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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-23716 Date JUNE 19, 1995
THIS CERTIFIES that the building ACCESSORY
Location of Property 50605 MAIN ROAD SOUTHOLD NY
House No. Street Hamlet
County Tax Map No. 1000 Section 70 Block 1 Lot a
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated SEPTEMBER 14, 1994 pursuant to which
Building Permit No. 22372-Z dated OCTOBER 7, 1994
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 A NON-HABITABLE ACCESSORY BUILDING AS APPLIED FOR.
The certificate is issued to CHARLES & HELGA MICHEL
(owner's)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE N0. N352375 MAY 19, 1995
PLUMBERS CERTIFICATION DATED DECEMBER 21, 1994 WILLIAM J. DANIELS
Building Inspe or
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 ........OCTOBERJv 19., 94....
N® 22372 Z
Permission Is hereby granted to:
CHRISTIAN„FORINE - A/C MICHEi. CHARLES„&„HELGA
4 P.-o-,. BOX 1563
r
! SHELTER ISLAND NY ]1964
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CONSTRUCT A NON-HABITABLE ACCESSORY BUILDING AS APPLIED FOR.
to
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C
MICHEL
(
50605 MAIN ROAD, SOUTHOLD NY
I at premises located at
i
County Tax Map No. 1000 Section ...........70.......... Block ...........I Lot No............. 0
j pursuant to application dated EPTEMBER... 14,,,,,,,,,,,,,,,,,,,,,,,,,, 19„94 and approved by the
r
! Building Inspector,
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Fee
p Building Inspector
Rev. 6/30/80
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form No. G
•w I, ~ _ ,.gyp'"
_XI~~~ TOWN OF SOUTHOLD ~j ~jCsl
II BUILDING DEPARTMENT ~ ~ -
JUN 1 3 1995 TOWN HALL
765-1802
APPLICATION 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 electrick installation from Board of Fire Underwriters.
4. Sworn statement from1pl.umber 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,`a 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 Buildine - $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 $15.00
/ Date ~
New Construction Y Old Or Pre-existing Building.... . . . . . . . . . .
Location of Property. ....C..fOa)'., yJ9~glit/ I?D. . JUVi~.
House No. Street
hamlet
onwer or Owners of ProperCy...Zj~J SL6/~j~..~G
County Tax Map No 1000, Section........
. ....Block ................Lot.............
Subdivision..
~j.. ..................Filed Map............ Lot.
?ermit No. A /„~.;tate Of Permit Applicant . .
Uealth Dept. Approval ..........................Under-writers Approval./Y-...... 7T
'tanning Board Approval
request for: Temporary Certificate........... Final Certicate...........
lee Submitted: c?Tr/O
Qe( f f`l (x`20 .
a le
y k IN
7 k t
Town Hall, 53095 Main Road ; a Fax(516)765-1823
P. O. Box 1179 Telephone (516) 765-1802
Southold, New York 11971
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
C E R T I F I C A T I O N
DATE :
t
Building Permit No.
C7~.~~i~ ham.. t
Owner: ~d/ ~ a
(Please print)
Plumber: " . Uc -A rye- l,.$ Jvca / ~1o f
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.
(Plumbers ign
,
Sworn to before me this
c:~Uh a day of
c~ cQ Le , 19
Notary Public, Fiat County
DOROTHY S. OGAR
Notary Public, State of New York
No. 52-8200218, Suffolk Co
Commission Expires 8/31/19
t
Ly ;.p:a 3$~G
L \M`
C. F. VAN DUZER GAS SERVICE, INC
,a
1,A! 1 "The Home of Boffled Gas and Stoves",
--n? SOUTHOLD, N. Y. 11971 r
Tel. 765-3882 - 3452
June 13, 1995
'Town of Southold
Building Department
Main Road
Southold, NY 11971
Attention: John Boufis
Ref: Ffelga Michel
Main Road, Southold
The gas lines and installation were installed
in accordance with NFPA 58 Section 3-1 to 3-2.2
and Appendix.
The Empire heaters were installed and vented in
accordance with the manufacturers specifications
and NFPA 54 6.28 through 6.28.3.
Kevin Boergesson
Manager
C. F. Van Duzer Gas Service
Ci F. VAN GUZER GAS SERVICE, INCe
,w y6 "The Nome of BoNled Gas and Stoves'
¦5'L
SOUTNOID, N. Y. 11911 Tel. 765.3892 - 3452
k June 13p 1995
'Town of Southold
auil.ding Department
Main Road
Southold, NY 11971
Attention: John Boufis
Ref: Helga Michel
Main Roads Southold
The gas lines and installation were installed
in accordance with NFPA 58 Section 3-1 to 3-2.2
and Appendik.
The smpire heaters were installed and vented in
accordance with the manufacturers specifications
and NPPA 54 6.28 through 6.2$.3.
Kevin toerg6sson
Manager
C. F. Van buzer Gas Service
}
L , I
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1185077 BUREAU OF ELECTRICITY
85 JOHN STREET. NEW YORK, NEW YORK 10038
Date MAY 19 ,1995 Application No. on file' 86444694/94 N 352375
THIS CERTIFIES THAT
only the electrical equipment" described below and introduced by the applicant named on the, above application number in the premises of
CHARLES MICHEL, 50 605 MAIN ROAD, SOUTHOLD, N.Y.
in thefollominq location; ? Basement ® Ist Fl. ? 2nd F1. OUT .Section Block Lot
was examined un MAY 15 ,1995 and found to be in compliance with the NagIGoal Electrical Code.
FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISHWASHERS EXHAUST FANS
OUTLETS ECEPTACIE$ SWITCHES INCANDESCENT FLUORESCENT OTHER AMI K.W AMT. K W. AMT. K.W. AMi K.W. AMT HP
6 13 2
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET DIMMERS
"r K. W OIL H. P. GAS H. P. AMT, NO. A. W. G. AMT AMP. AMT. AMPS TRANS. AMT. H. P SYSTEMS
NO.ST FEET AMC WATTS
1 F 3 600
SERVICE DISCONNECT No. OF S E R , V 1 C E
METER NO. OF CC. COND A. W, a A W G. A. W G.
AMI. AMP. "FE MEUIP 1,e'YW 1,03W J%JW 3%AW PER% Of CC. OND NO OF NI LEG OF 11-LEG NO. OF NEUTRALS Of NEUTRAL
OTHER APPARATUS;
PANEL130ARDSt1-6 CIR. 100
G.F.C.I:-1
TRACK LIGHTINGt-30
ROSLAK ELECTRIC LIC.#3677-E
P.O.BOX 164
CUTCHOGUE, NY, 11935 GENERAL MANAGER
Per-11 ZA!!,-
This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified y their credentials.
p i:.S. ECT ON ~~U,::S ~ ~Ua`fhEENTv III
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FOUNDATION (1st)
c -71>
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FOUNDATION (2nd) m
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ROUGH FRAME & -p-
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PLUMBING 6~ Ul
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INSULATION PER N. Y. I ' 3 b
STATE ENERGY I d
CODE. I x C3
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FINAL I 6nd
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ADDITIONAL COM TS:
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1,2
M-1802
BUILDING DEPT.
INSPECTION
( ] FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION 2ND [
[ ] IN LATION
FRAMING [ ] FINAL
/
REMARKS:
DATE ,4~1 INSPECTOR
3 7,2-
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING FINAL
a 1
REMARKS:
W. y y~ E fJ
"ev
s, ,a
DATE INSPECTOR
i
765-1802
BUILDING DEPT.
INSPECTION
FOUNDATION 1ST [ ) ROUGH PLBG.
FOUNDATION 2ND [ ] INSULATION
] FRAMING [ ) FINAL
REMARKS:
f
DATE A Iq INSPECT
r
1 BOARD OF HEALTH
1 FORM NO.1 3 SETS OF PLANS
CFP j 4 i'c)~~ TOWN OF SOUTHOLD SURVEY .
BUILDING DEPARTMENT CHECK . .
BLDG. DEPT. TOWN HALL SEPTIC FORM
TOWN OF SOUTHOLD -J SOUTHOLD, N.Y. 11971
/ TEL.: 765-1802 t70i1FY
C ; ',y~_ a~ 3D
Examined !~/7........, 19 . ALL . .
MAIL TO:
Approved 164., 6 19066rmit No............ .
Disapproved a/c
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
' Date Wtl.
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 rem 1 or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, building c housing code, and regula ' s, and to
admit authorized inspectors on premises and in building for necessary ins
(Signature of applicant, or name, if a corporation)
iPO. Bd-4 /563 si~cs~t ./.5e/ W, L
(Mailing address of applicant) /j~(pJ`
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
~C-!~
Name of owner of premises .M. l2.
(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
~-3.-.~~~
Plumber's License No .
Electrician's License No..J.<Dw
/
Other Trade's License No!." n
1. Location of land on which proposed work will be done. ~C"Dp ~7. I!?, !J ®U/~" n
House Number /Street / Hamlet p n 6 8
County Tax Map No. 1000 Section Block Lot /Y f .
Subdivision (N..................... Filed Map No. Lot:..............
ame)
2. State existing use and occupancy of premises and' intended use and occupancy pf proposed construction:
a. Existing use and occupancy ) &S~~~'N
b. Intended use and occupancy .
cCL soA~ SrlWb"J6 -
3. Nature of work (check which plicable): New Building Addition Alteration
Repair Removal Demolition Other Work
Ci I!~w (Description)
4. Estimated Cost Fee......................................
(to be paid on filing this application)
5. If If dwelling, garage, number number of of cars dwelling units Number of dwelling units on each floor , .
g g commercial mixed occupancy, specify nature and extent of each type of use
7
6. If business, . Dimensions of existing stru Les, if any: Front Rear . , Depth
Height Number of Stories Dimensions of same structure with alterations or additions: Front Rear
Depth . . . . . . . . . . . Height a a Number of Stories .
~uction: Front , Rear Depth 9 Y
Height ./5. ' prriber of Stories yy • • • . • • • .
9. Size of lot: Front Rear ; Depth .d.......... .
10. Date of Purchase i Name of Former Owner
11. Zone or use district in which premises are situated .
12. Does proposed construction violate any zoning law, ordinance or regulation: /YQ .
13. Will lot be regraded L
d~~ ~ % Will excess fill be emove from premises: Yes No
No
7, ' ' ,
14. Name of Owner of premises Address
Phone No.
Name of Architect
Address Phone No
Name of Architect .
`G/ 1 r
yw . -it7O ~1nTLS . Address I :•v. l `16 51~ "t'$l Phon 110:
15. Is this property within X00 feet of a tidal wetland? *Yes;.......
No..
*If yes, Southold ')'own 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, an show street names and indicate whether
interior or corner lot.
II
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STATE OF E RK, SI', S
COUNT O - - - - - - - -
• • • • • • • • • • • • • • • g y deposes and says that he is the applicant
above named. ' ' ' ' ' • • • • being duly sworn
(Ni m
ame of individua s tract)
i
He is the
(Co 6C or, 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 ~et forth in the application filed therewith.
Sworn to before meJJthis
JJ
`.).....day of .ti 19 .
No ublic, County
ELIZAB li ANNINEVILLE
Nota Public, Stetelof t! ^w York (Signature of applicant)
Nm 5-8126860, Suffolk CmintV
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PLuMSER CERTIFICATION J 1~ q II N v ,r
ON LEAD CONTENT BEFORE
CERTIFICATE OF OCCUPANCY
SOLDER USED IN WATER WEATH SHLG. 2-212~4~
SUPPLY SYSTEM CANNOT
EXCEED 2/10 OF 1* LEAD' v li 2sls-_-_,-=_-
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- - USE Is UNLAWFUL
- WITHOUT CERTIFICATE
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?iASeILFS:(it<,` OGSTR'JCTION MUST
F}td.4V_ FOE C.O. FAEE~
RF COh~'PdETF_
qko S K ~EQAh ~",l.V. CflNSTRUC710N SIiA THE N.Y.
7HE REQUIREMENTS OF ENERGY STATE CONSTRUCTION
NOT RESRONION FOR co es.
OFSIGN 0 R CONSTRUCTION ERRORS
F Mn ~ M?~ MICHEL
PR!PCSED ALCRY BUILDING
s 506-)2)5 IN D SGUTH L NY 7197
a SCALE F n ~O.• APPROVED EY DMWN by OV,
DATE:
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FLOOR PLAN
DRAWING NUMBER
y FOKINE CARD N Y
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DATE: 9 /D
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DRAVRNG NUMBER
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