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FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office o£ the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCOPANCY
No Z-22352 Date MAY 21, 1993
THIS CERTIFIES that the building ALTERATION
Location of Property 1875 JACK5ON ST.&615 FOURTH ST. NEW SUFFOLK N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 117 Block 9 Lot 14
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JULY 12, 1991 pursuant to which
Building Permit No. 20031-Z dated JULY 19, 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 ALTERATIONS TO EXISTING ACCESSORY GARAGE AS APPLIED FOR
The certificate is issued to MICHAEL GILL & ANO.
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE N0. N-275992 - MAY 14, 1993
PLUMBERS CERTIFICATION DATED N/A
ui ding In
Rev. 1/S1
I~
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° ~~~YJ1 Z Date 19.
Permission is herebyy gr ted :
.:....:fll ...j....j/t~i ~~~,J
of premises located at ....r/~'~/c~~,~r'.~ .....................~,T..:.~....1~~~....~k~••r
........................................:...lTrt~i~....'......~.
County Tox Map No. 1000 Section Block, Lot No........~.~.......
pursuant to application doted 19..~~., and approved by the
r
j Bu(Iding Inspector.
f -Fee S••.?..?
i
E=~~~"y. !Prt
4 ' B ing Inspector
Rev. 6/30/80
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"'"m,~`~3+"'~"""" ~ Form No. 6 @' ~ oC~ 7
l.:' r;y1i"~~1~~~i~ ~~I
i se 1 ~y
~~~,~'i w... ~ TOWN OF SOUTHOLD ~ 7~ y~~VAI~ J~~~
f~°1q ~ BUILDING DEPARTMENT
f MAY 2,~ i~~;~
TOWN HALL
k(,# E~:.`.. Y. ; ~ 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. ~
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 `
t, "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 - Residenti~a/l~ $15.00, Commercial $15.00
Date C`.~~...°2v.... j~/.~l 3
New Construction.........(.7. Old Or Pre-existing Building...(J.....~..y....
Location of Property....~3~. ~~.........~CrC~~v~J .............?1~<°~..~~~'D~...........
House No. Street Hamlet
Onwer or Owners of Property..,!.".~.(C;.K~G~';I, ,',7,~,i,l,', , , ;~1(!~~7"~f~,,, , , , , ,
County Tax Map No 1000, Section......~~.1....B1ock......C.........Lot.. ~H
Subdivision ..!Fi/led Map...........~./LJot./.
Permit No..a2.~~.J~..~Date Of Permit...7/I~7,/.j,~...Applicant..,l:CC<:~)-~~1...~7R~L.........
Health Dept. Approval ..........................Underwriters Approval./.tl..~
Planning Board Approval
Request for: Temporary Certificate........... Final Certicate..!~..,....
Fee Submitted: $
C~ ~ as
~ s ~ APP ICANT .
INSPECTORS
Victor Lessard , i`t7j,y
Principal Building Inspector
1': ,~J
Gurtis Horton J ' ; i~ SCOTT L. HARRIS, Supervisor
Senior Building Inspector ~ ~
~ cn ~ = t; Southold Town Hall
Thomas Fisher •t ,3, rn p.0. Box-1179, 53095 Main Road
Building Inspector ~ `
~~,r _ a ' ' Southo N}w York 11971
Gary Fish ,~~'~1 Fax 516 765-1823
Building Inspector - - Telephone (516) 765-1800
Vincent R. Wieczorek 't;-r~u`'..
Ordinance Inspector
Robert Fisher
Assistant Fire Inspector OFFICE OF BUILDING INSPECTOR
Telephone (516) 765-1802 TOWN OF SOUTHOLD
MARCH 15, 1993
MICHAEL E. GILL 6 O
-13&J--SFIFR9bR-, --i~PF- +156
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
%%7[ An application for Certificate of Occupancy is
not on file. (Enclosed)
%Xx No Underwriters Certificate on file. G"`L. '
&Yx The check is not on file.)$25.00
No Health Department Approval on file.
No final inspection has been made.
No Plumber Solder Certificate on file.
(All permits involving plumbing being
issued after April 1, 1984).
BUILDING PERMIT # 20031-Z
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
MELD IrsrECT1U,d puA.;; I co,K~JCUr~
,,011
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FOUNDATION (1st)
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FOUNDATION (2nd) _ m
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ROUGH FRAME & 1~,~~,
PLUMBING '~_1
3.
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IIJSULATIOPJ PER N. Y. '
STATE ENERGY
CODE
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ADDITIOPIAL COMMENTS: ~
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76$-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION iST [ ]ROUGH PLBG.
[ ] FOU TION 2ND [ ]INSULATION
FRAMING [ ]FINAL
REMARKS: ~
DATE INSPECTO
D ~ \~1 ~ FORMN0.1 ~OSETSO~PLd.`7S _
TOWN OFSOUTHOLD SURVEY
BUILDING DEPARTMENT CIIECh . .
TOWN HALL SEPTIC ronrt .
BL 0. DEPT• SOUTHOLD, N.Y. 11971
TpyyNgpgplp}Iplp TEL.: 765-1802 NOTIFY;
CALL
Examined .y. , 19 . N n I L T
A roved q , , , , .off, 0 G~ .~:d C~io1(,o~,t/~
pp , 19 %/Permit No. ~ f .~Q~J.C~.~at/~Q~, ~ • .1/fS4.
Disapproved a/c "°'tJ7. s y
`uildi Inspector)
APPLICATION FOR BUILDING PERMIT
Date t`~ 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.
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets
or arras, 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.
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, housing code, and regulations, and to
admit authorized inspectors on premises and in building for necessary ins tions. C,.__
(Signature of applicant, or name, if a corporation)
~6X •z~z l~J~ ~ ~ar~ tuY.ll~..
(Mailing address o applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
.....C~ ~:n el^
Name of owner of premises .~!cGta.e.~..~~!~`.'..~"~.°.~..~[t.".~a`rv`...~~=:'p:~>"te,'~!?:~.~:
(as on the tans 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 . .
I-louse Nw lier S/treet Hamlet
County Tax Map No. 1000 Section 6 Block Lot ~ .
Subdivision Filed Map No. Lat...............
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ~
`T b ~ ('n. , , s,.a • . •~i~• • • .
b. Intended use and occupancy ~~~iE...`~' : • %~~e~~' .
.
,
3. Nature of work (check whiRemo' licable): New Building Addition , Al;gratigtt .
Repair , , val Demolition Other Work ist. .
,p (Iriptjc~rH)
4. Estimated Cost .`3(70 e7 Fee ~5~. ~ l '
d~~.~.. .
(to be pa;d
o~'"fillpi"g,l;jjjg ~y~;ji]apa ion)
5. If dwelling, number of dwellin nits , , , , , , , , , Number of dwelling units on'eaeh-~ernr::~~~:~:*;~;°:^ , , ,
g g , .....~v~
6. If business commercial or mixed', occupancy, specify nature and extant of each type of use . .
7. Dimgensions of existing stru Nums, if any: Front Rear Depth , .
Hei ht ~erofStories............,.........,......................
Dimensions of same structure with alterations or additions: Front Rear .
Depth .Height , , Number of Stories .
8. Di gensions of entire new c ~nu~ ction: Front Rear Depth .
Hei ht tier of Stories .
Sze o o : ront
Rear Depth
f9Y4.. , ........Name of Former Owner .R~14~~. ~5~:~®- . . .
110. Sone or usecdistnct i~whi~ ra ~ •
p m~sesaresituated
12. Does proposed construction violate any zoning law, ordinance or regulation : . .
13. Will lot be regraded ./.2.a , , , , . ; , , , , , , . , , Will excess fill be remove from premises: Yes No
14. Name of Owner of premises ~t~~. t. Q v:~4YW,4r~ Address ~AX.~i.~ .~?a.1 ~u..«Phone No..Z3.Y-~YP7... .
Name of Architect ................Address ...................Phone No............... .
Name of Contractor ,
15. Is t:hisIfroesrtSouthold T " • Address . . . Pho e No............... .
00 feet of a tidal wetland? *yes........ No...?5.....
Y Gwn 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!
it
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STATE OF NEW YORK, S IS
COUNTY OF
' • • • • • • • • • • • • • • • being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named.
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 contair:ed 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
......daylof..l 19 9~
Notary Public, t' County
JOYCE M, WILKINS \ • • .(.~ji~/ v (s`~
p (Si
No, 2246 Suffolk C8pu jyrk gnature of applicant)
7arm Expires June 1 ~,,~7 9 .3
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