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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-21084 Date OCTOBER 14, 1992
THIS CERTIFIES that the building NEW DWELLING
Location of Property 675 CROWN LAND LANE CUTCHOGUE N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 109 Block 2 Lot 12.4
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated MAY 21, 1992 pursuant to which
Building Permit No. 20665-Z dated MAY 28, 1992
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 ONE FAMILY DWELLING WITH ATTACHED GARAGE & DECK AS APPLIED FOR
The certificate is issued to LEWIS EDSON
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 92-SO-23 - SEPT. 28, 1992
UNDERWRITERS CERTIFICATE NO. N-252155 - SEPT. 30, 1992
PLUMBERS CERTIFICATION DATED OCTOBER 6, 1992 - LISO PLUMB & HEATING
n I
Building Inspector
Rev. 1/81
FORK NO. f
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)
N°-N? 20665 Z Date ......~1~y..... 1919-
Permission is hereby granted to:
.1. o. ~sT .....A t°..:.........
i ,31 .
at premises located at
444
!5....`.~.........~'
.......j........ '7..................................................../.........
County Tax Map No. 1000 Section Block ....2A......... Lot No...,1~' „T
pursuant to application dated 19..(./:, and approved by the
Building Inspector. /
Fee 7.....
Vn
B 1 spector
R
ev. 6/30/80
Form No. 6
TOWN OF SOUTHOLD C
BUILDING DEPARTMENT
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 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. r
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,
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 - $5.00 over 5 years - $10.00
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
/ Date .
New Construction...V~. Old Or Pre-existing Building
Location of Property... ~?.~7..J.... c(y2.uwn+ ~.,rsrtt~.~a4'a.......
House No. Street Hamlet
Onwer or Owners of Property., h .~lt!4.S X27 S v11.
County Tax Map No 1000, Section 1®.2..... Block ...A ...........Lot. .
Subdivision ..:t-: t-t . ~.h at4~.. ..........Filed Map.6..;k 917...Lot.. 4
Permit ..Date Of Permit!' a~ ~~1.°Js~.Applicant.) ti.s~ .4°£4.OR~~•....
Health Dept. Approval. *.a?.~.•. ,.1 IQ- ...Underwriters Approval :
Planning Board Approval
Request for: Temporary Certificate........... Final Certicate..V.-__~.....
Fee Submitted:
~i2C_A/V 0 APPLICANT
CO -2-a?oa-y
u• sir:. h' ~ V \
Town of Soughold
r
;ia rr ar E
SCOTT A. RUSSELL
/p ASSESSOR
Road
5. .
~'",~,f:•~~°:I TOWN HALL
53095 MAIN ROAD (516) 765-1937
t'}f•+'`"''" " SOUTHOLD, NY 11971 FAX (516) 765-1823 _
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ASSESSORS OFFICE
Southold Town Hall
P.O. Box 1179 53095 Main Road
Southold, New York 11971
765-1937
::L go
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',4 re
S ~y.,a x 6.9/~3v. y s,
T41lS G~~(<n1gFc l te?~vt`l' ~r~~VAC {lt' -(0-Z„A~e -
LQt\,~~ SRC Ci t C?('ii{(~ ~55~50 hOVtt,niAll~ c'rtj
~ I?g f" fo fd ~~~ct the ~
v c ~Y1'St'. ,
T'>~t ~s r~.~taE~ ~so f}ss~~s ~ F I
PlA~ .
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ENERGY CODE REVIEW
F "
(non-electric)
7814 (Part 5) 6,000 degree.,days
Z dS n h wf
For Per Uwgs ~h h
Dated
Envelope CQmponent R-Value
Exterior Wall R-18
Roof/Celliny R-19
Floor R-19
Foundation Wall R-10
Slab Edge Insulation R-10
Glazing R-1.7
Entrance Doors R-2.5
All IIVAC Equipment to meet requirements of 7814.11
All IIVAC Controk Systems to meet requirements of 7814.12
All Duct Syst&s to meet requirements of 7614.13
All Ventilating Systems to meet requirements of 7814.14
All Piping Insulation to meet requirements of 7814.15
All Service Water Heating Systems and Equipment- to meet
requirements of 7014.21
All Electric Systems to meet requirements of 7814.31
To the bast of my knowledge,
belief, and professional
judgement, these plans are
in compliance with the code
~kOF NEWYO
y.~c~NC` r~. ~,f•
a
sae
0322E4-1 ~A~~fESS{C1~~~k.
c5~~~d(k~' TEL. 765-1802
OFFICE or 31~11.b1 o~gPECT0it
u : P.O. BOX 728
p ca TOWN HALL
SOUTHOLD, N.Y,11971
CB12_T ICATt0N
bete 0 4:'
Building Permit No. o f (Z
Owner L W 1,5 ~ D S o rsl,
lp ease print
Plumbed - r,
~.l S V . ~ ov /~'~p ec„r G a lrl.t~w~ ~,r}t
P ease print
a .
t
I ctl tii that th` 6 1t141 us6 c1 itt ~~r supply system
containl less than 2/10 of .jr,jdadd.
(plumber' gnature)
Sworn to before me this
Gr day of 0c7ca1-R ,
19 9z _r
Notary Public
Rotary Public, , f 44 County
DOLORES L. LISO
Notary Public, State of New York
Suffolk County • No. 4841022
Commission Expires Oct. 31, ~3
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
113W"I. BUREAU OF ELECTRICITY
85 JOHN STREET, NEW YORK, NEW YORK 10038
Date SEPTENDER 30,1992 Application No. on file 78037192/92 2521 r5
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant Homed on the above application number in thepremises of
LEWIS EDSON, CROWN LAND LANE, CUITCHOGG9, N,%1
in thefollowing location: ® Basement ® Lst Fl. ® 2nd Fl, GAR IOUT Section Black Lot ~
was examined on "SFFTFINBgR 28,1992 andfound to be in compliance with the requirements of this Board.
FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS ECEPTACLES SWITCHES INCANDESCENT FLUORESCENT OTHER AMT. K W. AMi K.W PMT K.W. AMT. K.W AMT. HP
30 55 38 2A. 2 1. 12.1 1 1.4 3 1;
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIALREC'PT TIMECLOCKS BELL UNITHEATERS MULTI-OUTLET DIMMERS
AMT K. W. 011 H. P. GAS H. P. AMT NO. A W. G. AML. AMP AMT. AMPS TRANS. AMT H. P. NO.ST SYSTEMS FEET AMT. WATTS
3 IF 2
SERVICE DISCONNECT NO. OF 5 E R V I C E
AMT. AMP TYPE METER I,e 2W 1 0 3W 303W 3 0 4W NO' or CC, COND A. W. G. NO OF HbIEG A W G A W G.
EQUIP, PER 0 Of CC. COND. OF HbLEG NO. OF NEVTRALS OF NEUTRAL
3 ?.00 CF3 1 % 1 410 1. 210
OTHER APPARATUS:
d09'ORsi.-P B'0'R O.P. C. 1.L-3 11
51#OK[i DhTNC:-1
THREE "C" ELECTRY.C ITC.F3327-E
RT. ;V1, NOS 45H
SOUND AVFNUN GENERAL MANAGER
R111FRNEAD, NY, 11901 t,l
Per U
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.
L LB's;:; I CDYR4ENI
1. li 'l9 m'S1
H
. y
FOUNDATION _ (1st)
c
FOUNDATION (2nd) m C7
2.
r
ROUGH FRAME & ~l
.PLUMBING
4.016 m
INSULATION PER N. Y. e Z o 6 -/r
STATE ENERGY p
CODE
a
4. °3
FIVAL I _
" ° O
ADDITIONAL COMMENTS:
O.
cm~
y
~ W
x '
- m 1
• - y ,
H
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ) ROUGH PLBG.
] FOUNDATION 2ND INSULATION
O FRAMING [ INAL
REMARKS:
l
DATEj~~INSPECTOR
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ I ROUGH PLBG.
FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
REMARKS: X24no ® 9
DATE III le? Z INSPECTOR ' ' r~~
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
REMARKS:
DATE /!/,'/I Z INSPECTOR
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
f
MARKS:. 44a
r
f
Y r
171
Z DATE Z/ INSPECTOR
r
765-1802
BUILDING DEPT.
M- INSPECTION
FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
FRAMING FINAL
REMARKS: !!~09(
771
DATE INSPECTOR /
ENERGY COME REVIEW
(non-electric)
7014 (Part 5) 6,000 degree,days
d
For L S h Per Dw9s__
Mated
Envelope Component R-Value
Exterior Wall tt-18
Itoof/Ceiling R-19
Floor R-19
Foundation Wall R_10
Slab Edge Insulation R_10
Glazing R-1.7
Entrance Doors R-2.5
All IIVAC Equipment to meet requirements of 7814.11
All IIVAC Control Systems to meet requirements of 7814.12
All Duct Systems to meet requirements of 7814.13
All Ventilating Systems to meet requirements of 7814.14
All Piping Insulation to meet requirements of 7614.15
All Service Water Heating Systems and Equipment to meet
requirements of 7014.21
All Electric Systems to meet requirements of 7614.31
To the lost of my knowledge,
belief, and professional
judgement, these plans are
in compliance with the code
~~or- aely ro
v
FV G32Fb1 ~
\n90f ES@MA'
2765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ } FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
REMARKS: a-esc ~lai~a~-~ c2 _ B ~Z-f
441
,
a INSPECTOR
DATE
rENERGY CODE REVIEW
F '
(non-electric)
' t
7814 (Part 5) 61000 degree,days
d
For G S ~ Per Dw9s
Dated
Envelope Component R-Value
Exterior Wall R-18
Roof/Ceiliny R-19
Floor R-19
Foundation Wall R-10
Slab Edge Insulation R-10
Glazing R-1.7
Entrance Doors R-2.5
All IIVAC Equipment to meet requirements of 7814.11
All BVAC control, Systems to meet requirements of 7814.12
All Duct Systems to meet requirements of 7814.13
All Ventilating Systems to meet requirements of 7814.14
All Piping Insulation to meet requirements of 7814.15
All Service Water Beating Systems and Equipment- to meet
requirements of 7814.21
All Electric Systems to meet requirements of 7814.31
To the best of my knowledge,
belief, and professional
judgements these plans are
in compliance with the code
~:~OF F~eWYe
y~P~oca 1,2,94
~ S
~
/ F± G3221-4-1
o~90fES~tUN* ~
1' BOARD OF HEALTH'
Ii{ FORM NO.1 3 SETS ~QF'PLA1;S11?:~
1 s TOWN OF SOUTHOLD SURVEY . .
MAY BUILDING DEPARTMENT CHECK . . . .
TOWN HALL SEPTIC FOa:1 _ .
SOUTHOLD, N.Y. 11971
r
TEL.: 765 1802 NOTIFY;
CALL
Examined . MA I L TO: • .
:approved ...5*P 19 9W-Permit No.. G~?`Z'
Disapproved a/c _ .
cli . .
j(ui dinInspector)
APPLICATION FOR BUILDING PERMIT
Date .t. 4 . aA 19
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3
ets 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
)r areas, and giving a, detailed description of layout of property must be drawn on the diagram which is part of this appli-
ation.
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
hall 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
hall 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
luilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
:egulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
he applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to
dmit authorized inspectors on premises and in building for necessary inspections.
(Signature of applicant, or name, if a corporation)
'r O 3 ~ >e `4 3 Gt - J r,..: 4 pa a 1,4 -Y
(NIailin° address of applicant)
sate whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
:amc of owner of premises . .
L s....~.4.
. . . . . . . . . .
(as on the tax roll or latest deed)
f applicant C01"poration, sig ature o duly authorized, oofficer.
(Name and title of corporate of tf c`er)
Builder's License No. , , , , , • , • •
Plumber's License No.
Electrician's License No. . , • , , ,
Other Trade's License No . /
Location of land on which proposed work will be done. • e ~~wr e j, a n. v , ~.p t2ls
Ilouse Number Street Hamlet Ale
County Tax Map No. 1000 Section C.6.~..... , Block Lot ..,V?;
Subdivision Aul~..~AAilf=........... Filed Map No. .1 Lot . .
(Name)..:.......
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
3. Nature of work (check whic
Repair Removal cable): New Building
R .il, . , , , , • Addition Alteration
• .
Demolition Other Work
4. Estimated Cost , , a~a (Description)
Fee
S. If dwelling (to be paid on filing this a placation)
„ number of dwelling • • • . • . • . • • •
S units .~7 , , , , , , , Number of dwelling units on each floor./ac,
If garage, number of cars . ,
6. If busi . , . ,
ness, commercial or mixed occupancy, specify nature and extent of each type of use . .
7, Drrnrnst°ns°t eels o es, if any: Front . -
Height Nw Rear . . . . . . . . . . Deptlt . . .
.
r s rcturtlbcr of Stories vith alterations or additions: front . .
Dimensions Depth • • Height Rear
8. Dimensions o of same
sc . .
•
new e con Number of Stories .
.3 , ruction: Front . v , , , , , , Rc•ar ..Cv.d. . .
Height Number of Stories . , Depth ~
9. Size of lot: Front , l O A P • .
10. Date of Purchase Rear 49 ! i
Depth .
. Name of Former Owner . ~
11. Zone or use district in which r ,
p remises are situated ' ' '
12. Does proposed construction violate any zoning taw, ordinance or regulation: N~, , , ,
13. Will lot be regraded ..!d,
14. Name of owner of premises t; Ewes ' ' ' • ' • • Will excess fill be removed from premises: Yes No
~k $¢•e--4 Address ti iv (4.4 Phone No. ;Wt;
?S
* LSU Ct,L Address CpFL sr!~owi,-
Name of Contractor * _ • • Phone No
15. Is lthi jf YopertSo`withi`' 00 feet *o a tidaldwetland ,VAT • Phone No. -~{,FS
v Yes..,..... No.........
d Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly all 'I buildings, whether existing or proposed, and, indicate all set-back dimensions front
property lines. Give street and block number or description according to deed, and show street names and indicate whether
interior or corner lot.
I
it
TATE OF NEW YORK,
Ou;NITY Of .................o s.s
w lLaNc tL
• • ' • • • • • • • • • being duly sworn, deposes and says that he is the applicant
(Name of individual signinglcontract)
)ove rallied.
is tile.......,, G.~.
.i.
(Contractor, agent, corporate officer, etc,)
said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this
plication; that all statements contained in this application are true to the best of his knowledge and belief; and that the
irk will be performed in the manner sea( forth in the application filed therewith.
om to before me this
........c. ~R-....day of :)f 19
Lary Public, ~i
county
,~A~~n~~ • . .
&
v7 - y ~
LINDA J. COOP" • • ,
Notary P,ubllr., State Of New York /re • .
No.4822ti6 SuffolkCoun(Signal of applicant)
Term Expires December 31,19
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