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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 .
N2 22564 Z 19..J1
Permission Is he 7y granted to:
..........f%~~.~i'~'
to r ............1 7,../ dr'Zo4 .L~..... ~ !~Gf
~ .................G?c ......................fem............%.........
. o..........<9 ° d '
..........p
6666 ' at premises located at............ ''./Q~
4~ ..........r~~' rd's
County Tax Map No. 1000 Section ../.6... Block .......4 .............LLot No.
pursuant to application dated [ll........................., 19.....`~?~..... and approved by the
Building Inspector.
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Fee S•
4 . ~
uiB lding Inspector
Rev. 6/30/80
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FIELD INSPECTION REPORT IIDATE II COMMENTS
FOUNDATION (1ST) I
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If 11
II 1 b
FOUNDATION-_--OND)
II it
II - JI -
II II
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ROUGA FRAME 6 II
PLUMBING C _
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I II N
INSULATION PER N. Y.
STATE ENERGY
CODE
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II II
II II
II II
II II
FINAL
ADDITIONAL COMMENTS:
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BOARD OF HEALTH
FORMN0.1 3 SETS OF PLANS
TOWN OFSOUTHOLD SURVEY
BUILDING DEPARTMENT CHECK
SEPTIC FORH
SOUTh.,-j', N.Y. 11971
TEL.: 765-1802 FY 14. 1:1 = 2 7
Examined .:...~l~J 1991 HAIL TO:
Approved /w 19! Permit No. _ _ ' .
Disapproved a/c _ .
ding Inspector)
job 19V APPLICATION FOR BUILDING PERMIT
L = , Date .t4........, 1995
. Cs. DH'7.LL
TOW. W. SOUTH OP 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, housing code, and regulations, and to
admit authorized inspectors on premises and in building for necessary inspections. ~.(pJ
. ?.clA~'
(Signature of applicant, or roy
e,' corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises Ug : ?y11~K, R ~r , . , .C.o K Q, : , , , , .
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
`.~•yT~ ~5 ~1.K1lS .
(Name and title of corporate officer)
Builder's License No . .
Plumber's License No .
Electrician's License No .
Other Trade's License No . . .
1. Location of land on which proposed work will be done. ....4! ? SST .,5t p 1? S N i 9P h(L,D L i3
....................S. H.I.P y f~.l?J? L !E s.19 2/ o rJ
House Number Street Hamlet
County Tax Map No. 1000 Section 7J~........ Block . 'Z~ Lot. .P:~..1.~.
Subdivision ..5yy%.y n .\t .E. ST. AT,E 4.•."AT&d Map No . Lot ....I...........
(Name)
State existing use and occupancy of c;, smile and intended use and occupancy of proposed construction:
a. Existing use and occupancy U V 'G~- 1P1 (7
b. Intended use and occupancy . . . . . .
i
3. Repair Nature of work (check which Removal New Building ..V, , , , , , Addition Alteration
, Demolition Other Work .
4. Estimated Cost (Description)
~I
Fee
5. If dwelling, of dwellin g (to be paid on filing this application)
number 6 units Number of dwelling units on each flgot i , , , , , , , , • ,
If garage, number of cars , , , , , , ,
6. If business, commercial or mixed occupancy, specify nature and extent of.cach t • • • .
7. Dimensions of existing stru to es, if any: Front ...~1A... , , , , Rear , , , ype of use .
nof Stories • . Depth , . • , , .
Dimensions of same structure with alterations or additions: Front .
Depth , Rear .
Height , . Number of Stories .
8. Dimensions of entire new construction: Front . ' ' • • •
Height 2cJ.. . , Rear . . .............Depth. r. .
. Number of Stories .
Y2-. 9. Size of lot: Front ...15 1..1 Rea
r S I:. V.3• Depth ..1.
10. Date of Purchase , . , , Name of Former Owner , • . • • ' ' •
11. Zone or use district in which premises are situated A t' °lo
12. Does proposed construction violate any zoning law, ordinance or regulation: . •
13, Will lot be regraded Will excess fill be removed from preM Yes No
14. Name of Owner of premises v5 y! l g , RS~k~•Tt( Address 13' 15 3, 7 kN phone' So
Name of Architect No , .
Q
Name of Contractor r~~Q, CoN i Ry~.. 1 • Address Phone .
15. Is this a t • • Address nd? F./?oM......... Phone
property within 300 feet of a tidal wetland? *yes " "
*If yes, Southold Town Trustees Permit may be required. No.•.••'•••
PLOT DIAGRAM
Locate clearly and distinctly all; buildings, whether existing or proposed, and, indicate all setback 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.
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TATE OF NEW YO K
OUNTY OF rlW S'S
• , , , . bDASAA' yv . ' G. G.I G" 1+1 T I • • • • • being duly sworn, deposes and says that he is the applicant
(Name of individual signing confract)
)ove named.
-te is the ,
ntractor, agent, corporate officer, etc.)
said owner or owners and is dug
. y authorized to the said work and to me and file this
plication; that all statements contained in this application are have oetl the best of his knowledge and belief; and that the
irk will be performed in.the manner gc't forth in the application filed therewith.
,otn to before me this
ay
,1945-
tary Public,
" ~ _..,w'ety .
ROB I SCOTT,JR. i4 of
UBL,C, State of N.Y. ( g of applicant)
NQTARY Si
. Nq. 4725089, Suffolk Cou
Term Expire
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EXPIRES REr2 YEARS SURVEY FOR
FROM DATE OF APPROVAL G U S M A R REALTY
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVtCE!1 LOT NO.1„ "SUMMIT ESTATES, SECTION
AT EAST.-MARION DATE'. APR. 22, 1992
FOR PR AL OF CONSTRUCTION ONLY
TOWN OF SOUTHOLD 9caLE: 40'
GATE HS REF. NO.~ SUFFOLK COUNTY, NEW YORK NO, 92.0332
e RSIWU7H04R1EE0 ALTERATION OR ADDITION TD THIS
APPROVED C NEWV TORK STATE EDUC'A7 ON LAWOM 7209 Of THE
Q > / +COrIES T THIS SURVEY NOT KAAfNO THE LAND OF NEW y
It P2/S P/~ Svyv S, SUR VErons INKED SEAL OA INf O33ED SEAL SHALL P.1 Mq9
KGU4 ANTEC301NDICATED HEREONI SHALL [ALINPONLY TO Q' 11
HEALTH OEPARTMEN
T•0 TA FOR APPROIAL TO CONSTRUCT THE PERSON FOR WHOM THE SURVEY IS PAEPAAtD 'L [ti
AND ON HIS SEHALF TO THE TITLE COMPANY, 0OVE11N• 2
R NEAREST WATER GAIN M1.: RSOURCE OF WATER, PRIW TC PVDIIC MENTAL AGENCY AND LENDING INSTITVTIOM LISTED UT
f "F CO. TAX MAP D"T30$4ECTION 29~ KACK -S LOi~. MEA[pl, AND TO THE ASSIOH EES Of THE LENDING
RTHERE ARE NO DWELLINGS WITHIN 100 FEET OF THIS PROPERTY INSTITUTION, GUARANTEES ARE NOT TRIHSFERA GI[ Ul
OTHER THAN THOSE SHOWN HEREON. TO ADDITIONAL IHSTITVTIONS'OA SVOSCOVCHT t7
K TLC WATER SUPPLY AMO AGE DISPOSAL SYSTEM FOR THIS A1310EMCX OWNERS
W WEALTH R 3MplVITDCt3, THE SiANOUlOS Of 1 THE SVITOIK C CO OUNTY DEPARTMENT R O DIESXITASTNCIME6S S SHOWN TU HRECRSEON ARE FROM PAR3POPEECRITFY IC LIMES 44
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APPLICANT, PURPOSE AND ARE NOT TO BE USED TO ESTAILISN A
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us- m 4 ~ef1LT~ PROPERTY LINES OR FDA THE ERECTION of frxCt3
ADORE" 16- I S 3-7 + h 8 yE _
L.~ c ,Ty m.7 VV 3ct2-C~8 (718) 544-7487
(71 110-64 Queens Blvd
8) 261-7351
NOTE; I. JAY FLAUM - ASID
Forest Hills, N.Y. 11375
SUBDIVISION MAP FILED IN THE OFFICE OF THE CLERK OF
SUFFOLK' COUNTY ON (NOT FILED AS OF 4/22/92)
A
R TK LWrCM WET Ru TIN$AFqOR DATA OS 00$tDArAOIT3TAl,. CQ F Hutc« F & J. PLAN ASSOCIATES LTD.
ARE LRCM F1CL0 ON[3ERWATONM(D'fRW OTM LRS
BRANDIS A SONS INC.
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" OCCUPANCY, OR
UNTIL 2nd SURVEY It P MA
USE IS UNLAWFUL DO J FOUNDATION HA LOCATION MA
EL]d ~ v7~IJIL sl GP~17G WITHOUT CERTIFICATE. F AS BEEN APPROVED y X
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OF OCCUPANCY !
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APPR
DATE: B.P. A
WAS NOTED p~~ss~' FEE: ~ ' W BY:
NOTIFY 85 LDING DEPABTM NT AT
788-1802 9 AM TO 4 PM FOR THE
PLUMBER CERTIFICATION FOLLOWING INSPECTIONS: 1. FOUNDATION TWO REQUIRED
1 I FOR FOUNDATION ON LEAD CONTENT BEFORE p POURED CONCRETE E-f In L A U C 7E, r LTD _.r LTD
LJ N CERTIFICATE OF OCCUPANCY 2• HOUGH • FRAMING & PLUMBING
~~,o~` CL EuA7ic SOLDER USED IN WATER 3. INSULATION 4. FINAL - CONSTRIJOFION MUST
SUPPLY SYSTEM CANNOT BE COMPLETE FOR C.O. ~E
EXCEED 2/10 of 1 % LEAD. ALL CONSTRUCTION SHALL MEET To ~ ( U V' E THE REQUIREMENTS OF THE N.Y. cHECRFq et DRAwN er er
limppen MM Is uttd STATE CONSTRUCTION e' ENERGY SCALE = I
fo?Weterdisolbuting CODES. NOT RESPONSIBLE FOR DATE DESIGN OR CONSTRUCTION EBRORB SIZE DRAWING NO. PLUMBING piping shell be
ALLPLUMBINGWASTE system; 7 r
B WATER LINES NEED F!,J types K or L R
TEBnNG BEPGRE COVERING UNDERWRITERS CERTIFICATE L
REQUIRED t
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EMERGENCY ESCAPE AS
REQUIRED BY PART. 714 OF
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PROVIDE OPENINGS FON DPENINGS FOR 9 --a e---~-
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REQUIRED BY PART. 7141 BY PANT. 714 OF n
N.Y. STATE BUILDING COD BUILDING CODE. r `J
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