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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-21177 Date NOVEMBER 24, 1992
THIS CERTIFIES that the building ADDITION
Location of Property 55 ROGERS RD. & 375 ORCHARD RD. SOUTHOLD N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 66 Block 2 Lot 20
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JUNE 1, 1992 pursuant to which
Building Permit No. 20684-Z dated JUNE 5, 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 ALTER AN EXISTING & ADD A 2ND STORY TO A SINGLE FAMILY
DWELLING AS APPLIED FOR.
The certificate is issued to TERESITA TAN
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. PENDING - NOVEMBER 23, 1992
PLUMBERS CERTIFICATION DATED NOVEMBER 16, 1992 - H.SMITH PLUMB & HEAT.
uilding Inspector
Rev. 1/81
FOAM 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)
NON? 20664 Z Date ..5 19..1y
Permission is hereby granted to,
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to Qp}..°~-~.u.c.7 ~..A ..1~.1•...........
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ova v_.,•••~ .
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at pre ises loc ed at IS(...
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County Tax Map No. 1000 Section .....64........... Block ....OZ......... Lot No......
pursuant to application dated .....1~! 1.......................... 19.,?W, and approved by the
Building Inspector.
Fee 7.<...
wilding Inspector
Rev. 6/30/80
~ Form No. 6
TOWN OF SOUTHOLD
` 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 psed in system contains
less than 2/10 of 1% lead.
5. Commercial building, industrial building, multiple residences'ancf 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.
S• 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.
• 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 ..~F! -,a.199a...
'w Construction..',,, „ Old Or Pre-existing Building . . .
cation of Property:..,'5--' q~ rs..l`S (3e i X e .
House No. Streep
'7-- ~ t . Hamlet
acr or Owners of Property... Tt 1 f f... f•;~
,
:nty Tax Map No 1000, Section(Pfq;Q;p?Q,Block
4?........Lot.....~
division....... .............::........~P. ./Fi9leo2d, Map A?.r. ....Lot..
nit N0.?P422.Y. Z Date Of Permit. ..Applicant.......
.
Lth Dept. Approval..........
..Underwriters Approval........,
Ining Board Approval........
lest for: Temporary Certificate.....,
Final Certicate.,
Submitted:
C~.~c . y 5 • .
ca a`1169. ~1") APPLICANT
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H. SMITH PLUMBING & HEATING, INC.
MAIN ROAD
SOUTHOLD, N.Y. 11971
(516) 765-3690
C E R T I F I C A T I O N
Date November 16, 1992
Building Permit No. 206862
Owner Teresita Tan
Plumber: H. Smith Plumbing & Heating, Inc.
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.
Henry P. Smith
Sworn to before me this
16th day of November ,
19 92
Notary Public, Suffolk County
Notary Public
dERNADETTE L. TAPLIN
NOTARY PUBLIC #4844893
State of New York
Raiding in Suffolk County
t;ommission Expires Sept. 30, 19
INSPECTORS _
Victor Lessard': JtFp
Principal Building Inspector
Curtis Horton SCOTT L. HARRIS, Supervisor
Senior Building Inspector c=am
Southold Town Hall
Thomas Fisher
BuildiP.O. Box 1179, 53095 Main Road
Building Inspector O 4 r :v
Gary Fish '4 Southold, New York 11971
Building Inspector ~1 '•`Y Fax (516) 765-1823
Vincent R. Wieczorek 7 Telephone (516) 765-1800
Ordinance Inspector
Robert Fisher
Assistant Fire Inspector OFFICE OF BUILDING INSPECTOR
Telephone (516) 765-1802 TOWN OF SOUTHOLD
NOVEMBER 20, 1992
WILLIAM SALMON
HORTONS LANE
SOUTHOLD, NY 11971
RE: TERESITA TAN
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
%R% An application for Certificate of Occupancy is
not on file. (Enclosed)
X= No Underwriters Certificate on file.
ffi The check is Yo3aUdEbM/not on file.)$25.00
No Health Department Approval on file.
No final inspection has been made.
XXX No Plumber Solder Certificate on file.
(All permits involving plumbing being
issued after April 1, 1984).
BUILDING PERMIT # 20684-Z
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
CC: TERESITA TAN
Ic, _V.:. .:'N IIJn: ~ a;ttt~Nr
H
7OU11DATIO^I (13t) J~
• c
'OUNDATION (2nd)
:OUCH FRAME & I o `
-PLUMBING
ti
/V y H
3. m
cn
y
INSULATION PER N. Y.
STATE ENERGY
CODE
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4
cZea
FINAL f/ d1coo
~
ADDITIONAL COMMENTS: x
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X
X
A ~p
H
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M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION 2ND [ ] IN LATION
FRAMING [ FINAL
REMARKS:
DATE l` ~/?~INSPECTOR
M-1802
BUILDING DEPT.
INSPECTION
[ FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING FINAL
REMARKS: 7~~ca
DATE INSPECTOR
-F~
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 15T [ ] ROUGH PLBG.
[ ) FOUNDATION 2ND [ ] INSULATION
[4 rRAMING [ ] FINAL
REMARKS:
i
t
t
E
DATE INSPECTO
l
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ } ROUGH PLBG.
[ } FOUNDATION 2ND [ ] INSULATION
FRAMING [ ] FINAL
REMARKS: lle-;~ Z=
DATE f~ INSPECTOR Q~
BOARD OF HtnI-&..
FORM NO. 7 3 SETS OF PLANS ,
TOWN OFSOUTHOLD SURVEY cs~
JUN 11992 BUILDING DEPARTMENT CIICCK . p/ . . . .
1
TOWN HALL SEPTIC FORM
SOUTHOLD, N.Y. 11971~~ Q--~--.~
1tdJPti,~t TEL.. 765-1802 r:aTl/ ~~a
CALL,... G7 „
Examined k5-...., 199)_ MAIL TO:
V A
Approved . c5 197. Permit _
Disapprove a/c
.
;Lo
.
(Building Inspector)
APPLICATION FOR BUILDING PERMIT ~y~
Date R-5........ 19 l
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, hou mg code, and regulations, and to
admit authorized inspectors on premises and in building for necessary insp Ps. 4i L °`r
(Signature of applicant, or name, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Y:)%l....~r?t^J !'?4.C.Any'
Name of owner of premises
(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. .13.0.7.1..11,T
Plumber's License No. .13. i. . P .
Electrician's License No. . a! 7.G.
Other Trade's License No . tt
1, Location of land on which proposed work will be done. .t d~ i. X•~ cx.atU. , .5, T ~S,, , , , , ,
Rogers.. IK.R Adk . .
House Number Street y ! Hamlet
County Tax Map No. 1000 Section ...A , Block .,5 ° , , , Lot .
Subdivision (N.... . . Filed Map No. , Lot .
ame)
1. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ~x. k gwti AcSe d.. rAx ;q
b. Intended use and occupancy 1~.vY~ . i.....14. C2 V ; .
.rurx (check which applicable): New Building Addition ...Y Alteration
Repair Removal Demolition Other Work .
lm ~ .
Fee . . (Description)
4. Estimated Cost 3,y eq( 00
4, number of dwelling (to be paid on filing this application)
5. If dwelling, g units Number of dwelling units on each floor I............
If garage, number of cars ,
6. If business, commercial or mixed occupancy, specify nature and extent of each type of u e .
7. Dimensions of exist' structures, if any: Front Rear . ~ Depth ,'~,-~•f ,
Height o ber of Stories
Dimensions of same t cture with alterations or additions: Front . Rear
,
Depth . .
( . Number .~G. 4L ' • Number of St-ones . , .
$ Dimensions ~f e ntirer new construction: n: Front ....z~ . Rear .7.8.: '~:f,... Depth Depth ,off, 4
Height .~.•~f-,
of Stories .
9. Size of lot: Front 3o A_.,....... Rear . j . Jr • , , , . Depth ..a' wC• . . , . , .
10. Date of Purchase Name of Former Owner G.(yad.j S.. h•.. G,o (j Am t4L. .
IL Zone or use district in which premises, are situated ve d p W , , E. fig S.... , • , • .
12. Does proposed construction violate any zoning law, ordinance or regulation: ........n.2 A .
13.
Will lot be regraded AJv , , , , , , • , , , , , , Will excess fill be re oved firom premises: Yes
14. Name of Owner of premises_te y-
_.4 -A 4 YS , ~Fi"/rl AddressQ~4-~1?~ ~..a Phone No. , ,715 , , • , , , ,
Name of Architect Address ;4;r .¢ert~ Phone No........... .
Name of Contractor i l- '
0~.. Address s . .h-!•k r.... Phone No. ,7,1P,5,' ,.,•S,"Yp,$Q,
15. Is this property within 30 feet of a tidal wetland? *yes........ No.........
*If yes Southold Town Tiustees Permit may be required.
PLOT DIAGRAM
I
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.
Il y
'I
I I
~I
i
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I1
I
STATE OF NWW ~
COUNTY OF S.S
• , . •.C~ .Y.4.... being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
ibove named.
I
Ieisthe................. _ ~
(Contractor', agent, corporate officer, etc.)
~f said owner or owners, and is duly authorized to pcr~orm or have performed the said work and to make and file this
pplication; that all statements contained in this application are true to the best of his knowledge and belief; and that the
fork will be performed in the manner set forth in the application filed therewith.
'worn to before me this
~I
.dayof...~{trzr r=.....,19
I
totary Public,&z!~ County
JUDITH T. TERRY. Ll'.
Notary Public, State wYak
No. c
(Signature of applicant)
ctw fiad in Suffolk Couttgr
Commission Expiraa May 31, 11
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AREA = 12,124 sq ft.
SURVEY OF
LOT 1
BLOCK 5
"MAP OF BE/XEDON ESTATES"
FLED MAR. 9, M6 MAP NO 972
AT SOUTHOLD
TOWN OF SOUTHOLD
SUFFOLK COUNTY, N. Y.
1000-66-02-20
Scale: 11f-30'
May 28,1992
0-
ci LIC. NO. 49618 Prepared in accordance with the minimum
standards for 111/e surveys as established
E C YO P.C. by the L.I.A.L.S and approved and adopted
M/ for such use by The New York State Land
A Title Association.
MAIN (4t
SOUTH 1971
j 92-181
OPT .
O ' • 89 P kn~
,01
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be
17
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n ..k 1
. 6~ s P h ae ~o° \rt Ba 00
s
o\ •ZO AO
O 5.60 N
AREA = 12,124 sq ft.
SURVEY OF
LOT 1
BLOCK 5
"MAP OF BGXEDON ES TA TES"
FLED MAR. 16, W6 MAP NO M72
A T SOUTHOLD
TOWN OF SOUTHOLD
SUFFOLK COUNTY, N. Y.
1000-66-02-20
Scale: 1"-30'
May 28,1992
c, LIC. NO. 49616 Prepared in accordance with the minimum
standards for title surveys as established
E C y. BYO ~W, P.C. by the L.I.A.L.S. and approved and adopted
f51
wkSE)r^0 for such use by The New York State Land
Title Associat/on.
MA/N (s9'
SOUTH 1971
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