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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-23675 Date May 31, 1995
THIS CERTIFIES that the building NEW DWELLING
Location of Property 400 SHORT ROAD CUTCHOGUE NY
House No. Street Hamlet
County Tax Map No. 1000 Section 116 Block 2 Lot 9
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated OCTOBER 4, 1994 pursuant to which
Building Permit No. 22403-Z dated OCTOBER 24, 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 ONE FAMILY DWELLING WITH ATTACHED GARAGE AND DECK AS
APPLIED FOR.
The certificate is issued to MARY D. HOLLAND
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL R10-94-0041 MAY 11, 1995
UNDERWRITERS CERTIFICATE NO. N351812 MAY 15, 1995
PLUMBERS CERTIFICATION DATED MAY 12, 1995 LARRY LISO PLUMB & HEAT
it ng 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-0 19./...z..
N2 22403 Z
Permisslon Is hereby granted to:
./...7
J~u~
........i..~.... Y ......a~... :.r...~......
. .
i
4xk
to AA41.4,0
'
j .
I
I at premises located at..... `47....
c
i .............................................................Yy!••••...`~.......
County Tax Map No. 1000 Section / Block , Lot No......G~ r................
pursuant to application dated 19..1 T.. l!//.,.., and approved by the
Building Inspector.
Fee
E
4 Q~
~ Buil ng Inspector
s
Rev. 6/30/80
Is z j ~~y ~11- Form No. 6 9
TouN OF souruoLD
MAY 2 6 1995 BUILDING DEPARTHEUT
TOWN HALL
765-1802
93
- APPLICATION FOR CERTIFICATE OF OCCUPAi:CY
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 electricrul 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 buildin~, industrial building, multiple residences and similar buildings
and installations,fa 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 - $20.00
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residenttiial. n$15.00, Commercial $15.00
Date J o~y J5
New Construction- uuOld Or Pre--e fisting Building
Location of Property 1l,.... .0
House No. J
Street Hamlet
Onwer or Owners uf Property.MI&I..,I/51. HIS III rjG~
County Tax Map No 1000, Section. .IJ.6 Block ...Q Tl ........ot O OF
Subdivision . . Lot............Filed F1ap............ Lot..........
Permit Floe.I.b..4. ..Date Of PermiCl. l a'~.1~7.J..... Applicant( l/~/A'
~ ~,N..S:../.1.~
Health Dept. App roval/.o.:.~y: ayl..{s,YJ V 1
Underwriters Approval..~~/.~'•1•~.,,~S,.
:Tanning Board Approval..A/
2equest for: Temporary Certificate......
Final Cer[icatc..x •
'ee Submitted; ~
miss . h. hit!
TEL. 765-1802
opSQEFULA(p0 TOWN OF SOUTHOLD
OFFICE OF BUILDING INSPECTOR
P.O. BOX 728
y 'IF TOWN HALL
0`t SOUTHOLD, N.Y. 11971
C E R T I F I C A T I O N
Date
Building Permit No.ZVOL -2~
Owner m(1 4 pn~
(Y ie se MAY 26 1992
Plumber c,*" Goo VLUle.
(please print)
-
I certify that the solder used in the water supply system
contains less than 2/10 of 18 lead.
(plumber' s gnature)
Sworn.to before me this
day of /X!~'Y • ,rf/~ ~it~~`
19
Notary Public
Notary Public, rv~~GC County
DOLORES L. USO
Notary Public, State of New York
Suffolk County - No. 40410
CommInW Expkaa Oct. 31, k
Town Hall, 53095 Main Road 10*2 -C Fax (516) 765-1823
C2
P. 0. Box 1179 W- Telephone (516) 765-1802
Southold, Now York 11971
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
May 15, 1995
Mrs. Mary D. Holland
P.O. Box 617
New Suffolk, NY 11956
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.L,,-
xx The check is not on file. $25.00
xx 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 # 22403-Z
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
O"f
MENTS
. y
IDATIOtf
(2nd) m
o_
;H FRAME - _70
~,<:••PLUHHING. 4` f=~..~r'~._"~~,susj _ M• ~
a s- s -3
L„TIOIf PER N. Y. ~I m
-a
STATE EIIERGY II .
CODE I ~*J
c7
H .
II
04, 9
FINAL I
ADDITIONAL COMMENTS'
/c
x
a
}
• O
H
• m
[+7
pp~
ENERGY CODE CALCULATIONS' dG~..
(For Non-Electric Heat) 15 .'R rJQn_Criteria 6,000 Degree',Days
I~ 3,~1 ~-O./A. 10°F I.A. ?70°F
FOR: IC : Y K~ PER: //Pe7hl ~vm d 3 r l
~
DATED:
i
DESIGN THERMEL REMARKS
SUBSYSTEM AREA "U" RATING
Exterior walls (Opaque) It ? ~g7 l~~
Glazing 8 `j 0 33, - 53 n p- , or adMrn.
.3 . e
Doors 3 9 4/0
Ceiling/Roof (Opaque) ®S
Skylights %
Floor > 0'f d
Foundation Walls
Slab Insulation
TOTAL h
Notes:
Building Envelope Systems to meet requirements of 7815.2
HVAC Equipement to meet requirements of 7815.11
HVAC Systems to meet requirements of 7815.12
Duct Systems to meet requirements of 7815.13
Ventilations Systems to meet requirements of 7815.14
Insulation of Piping Systems to meet requirements of 7815.15
Service Water Heating Systems & Equipment to meet requirements of 7815.21
Electrical & Lighting Systems & Equipment to meet requirements of 7815.31
To the best of my knowledge, of UE:y
belief, & professional 0
judgement, these plans are in y
compliance with the code.
03 -1 ^
c~~ ~J3W2€i8-i
-~i r Irv:-? Jv 7651802
;BUILDiING DEPT.
1 PCTION
[ ] FOUNDATION 1ST [ ] ROU LBG.
[ ] FOUNDATION 2ND [ SULATION
FRAMING [ J FINAL ~j
REMARKS-
DATE INSPE ;
M-1802
BUILDING DEPT.
INSPECTION
[ ] F DATION iST [ ] ROUGH PLBG.
[ FOUNDATION 2ND [ ]INSULATION
[ ] FRAMING [ ] FINAL
REMARKS: L~"Wv/-oL~4~
i
i
t DATE-1/ INSPECTOR ~
4
765-1802
BUILDING DEPT.
INSPECTION
[ FOUNDATION 1ST [ } ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
REMARKS:
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THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1135021 BUREAU OF ELECTRICITY
F 85 JOHN STREET. NEW YORK, NEW YORK 10038
Date may 15,1995 Application No. on file 87099095195 N 351812
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant reamed on the above application number in the premises of
MARY D. HOLLAND, SHORT RD., POLEWLIL 3, CUTCHOG'UE, N.Y.
in the following location; ® Basement ® 1st FI• ® 2nd FT, GAR/ATTIC/OUT Section Block Lot
was examined on MAY 08,1995 and found to be in compliance with the National Electrical Code.
FIXTURE ECEPTAClES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS INCANDESCENT FLUORESCENT OTHER PMT. K W. AMT. K W. AMT K,W AMT K W AMT. M.P
36 54 39 36 1 1.5 3 F
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIALREC'PT TIMECLOCKS, BELL UNITHEATERS MULTI-OUTLET DIMMERS
STE
OIL H. P GAS H. P. AMT. NO P W. G AMT. AMP PMT. AMPS. TRANS. AMT, M.P. SYMS AMT. WATTS
AMT. N. W.
NO.OF FEET
r 1 F 3 - 1 7 600
SERVICE DISCONNECT NO.OF S E R V 1 C E
AMi. AMP. TYPE METER 1,e' YW 1 g 3W 9 9 -3W73, <W NO.OF CC COND. A W. G. NO. OF HIAEG A' W G' NO. OF NEUTRALS A. W. TR
EQUIP. PER9 Of CC. COND OF H4LEG OF NEUTRAL
1 200 CB 1 X 1 410 1, 410
07HER APPARATUS:
,
MOTORS:3-F H.P.,3-1 H.F.
G.F.C.II-4
SMOKE DETECTOR:-2
I
i _
l
THREE "C" ELECTRIC LIC,#3327E
RT. #1, BOX 45H
SOUND AVENUE GENERAL MANAGE
RIVERHEAD, NY, 11901 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, ,
BOARD OF HEALTH
' FORM NO.1 3 SETS OF ItiS
TOWN OF SOUTHOLD SURVEY ~s
BUILDING DEPARTMENT CIICCK . , , _X
TOWN HALL SEPTIC FOR:I
SOUTHOLD, N.Y. 11971 . . . . . .
^
TEL.: 765-1802 t: DTI FY;
Examined, , 19 CALL . . .
MAIL TO:
Approved ~ 19<I.•Permit No.. Q.?-.~d0 9'd . .
Disapproved a/c O ,~4 11,956
' Ei+ 9
(Building Inspector) l 6LDG,DEPL
r. -rOVVN OF 60t1THOLD
APPLICATION FOR BUILDING PgRMIT._w
Date 19t.
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 necessarygnspection
(Sig ture of applicant, or name, rf a corporation)
6 6.19., A /V
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, arc rtect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises Q, l
.
(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.
1. Location of land'on which proposed work will be done.
v o' (14 ...1~m.d..........~V G. ~..g..y~r..
House Number • • • • • • •
Street Hamlet
County Tax Map No. 1000 Section . JA • Block
A Lot...! .9
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 ..IJ.Qr a j2, . • . • • . .
L•o.
v.
b. Intended use and occupancy n~ S . dell G. e .
3. Nature of work check whictj
( applicable): New Building Addition /Ulcl;ation
Re air moval
G
. • Demolition Other Work .
4. Est mated Cost ........Q Z', (Description)
Fee
5. If dwellin°, number o dwelii l (to be paid on filing this application)
n units f........... 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 .
7 Dimensions of existin structures, if any: Front Rear
g . Depth
g Number of Stories , , , , , , , " " '
Dimensions of same structure'', with alterations or additions; Front ' ' ' ' ' '
Depth . Height . Rear , . .
8. Dimensions of entire new construction: Front , , , , , , , , Re . Nurl f Stories . ~J
. Depth f rd i
Height Jr Number of Stories
9. Size of to nt ~ ! .
10. Date of Purchase pf $ Rear ../,,v,~ "
.~.G'/1.4C.(,,'!1. ` "J Depth ..~v~.~r
1 1. Zone or use district to which Name o Fo r Owner . ~~'C , , , ,
li ises are situated . , 1Y~d~S.c 2n fQ G
t
12. Does proposed construction olate any zoning law, ordinance or regulation; , , , , ,
13. Will lot be regraded I~
Will excess fil be removed from premises: Ye No
14. Name of Owner of premises liy~ t~ , • • , Address .
Name of Architect . ~'1 u • • • • . Phone No......... .
+ . Address . . Phone No.. .
Name i Contractor . . Address .
15. Is this property withini300 feet of a tidal wetland? ' " ' " " Phon No
* Yes........ No...
If yes, Southold'ITown 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.
q1--jw VF EXCESS FILL
3t:i:;r a, 1 n9FMISES Wf
- ~ ~ ~ r`.'~,iih'r ~tZ3•S~T?Ykt~rTi61~1
oC3ft STRUCTiON
~.r REMOVE EXCE95OII.L~
FROM aABOVE' PAP.AfiISO$ RV
ty, ~SfitsDING.LpT
rRf vEWAY eONHTR=10N
C~ESSPOOL CONSTRUC'~N -rr.w.n4 .
t,5 u m COMTRUC"m
YIjFP
STATE OF NEWS OIC~
COUNTY OF . ,5 s•. J*q S.S
being duly sworn, deposes and says that Its is the applicant
(Nam of individual signiri~~
g contract)
above named.
lie is the ...Z.0i(. l/i.GL C ue~ ~e..".. 1~. !~.L/. P IS Q~~?/Z
(Contractor, agent, corporate office ,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 set forth in the application filed therewith.
Sworn to before m~ I
ti
....dayof..ll 1
'`Otary Public . County
CLAIRE L. GL.EW
Notary Public, State of Newyork/
' No.4879b0b
Qualified in Suffolk County : '
Commission Expires Decemberfi, I9~, (Signature of applicant)
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DL TAT - IMOVi'rY R r{! DING RL
Tv F: 18'12 RNi TO FOR THE
1-OLLOWING INSPECTIONS: 7. FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE
- ROUGH - FRAMING & PLUMBING
H'JISULATIOIN
FimAL CONSTRUCTION MUST
. _ . - _ - ~ - BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET
_ THE REOUIREMENTS OF THE N.Y, - -
STATE CONSTRUCTION & ENERGY
_ CODES. NOT RESPONSIBLE FOR
DESIGN OR CONSTRUCTION ERRORS
f i[Il
- OCCUPANCY OR
- USE IS UMB11FUL
- - - - WITHOUT CERTIFICATE L J _ - - - - _ OF OCCUPANCY
i M L'Cpw LrbMtO In ta"
for wmw dbttrUAV yM
FRON`T' -ELh_V^-FION %%m pWng of"NKarLae
w uAq
i
V o~0 t
O o mom
DO NOT PROCEED W i t+{ 41'11 ~ V BER CERTIFICATION
UNIL 0MRVEYOF ON LEAD CONTENT BEFORE
FOUNDATION LOCATION CE)MRIZ TEOFOCCUPANCY
HAS BEEN APPROVED SOLDER USED IN WATER
SUPPLYSYSTEM CANNOT
r EXCEED 2/10 OF 1% WAD.
B E~
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