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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-20478 Date JANUARY 15, 1992
THIS CERTIFIES that the building ADDITION
Location of Property 155 WEST SHORE DRIVE SOUTHOLD, N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 80 Block 2 Lot 25
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 28, 1991 pursuant to which
Building Permit No. 20115-Z dated SEPTEMBER 3 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 MAHIN HASSIBI & ORS.
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE N0. PENDING - JANUARY 13, 1992
PLUMBERS CERTIFICATION DATED JAN. 4 1991 - PECONIC PLUMB & HEAT.
_
Building Inspector
Rev. 1/81
rows xo. •
TOWN OF SOUTHOLO
BU1LDING 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 01 15 Z Date 19.
Permission is hereby grant d • ~ ~
t
p~3'loeated at ..,1 ...............fol..-...~..........
' County Tax Map No. 1000 Section Bloek ..........:.G"~..:....gLot No
pursuant to application doted ............~5~~:8 19./x,/, and approved by the
Building Inspector.
Fee S.~'.~°..fF./ J'"
Build Inspector
Rev. 6/30/80
! Form A'o. 6 ~
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7, ' TOIJN OF SOUTIIOLD ~f k ~
~ BUILDING DCPARTh]GNT ~ ` ' .JAN ~ ~
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APPLICATION FOR C1;RTIPICATL OF OCCUPANCY
This application must be filled in by typewriter OP, ink and submitted to the building
inspector with the following: for new building or new use:
1. Final survey of property eoith 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 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 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 I're-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 ~~~~.~g~
t:ew Construction.. Old Or Prc-existing building„ .~~~r`/[:~~ ~
Location of Property...~s:s.,,,l}//c,s~,•• S~~~fc,....~~Jrv~z. ~o'~7H®Cy~
IIouse No, Street " " '
Hamlet
Unwc:r or Owners of Property....lt~~ss`.!~~ ,•/~~fH/p/ aJj~r,~e~'s'
!:uunty Tax Map No 1000 ~O
Section.... .......B1ock....~..........Lot.
Subdivision......
.Fil1led hi:~p............Lot....
'ermit No....c~O//S..z..Date Ot Permit....~',(~7/,R;/,,,A licant
Pp
!calth Dept. Approval.......
.Underwriters Approval..
'Luu~ing Board Approval....../,~~/f
,cquest for: Temporary Certifi//cate........... Final Certicate.,,~,
'cc Submitted: ~nS.
c~~.. ~3aa ~
qq
C~ ~q~LJ7~ ~ ~ APPLIC.1\T ?z
0~~~ F O~,CO/ TEL. 7G5-1802
TORN OF SOYJT~O~.D
~c OFFICE OF BUILDIi~IG INSPECTOR
o `+-'t'-~ ~ P.O., BOX 728
yep f~i ,c TOWN HALL"
SOUTHULD, N.Y. 11971
pl rua ~ .
JAIV1q;;,
C E R T I F I C A T I O N d'°•
,
Date. v~~~j7/~°
Building Permit No. ~O 2
Owner ~j¢SS~~O/y ~jg//~.,i 9~ u?/feel'
lease print) - ~
Plumber / G f~ / /,/~1?~j~~
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.
_ a
lumber's iynature)
Sworn to before me this
day of
Notary Publi
Notary Public, County at~RS.~tta~SrrPn!
' Pdatar €ubdi~:, ~afl/SKI
Y 5Ya8@ 04 N@Yd °fOPS:
Qt~a4ifiand irr ^yut^;o6u 0.
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CaPnm'vs~ian F.x,,irsuis ~0, ~ 9~~
INSPECTORS
Victor Lessard ~~y Oe~~&rrDl,r~~'~
Principal Building Inspector _ p~, t,
Curtis Horton Y s ~
' ~ SCOTT L. HARRIS, Supervisor
Senior Building Inspector ea .,,;U' -
cn ; ~ ~ N ~ ' Southold Town Hall
Thomas Fisher ~+'~"t~,
e" ' ' r. P.O. Box 1179, 53095 Main Road
Building Inspector ' ~ k>:*`
+w
Gary Fish " i~~``'"~n~ ~v~ Southold, New York 11971
Building Inspeaar , ~ Fax (516) 765-1823
Vincent R. Wieczorek Y`''~z~` Telephone (516) 765-1800
Ordinance Inspector
Robert Fisher
Assistant Fire Inspector OFFICE OF BUILDING INSPECTOR
Telephone (516) 765-1802 TOWN OF SOUTHOLD
JANUARY 13, 1991
BOB REHL'S HOME IMPROVEMENT INC.
BOR 520
SOIITHOLD, NY 11971
RE: MAflIN flASSIBI S OTHERS
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)
%x 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.
Xx No Plumber Solder Certificate on file.
(All permits involving plumbing beingy
issued after April 1, 1984).
BUILDING PERMIT # 20]15-Z
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
lELJ 1i:.~~.: -~~.:u:i ~IJ:~: j~ Cii:`fttENTS
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?OUiJDATION (lstj I a~pl`
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FOUNDATIOtJ (2nd) _ m~
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P,OUGH FRAME & I ~ "l
PLUMBING
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765.1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION iST [ ] RO GH PLBG.
]FOUNDATION 2ND INSULATION
[ ]FRAMING [ ]FINAL
REMA S: ~~~2~~~
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DATE ~ ~ INSPECTOR
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765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST ROUGH PLBG.
[ ] F UNDATION 2ND [ ]INSULATION
[ FRAMING [ ]FINAL
REMARKS: ~ ~ ~
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DATE INSPECTOR
f~~G
765-1802
BUILDING DEPT.
NSPECTION
[ FOUNDATION 1ST [ ] ROUGH PLBG.
[ ]FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ ]FINAL
REMARKS:
DATE ~ INSPECTO
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BOARD OF x~ ALTH
D ~
~ ~ ~ 3 SETS OF/PLANS -
FORM N0. 1 SURVEY . .
TOWN OF SOUTHOLD CxECK .SQ~~.. .
g ~ BUILDING DEPARTMENT SEPTIC FOR~M-,g . - , •
TOWN HALL NOTIFY •1°~ tcmav~
SOUTHOLD, N.Y. 11971 CALL ,35~"~
TEL.: 765-1802
TOWN FS MAIL T0:
Examined ....:3 19~~
Approved . 19~?•
• Permit No.
Disapproved a/c
a ns
~ildi pector)
APPLICATION FOR BUILDING PERMIT
Date 19 .
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-
caLSon.
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 pazt 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 inspections.
(Signature of applicant, or name, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician,wplup7ber or builder.
.
...........~~/N.p/46/G...Caar/?r.'1,CTae2... 9: ,B.ec{c.OAP'T .
Name of owner of premises ./I!~/1i~ . f~.4,S.,~~~/..y .H!rS~H. ~!ev°!z . f.E.~'~sNr,~!! ,~HAvi~u.i, , • , , , , , , , . , • ,
(as on the tax roll or latest deed) .
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
ALL CONTRACTOR'S MUST BE SUFFOLK COUNTY LICENSED
Builder's License No. . /.30..77. f7/~.......... .
Plumber's License No . .
Electrician's License No . .
Other Trade's License No . .
1. Location of land on which proposed work will be done . .
. IS.
S
........................wrzsr. ,~'/k~~ . , o~~ S ~ a7h'aco
House Number Street Hamlet
Count Tax Ma No. ]000 Section o~O ..a_ 2s Lot ,I ~ 3 y S
Y P Block } j..y...... .
Subdivision ~~Y~Q.~...S,~o..e,~.3." Filed Map No. ..li .3. ~ Lot .
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy l?~GG /ti„y. , • • , . • • . • , , , , , , , , , , , , , ,
b. Intended use and occupancy d G.l,RC .
~ .n...Gr!..
3. Nature of work (check which applicable): New Building AAd'd~it•on Ir 5~ . i' , o .
Repair RemoLal Demolition ~p~ rk..,
r..,.,..•, s' .
(Desori~il~ion)
4. Estimated Cost ~~f!"ej Oa v Fee . ytl • _ ~ ~ .
(to be ai n filing this application}
5. If dwellin number of dwellin nits ....C1 r~l~ Number of dwelling un son y~ .
g> g irS'Yf~f-
If garage, number of cars .....f
6, If business, commercial or mixed! occupancy, specify nature and extent of each type of use .
g , if any: Front ..3?..'......... Rear ..cS"6.......... Depth ,3~i.......... .
7• Hein htsio~~f existing stru Number of Stories ~ , .
D P ensions'of same stmcture wtih alterations or additions: Front ...3 ~ Rear ..~i.f .
De th ~ ~ .Height 746................ Number of Stories rZ,-................. .
Dimensions of entire new construction: Front ...3.1 Rear ,3,~ Depth c~,f!.`, .
Height ~G........... Nnml~er of Stories a .
9. Size of lot: Front ....~6 7... ~ Rear Depth a~.~ , . .
101. Zone or usecdistrict in which pre ~ ' ' ' ' ' • • • Name of Former Owner .
miles are situated ~~JYP„~•„Tiq G• , , • , , , , , , , , , ,
12. Does proposed construction violiite any zoning law, ordinance or regulation: o .
g ' • • ..............Will excess fill be removed from premises: Yes
14. Nameoof Owner of premises ~p.~' ................Address ...................Phone No............... .
Name of Architect ' ..Address ...................Phone No............... .
Name of Contractor . J3.6, , ,i
• •o bf/G s, yy,4.e, ~~,/~f<?. {NZ:Address . /.'t~9 cN .RO.,, ,o/l.,e,.;r.. Phone No. ~ ~S.z7.. .
15. Is this property located within 300 feet of a tidal wetland? *Yes No ?4...
*If yes, Southold Town Tru$tees Permit ma be re uired.
PLO DIAGRAM
Locate clearly and distinctly allbulldings, whether existing or proposed, and, indicate all set-back dimensions from
property lines. Give street and block qumber or~escription according to deed, and show street names and indicate whether
interior or corner lot.
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STATE OF NEW YORK, S S
COliNTY OF a
• • • • • • • • • • • • • • • • • • • • • • • • • • ....i • being duly sworn, deposes and says that he is the applicant
(Name of individual lignin contract)
above named.
He is the
(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 contai',ned 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.
Swom to before me this
n- .day ofa...//.....,.....,199(.
Notary Public, !'f~-~+!. , County
HELEN K. ~ YOE
NOTARY PUBUR State o~ New yYak (Signature of applicant)
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