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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-23545 Date MARCH 13, 1995
THIS CERTIFIES that the building ADDITION & ALTERATION
650 PRIVATE ROAD #16 &
Location of Property 580 CLEARVIEW ROAD SOUTHOLD NY
House No. Street Hamlet
County Tax Map No. 1000 Section 90 Block 4 Lot 11.1
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated OCTOBER 13, 1994 pursuant to which
Building Permit No, 22479-Z dated NOVEMBER 18, 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 ALTERATION OF AN EXISTING ONE FAMILY DWELLING AND AN ADDITION
OF A SECOND STORY AS APPLIED FOR.
The certificate is issued to JOHN & NANCY WISSEMANN
(owner's)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL INSPECTION SVC. 6993 FEBRUARY 20, 1995
PLUMBERS CERTIFICATION DATED FEBRUARY 17, 1995 MATTITUCK PLUMB & HEAT
Buil ing In ector
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 19..r
N® 22479 Z
Permission Is hereby granted to:
.......GtisF.- . c.-v.N
...~..P h' lei
1 ~C rl~o.
to ........fr.........~.X~4141/........... r~~-....., ° .1'...
Id
...............................~....j.................................................................................
at premises located at
JC;~"VCj
.............................................................../y.. ..ry....................................././...............
County Tax Map No. 1000 Section Block lO/ Lot No. ..../.~e/...........
pursuant to application dated !.......Z! 19....f......., and approved by the
Building Inspector.
Fee
uilnspector
Rev. 6/30/80
Form No. 6
TOWN OF SOUTHOLD
~ BUILDING DEPARTMENT;
7 7 TOWN HALL
765-1802
BLDG.P'PT.
TOWN OF'QLii01LT_p
PP
CAT ON 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 ahd sewerage-disposal(S-0 form).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Sworn statement from plumber certifying that the solder used in systefi ..contains
less than 2/10 of 1% lead.
5. Commercial building, industrial building, multiple residences and similar buildings
and installations, a certificate of Code Complinnce from architect or engineer
responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
3. For existing building
"pre-existing" land u or buildings and
1. Accurate survey a 0
unusual natural a C ) building and
2. A properly comple by the applicant.
If a Certificate shall state the
reasons therefor
~ f
Fees
Certificate of Oc
Alterations to du fling $25.00,
Additions to th, building'$25.00,
2. Certificate of Oc
3. Copy of Certifica
4. Updated Certifica
5. Temporary Certifl ial $15.00
aw Construction... Old, Or Pre-existing Building
)cation of Property 580. Cclearyiew Rd Southold'
House No. Street Hamlet
ewer or Owners of Property, John & .Nancy Wissemann
aunty Tax Map No 1000, Section..,.(Q,....... Block......,..... .Lot..l.ltl
bdivision. ~e............ Filed Map............ Lot
ll y
rmit No. j,,,,,..Date of Permit, AppliFant....J.ohn Wissemann..
r
alth Dept, Approval.,.., NA. X
..,,.......Underwriters Approval. .
inning Board Approval..... NA
.
west for: Temporary Certificate..,,.,..... Final Certicate..,X
Submitted: 25.00
~Raao
3J~~~ GG..AIICA~---
INSPECTORS ,
-ervisor
f iz 4 Southold Town Hall
Thomas Fisher w =tc l.e', P.O. Box 1179, 53095 Main Road
Building Inspector Southold, New York 11971
Gary Fish O[ a. rs Fact (516) 7651823
Building Inspector Telephone (516) 765-1800
Robert Fisher
Assistant Fire Inspector OFFICE OF BUILDING INSPECTOR
Telephone (516) 765-1807 TOWN OF SOUTHOLD
C E R T I F I C A T 1 0 N
DATE:/
Building Permit No.
owner:
(please print)
Plumber:` u L[<
(please print
I certify that the solder used in the water supply system
contains less than 2/10 of 12 lead-
(Plumbers Sig t
Sworn to before me this
s~!/,6)22-f~ day of 19 .
Notary Public, County
Notary Pu
lEDI1H RJAAKSON
Ndmy Ib MW of Naw Yak
Tom Feb. 18Iyro
02/22/1995 17:08 516-734-7206 LADEMAhik ELtC INN, PAGE 01 -
(516) 286.6642 ELECTRICAL INSPECTION SERVICE INC.
375 DUNTON AVENUF
EAST PATCHOGUE, NEW YORK 11772
6993
APPLICATION NO, ON FILE
DATE: 2-20-95
ADDRESS:. 580 Ciearview Road VILLAGE; 8outh_o}d TOWN: Southold
ISSUED TO: John wisse111ann
INTRODUCED BY: _ Lademann Ejgctric I_}r c. LTC. NO. _ 4141-E
AREAS LISTED WERE INSPECTED ON-2-20-25 AND WERE FOUND TO BE IN COMPLIANCE WITH THE
NATIONAL ELECTRICAL CODE.
LOCATION: BASE XX IST XX 2ND _3RD _ACTIC -POOL
xx SMOKE DFTECTOR _jM_DETACHED GARAGE
SERVICE I)ISCONNECF
METER AMPS I PI
THIS CERTIFICATE MUST NOT DE ALTERED IN ANY MANNER. za -
WSPECTORS MAY BE IDENTIFIED BY'tHEJR CREDENTIALS. HT GO S. S
PRESIDENT
.
1
M
ONMENT°
II
rri
1IID#1TION - -
_ 1st)
1IDATI011 N• I
(2nd) _ rn
i• / S- b rL ~Lde le-9 m
GH FRAME & - /d aTL- !N f ® \
•PLVrIBiNc
y
JLATIOII PER N. Y. II r y
STATE ENERGY I r
CODE
• II - Zo7'~. ~ ~ y
FINAL I Oh ~ ~
ADDITIONAL CO!-1~IE11TS: m
m
• x
H
a
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!..,`•'!"•^1p'~r,+siSew:.au.r......~. i`!33ti.~~1•.:.-;... r v,.- N . . - .t. - P1 ..~A :.h
v 7f
765-1602
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ j INS TION
[ ] FRAMING [ FINAL
REMry,A/gwRKS.
6 P Is
r
DATE INSPECTOR
2~7 _ ic9 7
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ) ROUGH PLBG.
[ ] FOUNDATION 2ND [ NSULATION
[ ] FRAMING [ ] FINAL
REMARKS:
DATE l ~3 S INSPECTOR
74
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
FO NDATION 2ND [ ] INSULATION
( FRAMING ( ] FINAL
REMARKS: m ew Z*L 1404019P-A/
DATE S' INSPECTO
C. F. VAN DUZER GAS SERVICE, INC
s , "The Home of Boffled Gas and Stoves" r. P
f~
SOUTHOLD, N. Y. 11971° N
_
Tef. 765-3862 - 3452 -
March 10, 1995
Town of Southold
Building Department
Main Road
Southold, XTY 11971
Attention: John Boufis
Ref: John Wisseman, Permit 22479
Private Road, Southold
The gas lines and installation were installed in
accordance with D"lFPA 58 Section 3-1 to 3-2.2 and
Appendix.
The Empire heaters were installed and vented in
accordance with the manufacturers specifications
ppand NFPA 54 6.28 through 6.28.3.
g~m^
Kevin Boergesson
C. F. Van Duzer GAs Service
CC: E. Williams p~
D U L;..
i~ 1019% ;
F
G. T.
TO\^!N OF SOUTHOLD
BOARD OF HEALTH
3 SETS OF PLANS
FORM NO. 1 SURVEY
TOWN OFSOUTHOLD CHECK
s OCT 1 31994 BUILDING DEPARTMENT SEPTIC FORM
TOWN HALL
`6A SOUTHOLD, N.Y. 11971 NOTIFY c
a -1802 CALL -1(!~5-.d(oLP
1"OVUiV UTEL.: 765
.
Examined ~G..... , 19 MAIL TO:
ermit No.a 47,?e
Approved Y......., IP74
Disapproved a/c .
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date 19
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, ho wing code, And regulations, and to
admit authorized inspectors on premises and in building for necessary inspections. A( Div/~
(Signature of applicant, or n e, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
o N ,"o.....................................................................................
Name of owner of premises . 11Ae- 911.,l /`ji,Q.$.. VOW-41. N-45N / t! .
` (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 .
. .
S~'o ~!?lElt~ ..Ro~FS? rIr ,Xp .
House Number Street Hamlet
County Tax Map No. 1000 Section Block Lot
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 . , {(GS/DEU(/i? L , , , , , , , , , , , , ,
b. Intended use and occupancy .uuf!EL
3. Nature of work (check which'Iapplicable): New Building Addition Alteration
Repair . Removal , Demolition Other Work
C (Description)
4. Estimated Cost . ~SotDoo
Fee
(to be paid on filing this application)
5. If dwelling, numb of of dwelling units , . , • . , • . Number of dwelling units on each floor
If .
garage,
6. If business, commercial or miffed occupancy, specify nature and extent of each type of use ,
Dimensions of existing structures, if any: Front (eP , • , , , Rear L......... Depth l! ler. , .4.;f OAe "
Height /~..9 : , • • • • Number of Stories ~ .
Dimensions of Depth . with alterations or additions: Front ,~4,y.6A/ 4c 10... Rear , , , , ,
8. Dimensions same structure tcon • • ' Height , 13
f Number ofStories
.V..kAx.
. zG yo "
struction: Front ...~PZ.......... Rear Depth..
Height f ° • • • • , , , , Number of Stories . .
' .
9. Size of lot: Front 3B'3• W.4's? Rear • • , • • • . Depth fit`7.,A4"'.. 1f
10. Date of Purchase !9rF,, , , • , , , • , , , , • Name of Former Owner
11. Zone or use district in which premises are situated !~~5,•...................
12. Does proposed construction violate any zoning law, ordinance or regulation: .
13, Will lot be regraded .410.... ; . , Will excess fill be removed from premises: Yes No
14. Name of Owner of premises Yi l /pADC}!. O/S.S, /L; Address Ax. 0A. 0-5q o • , , , Phone No. ~d rL
Name of Architect -06AIA~O- , "(4 , • • , Address,44or3F441 - fix. -f4y.. Phone No..?2 Z 3S
Name of Contractor 1 . . Address 7 . Phone No. .
15.1s this property located within 100 feet of a tidal wetland? *YES.?...NO....
*If yes, Southold Town 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.
~I
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I~ .
STATE OF NEW YORK,
S.S
I
COUNTY OF . . . . l ~s~i p vt~ ~w
being duly sworn, deposes and says that he is the applicant
(Name o individua signing contract)
above named.
lie is the !v E K
(Contractor, 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 set forth in the application filed therewith.
Sworn to before me this
~5-e_4r..........dayo19.Q C
Notary Public,
, . , , • , • County
gam,
LINDA J. COOPER
Notary Public, State ofNevr7ork (Signature of applicant)
No. 4622563, Suffolk County
Term Expires December 31,18_ c
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PLUMBER CERTIFICATION APPROVED AS NOTED
ON LEAD CONTENT BEFORE DATE: / P.# S L 7~l t Flom O'ENI M
CERTIFICATE OF OCCUPANCY FEE / BY: ~ _ EVErGEM ESCAPE AS
SOLDER USED IN WATER NOTIFY BUILDING DEPARTMENT AT REQUIRED a Mt 714 Of
765-7802 9 AM TO 4 PM FOR THE
SUPPLY SYSTEM CANNOT FOLFOUNDATISP CTIOwO REQUIRED NA STATE ONIUMNO CODE.
EXCEED 2/ 10 of 1916 LEAD. FOR POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING
3. INSULATION
4. FINAL - CONSTRUCTION MUST-,_j~~~•.BE COMPLETE FOR C.O.
PLUMBING ALL CONSTRUCTION SHALL MEET
ALL PLUMBING WASTE THE REQUIREMENTS OF THE N.Y.
_ & WATER LINES NEED STATE CONSTRUCTION & ENERGY
TESTING BEFORE COVERING CODES. NOT RESPONSIBLE FOR
w DESIGN OR CONSTRUCTION ERRORS
Z OCCUPANCY OR
if copper tubing is used USE IS UNLAWFUL
for water distributing WITHOUT CERTIFICATE
system; piping shall be OF OCCUPANCY
of types K or L only
UNDERWRITERS CERTIFICATE
REQUIRED
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OCCUPANCY OR
- USE IS UNLAWFUL
WITHOUT CERTIFICATE
} OF OCCUPANCY.
AS NOTED ~aL~o
f 1 DATE P.11b
FE By.
NOTIFY BUILQINO DEPARTMENT AT •II 788-1802 0 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS:
t 1. FOUNDATION • TWO REQUIRED
- 1 FOR POURED CONCRETr,•,,,,.
t 2. ROUGH - FRAMING -k Pk RING 9. INSULATION i
4. FINAL - CONSTRUCTION MUST
BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL, MEET °
i THE REQUIREMENTS OF THg'WY. ` STATE CONSTRUCTION "•R,;,GNORGY'
I ~EArElOEACYElmu CODES. NOT RESPOIIIJIp'EFO
DESIGN OR CONSTRWRON EBRON
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PLUMBER.CERT FICAT/ON
ON LEAD CD BEFORE
CERTIf/CATL~; `CCUPANCY
SOLDER US' WATER
SUPPLY SYS pNtvOT ~{I /~'+y-~~. ` I. ~tl-. g0 ARC
EXCEED 211-.'-,It aAD. ti -1 ~~L ~S.r^' ~-:~•i.h.~ r~~~' C.l ~'Nti.l i Gr''r+ (lyPp ALAN ~~?C~,
4
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- PLUMBING ST ryo .ao,~5 ib 9Tr N?J~
ALLPYIMBW~GVMM
BM~E~ByL~WppF9yWy~E~Dyy~ TEBTWG BEPORE 40NERNO
K Popper tubing M and jNfiJS.~U,G~CL~'F'
for watw distrryp ibuting
system; piping shall be
of types K or L only
UNDMITERS III MATE FqUMED
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