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4
FORM N0. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Ha11
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-22122 Date IANUARY 22, 1993
THIS CERTIFIES that the building ADDITION
Location of Property 2025 LITTLE PECONIC BAY LANE SOUTHOLD, N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 90 Block O1 Lot 14
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated MAY 3, 1991 .pursuant to which
Building Permit No. 20003-Z dated IDLY 8, 1991
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 STANLEY & DORIS ROGALSKI
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N-258446 - NOVEMBER 25 1992
PLUMBERS CERTIFICATION DATED N/A
Bui ding Inspector
Rev. 1/81
108M 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°_ 2 0 0 0 3 Z Date .........~....~-c~.....~ 19 q..1
Permission is hereby granted to• J
i.t... 4. ~ .
. C.~... ~..:~.=....i.a.
q!~.~:......
. . . .
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of premises located at ...c~a.~.A.r~..\~....r~hr.~X,R....JP,.R.~^.S.tt ...............11:''""~....
County Tox Map No. 1000 Section Block Lot No......~.`~
pursuant to application doted .............QA./....~........................, 19.~~..~..., and approved by the
Building Inspector. (v~
~ Fee S`~~:.:~/
'L.C:.Y....
.
wilding Inspector
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Rev. 6/30/80 ~ _ t
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Form No. 6 ,te-~ '
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! t~,F~. ~ TOWN OF SOUTIIOLD ` ~i In '
s,',1j % ~ BUILDING DEPARTMENT ~~yR.~ ~
~I ~ ~ QPR Q ~ TOWN HALL O
' 765-1802
TOVJf OF'D',°hIO~E,n„~,,, a tl: ~ ._;1 ;~t'
" APPLICATION FOR CERTIFICATE OF OCCUPANCY jtE,;i ,
A. This a lication must be filled in b t 'g. ~~,y
pp y ypewriter OR ink and sub~~i~~'~red`~E8' gh~ tiding'
inspector with the following: for new building or new use:
1. Final survey of property with accurate location of all builq~ing~s~,,property:'lides,
streets, and unusual natural or topographic features. °"~~°~~~~~-.,.~."~~t_~;~~:i~ '
2. Final Approval from Health Dept. of water supply and sewerage-disposal (S-9 forms.
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 17 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 t?y 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
March 20 1992
Date
New Construction........... Old Or Pre-existing Building..9ddi~iav.......
Location of Property.,Little Peconic.Bay Lane Lot dk90: Southold
` House No. Street Hamlet
Onwer or Owners of Property.,,Doris and Stanley Rogalski
. .
County Tax Map No 1000, Section,,,090 ,,,,B1ock.,,01 Lot ~~~,14
Subdivision ....................................Filed Map............Lot......................
Permit No „ 20003 Z „Date Of Permit„ July 8 1991 Applicant.,V.R; Weile Architect
. . .
Health Dept. Approval...f~1Fa .....................Underwriters Approval....
Planning Board Approval...~A
Request for: Temporary Certificate........... Final Certicate.,,,XXX
i
$~nrlor c pl't.
Fee Submitted: 1°" ;
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a2~ .f.I.APPLICANT
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THE NEW YORK BOARD OF FIRE UNDERWRITERS ` PAOE a
1000121 BUREAU OF ELECTRICITY ~
85 JOHN STREET, NEW YORK, NEW YORK 70038 A
DgtP NOVEMBER 25,19$2 APPIic¢tionNo.onfile 75911792192 298Atih
THIS CERTIFIES THAT
only the electric¢l equipment as described below and introduced by the ¢pplic¢nt named on Lhe ¢bove application number in the premises of
STANLEY ROGALSKI, ?.025 1,IT1'[FE PECONiC BAY RLVll., 1~OLE #9, SOIiTHOLO, N.Y> ~
in thefollowinq location; ®Basement ® /st F/. ? 2nd F7. NNT .Section B/oek Lot 3
was examined orz NOVEMBER 20,1992 andfoundto be in compliance with the requirernerzfs of then Ro¢rd.
FIxiURE FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
ECEPTACLES SWITCHES
OUTLETS INCANDESCENT FWORESCENT OTHER AMT K W AMi. K.W AMT, KW. AMi K.W. AMi. H P C
7 7 4 7
DRYERS FURNACE MOTORS WTURE AP%IANCE FEEDERS SPEOAL REC'PT TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET DIMMERS
AMi N. W. OIL H. P. GAS N. P. AMT. NO. A W. G. AMi AMP qMT. AMPS. TRANS. AMT. H P, SYSTEMS qMi WATTS
NO. OF FEET
SERVICE DISCONNECT NO.OF S E R V I ~ C E
AMT AMP TYPE METER I ]W I ~ ]W 3,0' 3W 3,a' 4W NO OF CC COND. A W G. NO OF HFIEG A W. G' NO.OF NEUTRAW A. W G
EOUIP. PER .e' OF CC COND. OF HI-lEG Of NEUTRAL
,r 7
3 1 150 CB 1 K 1 1l0 1 1{0
d
'ge OTHER APPARA7U5:
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HAUL R. BURNS LIC>#282-E G//~~
275 TOWN HARBOR LANE
SOfIY'WOLD, NY, 11971 GENERAL MANATiiER
11 }
Per v
This ceriifiicate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by (heir credentials. -
• '
l ,
INSPECTORS a
N%'
Victor Lessazd ~rs~i ~OCr{'
. Principal Building Inspector o~ G',~~
Curtis Horton ~.w: SCOTT L. HARRIS, Supervisor
Senior Building Inspector ~ ~
" > Southold Town Hall
~ :r', r'''k1~ a
Thomas Fisher ~ '°S~'f' ~
Building Inspector ~ ' ' ~ P.O. Box 1179, 53095 Main Road
x ~ ry`o~ 1 Southold, New York 11971
Gary Fish ~~!t,
j ; <;~j Fax (516) 765-1823
Building Inspector ~r Telephone (516) 765-1800
Vincent R. Wieczorek
Ordinance Inspector
Robert Fisher
Assistant Fire Inspector OFFICE OF BUILDING INSPECTOR
Telephone (516) 765-1802 TOWN OF SOUTHOLD
MARCH 18, 1992
V. R. WEILE, ARCHITECT
BOX 99
GREENPORT, NY 11944
RE: STANLEY ROGALSKI
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
XXX An application for Certificate of Occupancy is
not on file. (Enclosed)
XXX No Underwriters Certificate on file.
XXX The check is X(~h~lc~~~rlnot 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 ~ 20003-Z
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
CC: STANLEY ROGALSKI
c lELD I;:S:'EC:lU;7
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P,OUGH FRAME & o
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IIJSULATIOAI PER N. Y. ~ m
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STATE ENERGY
CODE
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ADDITIONAL COMMENTS: ~
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' ~ DEPARTMENT OF THE ARMY
NEW YORK DISTRICT CORPS OF ENGWEERS
_ JACOB K. JAVITS FEDERAL BUILDING
y ~ Y~ NEW YORK, N.Y. 10278-0080
~ PEPLY TO
EasteriiTE`~°ermits section 2 5 JUN 1991
SUBJECT: Joint Application with New York State Department of
Environmental Conservation
Mr. Regi Weile
C/0 Doris and Stanley Rogalski
211 North Street
Greenport, New York 11944
Dear Mr. Weile:
We have received a copy of the Joint Application for a
Permit which you recently filed with the New York State
Department of Environmental Conservation.
Based upon the information contained in your Joint
Application Form, it does not appear that a Department of the
Army permit will be required for your proposed work.
Accordingly, we are herewith returning to you the copy of the
Joint Application for a Permit and any supporting documents.
Please be advised that a Department of the Army permit
is required for construction activities in, over or under any
navigable waters of the United States or for the discharge of
dredged or fill material into all waters of the United
States, including coastal and inland wetlands. If your
proposal is modified to include work within Department of the
Army jurisdiction, you should contact this office immediately
so a determination of permit applicability can be made for
your proposal.
Sincerely,
a es W. Haggerty /U~ J
C ief, Eastern Permits Section
Enclosure
CF: NYSDEC
'^e+:~3zS.~wE~Y=i'3ii~-..,.., ~7iackri;'~'w3i1i~'.
=+~"~z&':.Iva~~..tuTi`?,.-- ~ a - ...r.,.. x
_ NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION
R X,
~ ~ JOINT APPLICATION FOR PERMIT US.ARMY CORPS OF ENGINEERS APPLICATION NO.
Please read ALL msiructions on back before completing this apptlcahon Please type or print clearly in ink. Attach additional information as needed.
?ARTICLE 9, TITLE 1, ARTICLE 43 6NYCRR 646 (LAKE GEORGE RECREATION ZONE)' ~ ~ -
?ARTICLE 15, TITLE 3 (AQUATIC PESTICIDES CONTROL) ?6NYCRR 327 (AQUATIC VEGETATION) ?6NYCRR 328 (FISH) ?6NYCRR 329(w5ECi5)
5 ~ ?ARTICLE -t3, TITLE 5 6NYCRR 608 (PROTECTION OF WATERS) ~ ~ ~ ~t' - - -
A ?For the construction, reconstruction, or repair of a DAM or other impoundment structure - ~
T ?For the disturbance dt'a STREAM BED OR BANKS or excavation m or fill of NAVIGABCE~WATE RS: " ' ?40PWATER QUALITY CERTIFICATION
E ?ARTICLE 15, TITLE t5, ~ ?6NYCRR 601 (WATER SUPPLY) ?6NYCRR 602 (LONG ISLAND WELLJ._;'~•'; ; . ~ ~ '
?ARTICLE t5, TITLE 27 6NYCRR 666 (WILD„SCENIC AND.RECREATIONAL.RIV,E RS) ~ v 4
?ARTICLE 24 6NYCRR 662, 663 (FRESHWATER WETLANDS) ~ - , . ,
?ARTICLE 256NYCRR 661 (TIDAL WETLANDS)', ?ARTICLE.34~bNYCRR305, (COASTAFEROSION)'t'E~.~'r: ~.'+t.
_ ,J P, _ 6 ~ _ _ _
?SECTION 10 (RIVER AND HARBOR ACT OF 1899) for structures and ork in navigable ware s of the U 5 ?COASTAL CONSISTENCY CERTIFICATION
E r. +
D ?SECTION 404 CLEAN WATER AC'j OF 1977 for dis oral of dyed' ed or fdl matenal m waters of the U 5 . ; , , _
?SECTION 103 (MARINE PROTECTI+ON, RESEARCH AND SANCTUARIES ~rGT) for the transportation of dredged materials for dumping into ocean waters.
1. LIST PREVIOUS, PERMLT)AP,PLICATION NL?MBERS AND DATES (If any) ~ i...,p - i - ~ - ,
,
nr~-.
i 2 APPLICANT I$ AIAN Owner ,a~r p +Q ~ ~ ~ ~ - ~
O era[or ?Letsee Municipality)Governmental Agency. , ~ (Check as.many es apply),.
3 NAME OF APPLICANT (Use Full Name],, .1.11 ar :'l-+s,~ ~ Hca- F ~~'E<~^r`'~ ~ !
OYtS 4
MAILING ADDRESS ' ~ ~ TELEPHONE (Where;5an be leached during day)
I
I 3 W 1 ~ b9
,POST OF C6,~ s. ' + u, _ STATE ZIP LODE,
k C
J ~ - ~ ~ -
4 NAME'OF" E ~ t . _
i Owner ' ` (o:Agent~Contact Person ~ (ChedK brie)
MAILING A DRESS ~ ~~'~""~s`',u,. r"~` ~ ~ ~ TELEPHONE (Where cAn ~be reac~ed during day)
POST OFFICE . °-u: r,. k E^rd:.4h.v: 'tfs,:.: _ errs+t•°i:r. „ , ~ STATE;, t: .ZIP, CQDE
Y
5 PROJE 'FACILITY OCATIQN (Mark Igca(ion;on inap,_see Nuipber+ta_on reverse side) z
County SV pt~ ~ Town or my 5cj t,Li t(\Dt VJlage
STREET ADDR 5 (If different from applicanfj ~ ~ - ~ ~ ~ ' ~ ~ ' , '
. ,Di.k
POST OFF14E,._ . - ~ ~ - ~ -yST~ATE ~ ~~ZIP CODE ' ~ .
, _ 1v ~ ,
6"NAME OE STREAM OR BODY OF WATER_ ~ ~ . ~ - ~ ~ '
~W e5 ~k"e;
7 HAS WORK BEGUN ON PROJECT? If YES, attach explanation on starting work without permit include dates. 8 WILL PROJECT UTILIZE STATE LAND>
?Ves ~ No ~ Show work on map andJor drawings ~ ?Yes d
9 PROPOSED USE: 70 PROPOSED STARTING DAiE it APPROXIMATE COMPLETION DATE 12 FEE OF (NY$ Permit Only) .
Private -
? Public ? Commercial g g~~."s~.~ it
91 S ~ D~ Enclosed
t3 PROIECT DESCRIPTION: (e.g quantity and type.of matenal to be excavated, dredged or used for fill or rip rap, location o! disposal sites, type of
structurB fo'be installed, height of damsae of impoundent, capauliei of proposed water sources, extent of distribution system, etc) '
Ac1d;~tio-n '~o e~15~iv~ReSi~ennco>,Size~ add,hv~~= l~Lssy..(''t, Dli~a~w~'m~ ~~~tUIU
,:~~,1-k = ~ tas No ~6DTY~,T,y chT~~s.
14 WILL THIS PROJECT REQUIRE ADDITIONAL FEDERAL, STATE ANDIOR LOCAL PERMITS> ~ ? Yes ~ No If yes, please list
' 15. CERTIfICATION' ~ ~ -
I hereby affirm that under penality of Pe`rjwy that mformptioq provided on this form and all attachments submitted herewith is true to the best of my knowledge
and belief False statements made herein are.pUnishable'Si"d Class A misdemeanor pursuant to Section 21045 of the Penal Law
Further, the applicant accepts full responsibility for ,all dareE:'q`ge, direct or indirect of whatever nature, and by whomever suffered, arising out of the project
described herein and agrees to indemnify and save harmless thtate from suits, actions, damages and costs of every name and description resulting from said
project in addition, Federal Law, 18 U.S C. Section 7007 provides for a~fine of not more than 810,000 or imprisonment for not more than five years, or both.
where an applicant knowingly and willfully falsifies, conceals, or covers up a material fact, or knowingly makes or u,s'es aYYfalse(~YYfictiitous`o_r fraudulent statement
?I hereby authorize the agent named in Number 4 above to submit this a plicahon on my behalf, Sg~, UjjAC~Qd( 1eT~y/
6.
- "~i 7~
` A E - I NA UR TITLE
PLEASE READ ALL INSTRUCTIONS ON REVERSE SIPE
CORPS OF ENGRJEERS
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765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ]ROUGH PLBG.
[ ]FOUNDATION 2ND (]INSULATION
[ ]FRAMING [ ]FINAL
L
REMARKS: .
DATE INSPE
i
' 60,1 (i0 OF HE.\LTFi ,
FOFIMN0.1 3 SETS OF PL1:JS
TOWN OF SOUTHOLD SURVEY _ _ _ .
BUILDING DEPARTMENT CIICC(~
TOWN HALL SEPTIC CORN . .
SOUTHOLD, N.Y. 11971
`7 TEL.:765~1802 i10TIF'f;
• 6.... CALL
ixamincd . , 19 MAIL TO : . _ . _ .
~PProved 8...., 199 .Permit No??000$'Zt.
)isapproved a/c _ .
...............................~C/,. '
(Bui dmg Inspector)
APPLICATION FOR BUILDING PERPAIT q/
Date .M.d!',3,,,,,.,,,,., 191.
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3
~s 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
areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli-
%aion.
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
all 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
all 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
iilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
:gulations, for the construction of buildings, additions or alterations, or fcr removal or demolition, as herein described.
ie applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to
mit authorized inspectors on premises and in building for necessary inspections. /n
(Signature of app i ant, or name, if a corporation)
Pd~~~.9.9 ~ ru~c~trv4, ti~ .119.y~!
(Mailm~ address of appli ant)
ate whether applica~~nt__//is''owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
..............~'FMJ'C4~......................
.
ime of owner of premises .~o5.4~t~t, t ..U.~,Ti9!I/L G1~
(as on the t:rt roll or latest deed)
:applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer) l1 t A
Builder's License No. ~w10T 61~ YGd • PLv1dINa~ A"ppv~va~,
' Plumber's License No . . .
Electrician's License No . . .
Other Trade's License No . . .
Location of land on whic}t proposed work will be done. .
.?~~~~(~1~:.~PCOVIIG,~~ ~a12¢~.....~,S,u/!!ID/A,~,!V~21~1 ~DY~„
House Number Street EIanilot
County Tax Map No. 1000 Section Block J...', , , • • • • , . Lot ..~7...... .
Subdivision Filed Map No. Lot .
(Name)
State existing use and occupancy of premises and(n/intended use and occupancy of proposed construction:
a. Existing use and occupancy ~~(iK . ~}It~lt~ ~A
b. Intended use and occupancy . . • ~eiutt~akrrlll.~r, '1~~~
3. Nature of work check which a
p
( . • • , Remo licable): New Building Addition ~ ,Uteration
Re arr
p ' ' ' ' ' ' ' • . , Demolition
Fat....... Other Work...............
4. Estimated Cost ~s L1D,'DD (Description)
{ Fce......................................
g ~ (to be paid on filing this application)
wel in number of ciwellrn u
g 'nits b(Ut''{ Number of dwelling units on each floor .
g g
6. If business, commeorcialrormixed' .
occupancy, specify nature and extent of each type of use . .
7. Dirnensions o existing structures; if any: Front ...~$.'.fl. Rear ~ « • ~ •
Hei itt ~ rr Depth .
S ~...P.......,Nwnh 1~
er of Stories ......4!v~ ..r... r .
Dmmensrons of same structure with alterations or additions: Front ;4~ , IZx,I~ ,SQQ,V,b19'33r
..1'IIiY! Y .
6 ~ .Height ....Number of Stories OiV~ . (L.tl.?,{~s/O!' ,
8. Dimcnsrons of entire new constru
Hei ht ~ • •r"a" ;Numbction: Front 4•~ :Q~r....... Rear Depth .~~t=1~.t. l7'.rl`/; ;
er of Stories . . .
9. Size of lot: Front .../.08.0, • • • • • • • • • • • •
~4......... Rear.... A r~
10. Date of Purchase /'4••••••••••••••• Depth ..131r.:Fp,ZI~
~••••••••••....•.Nam ofFomerOwner .,t~J+tq~...
11. Zone or use district in wh~h pre 'ices are situated . , ,RG~I
12. Does proposed construction yrolaYe an z nin ~ ~ ~ ~ ~ ~ • • ~ ~ ~ ~ ~ ' ~ ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' '
13, 5Vil1 lot be regraded ,Qh~,rFT, nGil q d~ b law, ordinance or regulation: . NQ .
r • • ~~1 • .......Will excess fi~1 be rc ov d from premises: Yes Nod(
14. Name of Owner of remises . Ri gIJk1; , , , , , , , , , ,Address (.t.~~(+,~r{.gtjti ~jl,~iyj~j, Phona No, ~!(OCj r ~rj~
Name of Archrtect U.Q . , ,
P ~ ...............Address ~h'QMr1KG[7t~.(~,,..... Phone No. Q~7~'.°~.a~J'S, .
Name of Contractor Address Phone No.
t5. Is thi* propert within 300 feet of a tidal wetland? ,t " " " " " " " "
Yes..Y..... No......... ~
If es, Southold To
Y wn 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
II
I ~
I
~ it
ATE OF NCW YORK, I
AUNTY OF S.S
• ~ ' ' ' ' ' ' ' ' ' ' • • • • , being duly sworn, deposes and says that Ite is the applicant
ove named(Name of individual si nin c',I ntract)
s g
isthc .
(Contractor, agent, corporate officer, etc.) ~ • ~ ~ • ' • ' ' ' ' ' ' ' ' '
said owner or owners, and is duly authorized to perform or have perfonncd the said work and to make and file this
rlication; that all statements contained', in this application arc true to the best of his knowledge and belief; and that the
rk will be performed in the manner set forth in the application filed therewith.
orn to before me this
.....dayof..~,(~ .......,19~.~
tart Public,
• \ County
M.VYI~ ~1•'%......
1YHn ~ ~ (Signature of applicant)