HomeMy WebLinkAbout22139-z
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-25698 Date: 05/01/98
THIS CERTIFIES that the building ADDITION
Location of Property: 2905 WESTPHALIA ROAD MATTITUCK
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 114 Block 10 Lot 1
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JUNE 3, 1994 pursuant to which
Building Permit No. 22139-Z dated JUNE 20, 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 ADDITION TO EXISTING ONE FAMILY DWELLING AS APPLIED FOR.
The certificate is issued to CLIFFORD D. POLACEK
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. PENDING 04/24/98
PLUMBERS CERTIFICATION DATED N/A
ui ding Inspector
Rev. 1/81
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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)
f
Date ....v 19
NO 22139 Z
4
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Permission Is hereby granted to, .............1/........T
1 ~.'O......... 0
.......N--Y/
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to .....41~1'1.,~'....r(....14`.c1 tl„tr.®?4......,.G~...l
to 1..~s ~ ......~K?.$ 'a..............
.........,.ate. de,
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at premises located at ......VIO........ . ......7? IF .U "e
IMA......7.II c.ck......... t~.`P.:........................................
{ County Tax Map No. 1000 Sectlon ......(..1.7.......... Block Lot No. j.......................
t Gj
pursuant to application dated .~N..~..........3 19. l..Y...:., and approved by the
Building Inspector.
Fee 51.....y........
i Building lnspe of
Rev. 6/30/80
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(x• ~,il,,.i..wr._.
Form No. 6 It
TOWN OF SOUTHOLD'
BUILDING DEPARTMENT €3• APR 1 7
TOWN HALL, ^•.o _..z_ . ~F
765-1802 ;"t "'T
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 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,
01 Additions to accessory building $25.00. Businesses $50.00.
2. Certificate of Occupancy on Pre-existing Building - $100.00
3. Copy of Certificate of Occupancy - .25c.
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential$115/.~00,lCommercial $15.00
Date .....4111/. . l.til, . L..r.
/
New Construction........... Old Or Pre-exist fui]/,ding..n..... /V,
Location of Property... U.[.0.....?.~~/7.~.~:.l...! 1C'..l,/...
House No. t/' Hamlet
Onwer or Owners of Property..... L j~~Y.r ~ C e": • • • • • • • • • • • • • • • " "
County Tax Nap No 1000, Section../.~ 7 0...... Block L.0 .......Lot.......)
Subdivision .......~.7.............................Filed Nap............ Lot......................
Permit No 2 a. ?.l.'•.Date Of Permit ................Applicant.............................
Health Dept. Approval ..........................Underwriters Approval.........................
Planning Board Approval vl~
Request for: Temporary/Certificate........... Final Certicate...........
"W
Fee Submitted:
6Z~c, sq3 77
L~ ~dr~ p 0 /Y APPLICANT
=o~~g11FF0(,~C
G
Town Hall, 53095 Main Road co Z Fax (516) 765-1823
P. O. Box 1179 W- A~ Telephone (516) 765-1802
Southold, New York 11971 ay
~~l ~ Sao
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
April 15, 1998
Clifford D. Polacek
2905 Westphalia Dr.
Mattituck, New York 11952
RE: 90 Deer Dr., Mattituck 1000-114-10-1
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)
No Underwriters Certificate on file.
XX The check is (not on file.)$25.00
No Health Department Approval on file.
No final inspection has been made.
No Plumber Solder Certificate on file.
(All permits involving plumbing being
issued after April 1, 1984).
BUILDING PERMIT # 22139-Z
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
o~Qg~FFO(,I-CD
Gyre
Town Hall, 53095 Main Road y Fax (516) 765-1823
P. O. Box 1179 Telephone (516) 765-1802
Southold, New York 11971 •
~~l ~ Sao
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
April 21, 1998
Clifford D. Polacek
2905 Westphalia Dr.
Mattituck, New York 11952
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
An application for Certificate of Occupancy is
not on file. (Enclosed)
XX No Underwriters Certificate on file.
The check is (not on file.)$25.00
No Health Department Approval on file.
No final inspection has been made.
No Plumber Solder Certificate on file.
(All permits involving plumbing being
issued after April 1, 1984).
BUILDING PERMIT # 22139-Z
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ )ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [r?]/FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS:
DATE/ T INSPECTOR,
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r1 COMMENTS
FOUNDATION (1st) - -
FOUNDATION (2nd)
ROUGH FRAME 4. o
.PLUMBING
-3
3.
INSULATION PER N. Y. I m
H~
STATE ENERGY II
CODE I C
r'ry
FINAL
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ADDITIONAL COMMENTS:
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-b~~d.`+~`e@~.+~~~v y _ aw... . e J.ew/-a r..~ s'r~44 e. }^,..x . a . . . < r . • - s r ~
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765-1802
BUILDING DEPT.
114SPECTION
[ ] FOUNDATION 1 ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] IN CATION
[ ] FRAMING [ FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS:
I
i
t
DATE / INSPECTOR / l ,A~
M-1802
BUILDING DEPT.
INSPECTION
[ I FOUNDATION 1ST [ ] ROUGH PLBG.
[ ) FOUNDATION 2ND [ I INSULATION
[ 6T-iRAMING [ ] FINAL
REMA KS:
DATE I lqf9
M-1802
BUILDING DEPT.
INSPECTION
[ FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ I INSULATION
[ ] FRAMING FINAL
REMARKS: G-
DATE INSPECTOR "Y
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# N -York State Department of Environmental Consorntlon
Bull !no 40-SUNY, Slony Brook, Now York 11104
GAM
a9a:> W.~.~~~rlk.(x~ 1 •e9 )v-w1Hv/Ovc~al-C-4
/y J Re t~c~~ m
14
lflq
c t44 xk•..JIj 1"' yrnN)cc-, Thomas a Jorling
Commissioner
Dear
A rdview has boon made of your proposal toi 0~ O c„ u~Kl ,w
wn y` "~""0 c1 r~ c.1 tc.c~i~ 1cr O'n lwt+71 G`' v "'~~t "n
un t r.,.~ G >u a, Sul lrJ, , c..r"/ / c.!~. qtr 3419 bc)
eased on the information you have submittod, the New York State Department'
of Environmental Conservation has determined that the parcel
project lac
_ Greater than 300' from inventoried tidal wetlands.
Landward of a substantial man-made structure
greater than 100' in length which was constructs pr or E37§7-j-077-7-7
4'-V Landward of the 10' above moan sea level elevation contour on a
gradual, natural slope.
Landward of the topographic crest ur a blutt, cliff or dune which is
greater than 10' in olovatiun above mown sea level.
Therefore, n6 permit is required under the Tidal Wetlands Act (Article 25 .
of the Environmental COnsorvatlon Law). Please be advised, however, that ,
no construction, sedimentation or disturbance of any kind may take "place
seaward of the 10' contour or topographic crust without a permit. it is
your responsibility to ensure that all necessary precautions are taken to
prevent any sedimentation or other alteration or disturbance to the
ground surta+:e or vegetation in this area as a result of your project,
Such precautions may include providing adequate work area between the
10' contour or topographic crest and the project (i.e. a 15' to 20' wide
construction area) or erection of a temporary fencer barrier, or hay
bale berm,
Please note that any additional work, or modification to kbe rojpct as
described, may require authorisation by this Oepa;ttmenk. Pxe so pont4ot
this office it such are contemplated,
please be further advised that this letter does not relieve you of the
responsibility of obtaining any necessary permits or approvals from other
agencies.
vary truly yours,
Deputy Region& Permit A ministrotor
BOARD OF HEALTH
1 SETS OF PLANS
FORM NO. 1 SURVEY
TOWN OFSOUTHOLD GLHECK
BUILDING DEPARTMENT SEPTIC FORM
TOWN HALL NOTIFY
1!1 SOUTHOLD, N.Y. 11971
TEL.: 765-1802 CALL • • • • • • .
(i MAIL TO:
Exa j.//~..., 19 ~J a
Approved ......4P/. f-E_I...1 19 ~rmit No.c '
Disapproved a/c
Building Ins ector)
AP LI ATION FOR BUILDING PERMIT
Date 19
INSTRUCTIONS
r
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.
I 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 unt weA.nexlf~icy
shall have been granted by the Building Inspector. F1#11tt##`11 i#b 4018
t# n~~
APPLICA~~fi1 I~"HEREBY MADE to the Building Department for the issuance of a Build a the
Building Zone Q~dinanm of the, Town, of Southold, Suffolk County, New York, and other apple , r i antes or
Regufa-tions, for the construction of buildings, additions or alterations, or for removal or demolition,.as: ere d't)scribed.
c.a
The applicant. agrees to comply with all applicable laws, ordinances, building code, housing code,Ia~nrgyatjnypand}to
adiiii_autliorized inspectors on premises and in building for necessary inspectio u : r c
(Signature of applicant, or name, if a corporation)
~v .
Duo 02 G 7 ~v/`", a c- yG, ¢ !'~Gt' (C Y 3
(Mailing address of Applicant):"'
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
..................................J.......,......................................................
Name of owner of premises C. 1.1. FlclyvJ . i.•.. P0. 6~ C. q,~ 1<.. APPROVED AS NOT
(as on the tax roll odl tPP~I B , #
If applicant is a corporation, signature of duly authorized officer. FEE: Y; - v
NOTIFY BUILDING ARTME AT
765-1802 9 AM TO 4 PM FOR THE
FOLLOWING INSPECTIONS:
(Name and title of corporate offieer)_. 1. FOUNDATION - TWO REQUIRED
ALL
Builder's License No . MUST SUPBOLK COUNTY LICENSED FOR POURED CONCRETE
(p 2. 13051OH FtdAtt, NG & F'L LAAR1NG
3 Ir'' `)t E~'iltl
Plumber's License No.
Electrician's License No.... •
')61 SHALL
MCET
T,: a^,"ntltt~!'15 OF THE NY.
Other Trade's License No .
1. Location of land on which proposed work will be done. . . V.1 1 c,1g4i,HUC.1.1OW ERROM.,
.
House Number /Sttrreet Hamlet
County Tax Map No 1000 Section ~l/ l......... Block Lot , ........11 .
Subdivision Pain\........... Filed Map No . Lot l.. .
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy , , , , , , , , , , , , , , , , ,
b. Intended use and occupancy kill
3. Nature of work (check which applicable): New Building Addition Y t'
Repair Removal Demolition O * Ft .
~ I~ ' '~piion)
4. Estimated Cost ........J` .S!.0. Fee .
g g .ion)
5. If dwelling, number of dwelling units Number of dwellinto be paid en filing this a at
If garage, number of cars 11
6. If business; commercial or mixed occupancy, specify na ure~and extent of each typePf use .
7. Dimensions of existing structures, if any: Front p....... Rear ....J:? Depth ...K/
Height ......3A Number of Stories .
Dimensions of s e structure wi h alterations or additions: Front .....Jq...... Rear
Depth Height Number of Stories . .
S. Dimensions of a tire new construction: Front Rear , Depth , .
Height Number of Stories
9. Size of lot: Front Rear Depth
10. Date of Purchase L Name of Former Owner
112. Does Zone or r use district in construction which of re ~nises are situated .
p p to any zoning law, ordinance or regulation: .
13. Will lot be regraded .........~f D....... Will excess fill be remov da fr m premises: Yes No
14. Name of Owner of premises 1 t661A 1.•.POUCRKAddress .2~lUJ, lry Q0. Phone No.
Noma of Architect Address Phone No.
:t
Name of Contractor . 01/.. N:K 9.y Address k? Lt NY, P~lone No..72, L ~a!q
15. Is this property loc ted ti thin 300 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 s
M $DPW tubing is uNSd
fOr wst*m d1wibutlnp
K a, sn l be 2~< APPROV D As NOTED
r DATE: B,R E /
PLUMBING N UIWING DEP AT
ALL PLUMBING V1 AM 765.1802 8 Tp 4 M FOR THE
& WATER LINES NEED FOLLOWING INSPECTIONS:
TESTING BEFORE COVERING
1. FOUNDATION • TWO REQUIRED
I zr t FOR POURED CONCRETE
X3,3 2. ROUGH . FRAMING t'x PLUMBING
q1~ /a L 3. INSULATION
UNDERWRITERS CERTIFICATE% 4. FINAL - CONSTRUCTION MUST
REQUIRED BE COMPLETE FOR C.O.
ALL CONSTRUCTION SHALL MEET
THE REQUIREMENTS OF THE N.Y.
STATE &
COCCUPAN CODES,C NOT RRESPONSIBLE NEFOR
DESIGN OR CONSTRUCTION ERRORS
t~''
USE IS UN
VITHOUT E TI I TE f / PLUM,&ER CERr'1F1CArroN
F UCCUPA 4 cERnicAre4p~ o cup Ncv
STATE OF NE7WRK
. . . . . . . . S SOLDER USED IN WATER
kl~ COUNTY OF F . SUpf Y SY
(Name f individual signi being duly ra~, deppspc~ldrtlla>pplicant
contract) c,CCCtttj L JC Of 1 % LEA11
above named.
4
Heisthe
(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 the
day of . c t ~...........1 19 9~ (
Notary Public, .G4!:. Is ount
HELENE D. HORNE • • .
NotaryPNo 9t5eofNowYork (Signature of applicant)
Qualified in Suffolk County
Commission Expires May 22,19
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NOTE
a : MONUMENT.
SUEDIVIS/ON NAP F(gD IN THE OFF/CE
OF THE CLERK OF SUFFOLK COUNT' OAi i iI
TAX MAP JULY 25, /960 AS FILE N0.3204„' '+'jtI Nb
4 BILK 10 LOT i
REVISIONS YOUNG & T"if
OCT. 22, 1990 400 OSTRANDER AVENUE, RIVERHEAD{ W Y'b&K ,
t
AUG. 1991 ALDEN W YOUNG 7 F~hWAf3b~12*~
PROFESSIONAL ENGINEER AND L>CNrf 8(}NVBYCI
LAND SURVEYOR, N.Y.S. LIC_ NO, 12845 1`, NTY $1, L1C1 ,NO..
SURVEY-FOR:
b~ UNAUTHORIZED ALTERATION OR ADDITION 10 'T+
0" , 1419 SURVEY IS A VIOLATION OF SECTION CLIFF OLA CEK ?`s y
i ?209,OF'THE NEW YORK STATE EDUCATION I,•C t. It
LAw, LOT NO. /9A ??DEER PA
in COPIER OF,TNIS SURVEY MAP NOT REARINO
~~tc ilm,M1 t
rs4fi THE LAND SURVEYORS INKED SEAL OR
II3 , 'EMS66SED SEAL SHALL NOT BF CONSIDERED ` p
to 8E A VALID TRUE COPY 0 AT ILIA (l 1 D 7
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MA r ri rucK ,
n
T FY -0 U4RANTFCS INDICATLO -IEAR ON SHALL RUN
Y~Y f t }+'S'URYE R
To T EPAfD, AND f,N+,Li DFHAtF TOWN OF P 1i+3 P' Ia ~}.r Y 19 r~s+~P4}Y y}'*to IHE TITLE 00MPANY ;tOVrRIMEI.TAL SOU L
EE LV T 11 AUNNCY AND LENIRN4 INS11I+ N y1F0 6Y I,.
HENEDN AND Tb THE A~11'iNFE% tt~, T4E SUFFOLK CO., N, Y.
LENUINO INEnnIr uN cu+,RA'. ='S SANE
a Not I TRANSFP.RABIE TO ATPWNAL SCALE: 0, DATE-
`f ~,~T ~s?t~riDNa aP CI)NSCOUtNr;,dNERS / = 40 ,.-.MAR 2L 19$~ ;81
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