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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-25155 Date JULY 24, 1997
THIS CERTIFIES that the building ADDITION
Location of Property 800 HAYWATERS RD. CUTCHOGUE, N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 111 Block 3 Lot 5
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated SEPTEMBER 25, 1992 pursuant to which
Building Permit No. 22894-Z dated JULY 17, 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 SHED DORMER ADDITION & STAIRS TO EXISTING ONE FAMILY DWELLING
AS APPLIED FOR.
The certificate is issued to CARSON & GLORIA RUSSELL
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE DATED NOVEMBER 6, 1995- #3495
PLUMBERS CERTIFICATION DATED JULY 21, 1997-CARSON RUSSELL
s
Bu' ding Inspector
Rev. 1/81
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)
Date 1 2..................., 19/..
NP 22894 Z
-t
Permisslon Is hereby granter
~
. .
at premises located at
County Tax Map No. 1000 Section Block .............0......... Lot No.
pursuant to application dated ..........19 ?77-and approved by the
Building Inspector,
Fee .........lv , .
< d Bulldin Inspe or
Rev. 6/30/80
_ LL Form No. 6
.11 TOWN OF SOUTHOLD
BUILDING DEPARTMENT
9 'I TOWN HALL
765-1802
k
LD ICATION FOR CERTIFICATE 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-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.
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 Buildine - $100.00
3. Copy of Certificate of Occupancy - . .25c,4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15..0/0, Commercial $15.00
Date .....y/9.,/97
New Construction........... Old Or Pre-existing Building..
Location of Property.....COQ ~RZgJA1Kns, ,2,0, ...........0 ; _*,Agy.UN........ .
House No. A treet Hamlet
Onwer or Owners of Property........ ~~JJ C A,5S!'. ~i' ~4Rt a..~JS la
County Tax Map No 1000, Section 8.1....... Block....... ........Lot....
Subdivision.......... J.........................../Filed Map............ Lot......................
Permit No...9.//7..... Date Of Permit. ..7~/7~ ~~.....Applicant ...6"apiv. RUS .
Health Dept. Approval ..........................Underwriters Approval.........................
Planning Board Approval
Request for: Temporary Certificate........... Final Certicate...........
Fee Submitted: $.....GC .
-3 3) K APPLICANT
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016) 286-6642' . ELECTRICAL, INSPECTION;,§EXVICE JNC
37$ DUNTON AVENUE ~ '
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c EAS I PATCHOQUE, NEW YORK 11772
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c ADDRESS. ~Q FI~3 gl Yii 174 VILLAGE edi
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c INTRODUCED $Y-, Hdne Owner TIC NO
AREAS'LISTED WERE INSPECTED ON: I -6 95' AND WERE MUM), TO BE IN COMPLIANCE IT H TPIT
N.ATiONAL LI PCTRJG, G CODE
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LOCATION * ABASE 4ST 2Nd"x~ 3RI) ~ATTIj," `tiPCIOL
SKTdIM
c 7 1' SMOKE DETBCTOI DETACHI IA GARAGE
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c 7 FIXT[IR$/OU"ILhPS
1. , AN ELECTRICAL SURVEY HAS 6EN
err 11, TD J )F THE EOMb EL~CTRt(?AL
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THIS CI?RTIFtG~ATE MUSS NOT BE ALTERI p III ANX,tv)AN1sIER ,
INSPECTORS jjA EE IDEN 4 FIED EY THI IR tEDENTIALS; GQ S ;
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Town Hall, 53095 Main Road °y 2 ti Fax (516) 765-1823
P. O. Box 1179 vl Telephone (516) 765-1802
Southold, New York 11971
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
C E R T I F I C A T I O N /
DATE: Jv~ 7,, J igy7
Building Permit No. L 2 8q~
Owner: ('4'es.y Ausse U
(please print)
Plumber: Se/F
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.
(Plumbers i ature)
Sworn to before me this
..2151 day of 199q
/
Notary Public, t~ County
012,
1MAt/ q j
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ J ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INS TION
[ ] FRAMING [ FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS:. coy
DATE INSPECTOR
pp~
M-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ] ROU PLBG.
[ ] FOUNDATION 2ND [ NSULATION
[ ] FRAMING [ } FINAL
REMARKS: ECG r~rr'
DATE -G INSPECTOR ~il.~
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ W-k000H PLBG.
FOUNDATION 2ND [ ] INSULATION
[t,eF~RAMING [ ] FINAL
REM RKS: ~~~~~•r>~.~ C-
DATE INSPECTOR
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OUNDATION (1st)
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OUNDATI011 (2nd)
C3
OUCH FRAME
-PLUMBING
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.11SULATION PER N. Y.
2
STATE ENERGY
CODE
FINAL
ADDITIONAL COMMENTS: m
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FORM NO.
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)
NSN60 21005Z Date ° zP--
i
f Permission is hereby granted to:
Q~.~`~a?
h >I.e~a4 .
at premises. located at Q 1........
.
County Tax Map No. 1000 Section Block Lot No.....J~--......
pursuant to application dated w~ 19.9,4 and approved by the
Building Inspector.
Fee $.t..:~.In17~~~/
{
/ Bull g I for
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Rev. 6130180
gcpb ~GCJ/4 air S c~/
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90,6
HiP l ~Ti 5,57e54~ ~t~rE EE
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- _ ~ RQAp 4.1N8_ X144- 1. F IN15 { a
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I STORY
FRmo.
Y t.. _ 1
V SEfQWtR I
~ ~ ~ %4 Ir J
AREA 9i2 SF. (TO Tie LING) Cj
J~ u
"l !2 L
MAP OP PFZOP~.R'ry
GUIIZ ./EYED POR a o .
AR S
I S K i t~,r
ly E L L cS
t`. AS5_AU POINT - , 6 ~yd c h F
la ~i
TOWN OF SO _u}'HQ~.-D
l ZA:W ~Y V ` i ~
NQTES: GUNZANTBED TO B[2,WlE IAMPTOW WATIi, M9 v
i. T,Nq~,R FkCY Tp f1EVI EU BANK AND To tJ4aS a ABSTf2ACT a °TP rsx
YUBDIVtSfON- PTZOPER'7Y OF A± S[JRV6 fE I t
T - - Ai2.17,Cgy I
'4LC~NZa ~ECZSCY~ FlLt?047Tr-t.0E EZfC VAN T 1Y I_ P, a:
SUPF. COCLERK 5 4~t 1G AS h'fAF 76'x,« N
LSUFPCO.TAV MAP DATA f000 I I1-3-S. lG B' x
3 .TITLE NO. BB1581146-7 it 1-!C, ?-ANA ~gRYq-ypiQIj
I
m
BOARD OF HEALTH
i
; FORM NO.1 3 SETS OF PLANS
TOWN OF SOUTHOLD SURVEY
J~J~ tZ ~Mt, BUILDING DEPARTMENT CHECK
TOWN HALL SEPTIC FORN
SOUTHOLD, N.Y. 11971
• - - - TEL.: 765.1802 NOT I FY ,
/t CALL
Examined . ?P/7 , . , , , , , , MA I L TO:
Approved , 19 ~ Permit No. a~0 o S .
Disapproved a/c
..............................C--."~...... ..mac.....
( uild' Inspector)
APPLICATION FOR BUILDING PERMIT
911.7.-.5 Date 199a~
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3
ets 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
:r areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli-
ation.
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
JiQll 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
hall 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
tuilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
,egulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
'he applicant agrees to, comply with all applicable laws, ordinances, building-code, ousing code d regulations, and to
dmit authorized inspectors on premises and in building for necessary inspections.
- (Si.gnature of applicant, name, if a corporation)
(Mailing address of applicant) IFS r
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
q!pk4 ~
Jame of owner of remises ~R~SCN gNa°. ,~?,!~02 /F7uSS
(as on the talc roll or latest deed)
f applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No....1 , , , , , , , , , , `IT 28 Plumber's license No .
Electrician's License No .
Other Trade's License No .
Location of land on which proposed work will be done. . 80D. f~~i+t~ fuc4 a~
:;W;
House Number Street Hamlet
County Tax Map No. 1000 Section Block ........3 Lot
Subdivision Filed Map No. Lot
(Name)
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
6
a. Existing use and occupancy S!! w , , , , ; , , , , , ; , , , , , , ,
r
49
,ee s?Y!<
b. Intended use and occupancy . , S w~a ~ z4A
i. .
3. Nature of work (check which applicable): New Building Addition Alteration . X,
Repair Removal Demolition
Other Work.,,.,,
.
(Description)
4. Estimated Cost .....~~5^d4~ Fee .
(to be paid on filing this application)
5. If dwelling, number of dwelling units ......I , , , , , , , Number of dwelling units on each floor . .
If garage, number of cars .
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use .
Dimensions Of existing structures if any: Front ` A.~ Rear ..!543. Depth ...'S~ , , , . ,
Height a, >5 Number of Stories / .
with alterations or additions: Front S!~?7 e Rear 15"4;1 r , , , , , ,
Depth .Height...` Number ofStories ../..1/,Q',,,
Number Front !L/el , , Rear n!,l!?....... Depth !v~f? , , , , , , ,
8. Dimensions of entire new constnter of Stories . , .
Height
9. Size of lot: Front Rear %o t
71.7. (a F....... Depth 3.42$.. 70
10. Date of Purchase , , , , , , , , , , , , , , , Name Of Former Owner 9'e''4 C . d /
11. Zone or use district in which premises are situated .
12. Does proposed construction violate any zoning law, ordinance or regulation:
13. Will lot be regraded Will excess fill b removed from premises: Yes
14. Name of Owner of premises emsq y/I woi Address Q.ft , Phone No.S/.(o . 7;?-9. $Sdg ,
If yes, Southold To Address Phone No...........,....
Name
* iK ..............Address Phone No.
15. Is this thi of s property tContractor .within 30;0 feet of a tidal wetland? Yes,,,,,... No
tan Trustees Permit may be 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.
`r
;TATE OF NEW X.ORK, S S
:OUNTY OF v~ .
• • r~ • • • • • being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
bove named.
ieis the ........................d:
(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
;)plication; that all statements contained in this application are true to the best of his knowledge and belief; and that the
ork will be performed in the manner set Iforth in the application filed therewith.
worn to before me this
ad o
,19~Z
otary Public, ....tom
County
R06ERT JR. u Y.
.
yypp (Signature of applicant)
Term co
Expires~May 8 ,19
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~e"Reor+o c e~ .,Ew r)
70
M1 TiAC Zoe de J /.v Ties
Poi- PLUMBING
- ---r=-- ALL PLUMBING WASTE & WATER LINES NEED
I TESTING BEFORE COVERING
i
Cam- PLU/I PLUMBER CERTIFICATION
ON LE ON LEAD CONTENT BEFORE
CERTIFICATE OF OCCUPANCY
i CERTII SOL SOLDER USED IN WATER
SUR SUPPLY SYSTEM CANNOT ' AOo paj (j 2 8198Z
EXCI EXCEED 2110 of 1% LEAD. i SEP APP 0 ED AS NOTED
TOLt.'C:~, DATE~~ 7 g B.P,k:2 /0 a
i NUTIFY B NG DEPART T 'AM 766-1802 9 AM TO 4 PM R THE
It Copper tubing is used FOLLOWING INSPECTIONS: for system: Water dlalrlbOll be t. FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE
piping 2 ROUGH - FRAMING A PLUMBING
Of types K Or L L only 3. INSULATION
4. FINAL - CONSTRUCTION MUST
BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET _
THE REQUIREMENTS OF THE N.Y.
! STATE CONSTRUCTION d ENERGY
CODES. NOT RESPONSIBLE FOR
APPR VED AS NOTV DESIGN OR CONSTRUCTION ERRORS
DATE:
FEE'.
NOTIFY B ING RT NT AT
765-1802 N1 T 'M R THE FOLLOWING 'P M ES'
Now 1. FOUNDAT n O fr C!UIRED j FOR POU C -7F i 8~'.Iq<. .~'~~/~"IF!'?'~/
2 ROUGH - P!41 i UMBING
3. ENSULATI
OCCUPANCY OR _ USE IS UNLAWFUL WANLY OR 4. FINAL C'O 3, RI N MIL)ST BE CO ETE FOR' J. Pholle 477-0400
;UNLAWFUL ALI. Co UCn0N a L FET Main Road
WITHOUT CERTIFICA F CERTIFICATE THE u EMEN7s F HE v. GRE NPORT[, STAT CO .Y. 11944 TRUCTiON ENER .
OF OCCUPANCY CCUPANCY CODES. N RESPOIUSI E FOR DESIGN OR NSTRUCTIUN RRORS NIJTE VERi+r ALA b,*<+C-NSIONS 5-42
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GREENPORT, N.Y. 11944
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