout .... ::...,: ......... :.. Rear ..................... Depth 10. Date of Purchase ................ i ' .......... Name of Fonuer Owner ............ 11. Zone or use district in whicll premises are situated ' ' ' ' ~: ...... 12 · ' ............. · Does ploposed cot strt etlon violate ally zolung law ordinance r regulahon' . Willldtb d d ' ' · Will fill b I ' 13 e regra e ......... i ................... excess e remove( front prellllSeS: Yes No 14. Name of Owner of premises .. ) ............... · Address ........ · ' .......... Phone No .............. Nmue of Coutractor Address - Phone No ' 15. I.s this property within 300 feet of a tidal wetland? *Yes ........ No ......... · If yes, Southold '~'own Trustees Permit may. be required. PLOT DIAGRAM Locate clearly and distinctly all[buildbtgs, whether existi.g or proposed, and, indicate all set-back dimensions fr~nl property lines. Give street and block mmber or description accordh~g to deed, and show street naules and indicate wlletlher interior or corner lot. 0F OOOUPA ,C¥ )TIFY Bt.IILD~NG D[~EN~ 765-1802 9 AM TO 4~HE FpL.LOWING tNSPEC~IONS: ,I, ~OUNDADON ~ ~OREQUff~ED FOR POUR[D CONCRETE 2, ROUGH. FRAMING & PLUMBING 3. INSULATION 4. FINAL CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL ME~ THE REQUIREMENTS OF THE N.~ STATE CONS~UCTION &, ENERGY CODES. N~ RESPONSIBLE FOR ,.. DE~I,GN O~ CONSTRUCTION ~OR~ STATE OF NEW V<~l~/,~,, ~,, $ S CO<0~l'y OF ...~l'37, t ?~_._ ' (Name of individual signing contract) abOve named. being duly sworn, depose? mid says that he ' ' .... ts the appbcant {Contractor, agent, corporate officer, etc.) of said owner or owners, Bud is dulylautborized to perform or bare performed the smd work and to m~e and file tbls applmahou;, that. all stately, e~ ~ntaij]edl work will be performed m t e am net et forth ] tim a ' ~e aa~ ~ n,, ~pbcahon filed tberewdb. ' Sworn to before ~!]e fids / No. 47~~C~n~, . . ' (S~guature of appbcant)