HomeMy WebLinkAbout19658-z FORM NO. 4
TOWN OF SOUTHOLD
BDILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-20053 Date JULY 3, 1491
THIS CERTIFIES that the building ADDITION
Location of Property 6355 MAIN ROAD MATTITUCK N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 115 Block 1 Lot 3
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated FEBRUARY 4, 1991 pursuant to which
Building Permit No. 19658-2 dated FEBRUARY 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_ RICHARD KUBIAK
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N-189293 -MAY 31 1991
PLUMBERS CERTIFICATION DATED MAY 16 1991 - MATTITUCR PLUMBING & HEATING
Building Inspector
Rev. 1/81
sossa xo. s
TowN of soUTHOLD
6UILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. °r.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
Q
N ° ~ ! 6 5 $ Z Date ...P~ 19g~.
Permission is hereby granted to• ~ /
to ~~~'~i~~Z~C~.a~~t...~.er~~~,~1,~~. ..~:4~!~......~'r7+~y./trra~:...:.~./~, Cfit~ vim-`
at premises located of ...,/.,,.~B.Gl.~"~... ~L,r
County Tax Map No. 1000 Section ...lf.~........ Btock ..............1..... Lot No..::~...............
pursuant to application dated 19~j1., and approved by the
Building Inspector.
a~
Fee S+-~'.r'/'~~'•
r
Buf inspect r
Rev. 6/30/80
. Form No. fi ~ - - ~ _
TOIJN OF SOUTIIOLD .1 Y ~ • ~t ;
BUILDIYC D[PAKT[•fCNT
TOIJU l1ALL
765-1802
APPLICATION iOR CGRTIFIC,ITC OF OCCUP.\;:CX
This application must be filled in by typewriter OE ink and submitted to the building
inspector with the following: for new buildinS or new use:
1. Final survey of property with accurate location of all buildings, properly lines,
streets, and unusual natural or Copo;raphic features.
2. Final Approval from Health Dept, of water supply and sewera,e-disposal(S-4 form).
3. Approval of elec[rical installation from Board of fire Underwriters.
4, Sworn statement from plumber certifying that the solder used in sys[em contains
less than 2/10 of 17, lead.
5. Commercial building, industrial building. multiple residences and similar buildings
and installations, a certificate of Code C~nnpliance from archi-_ect or engineer
responsible Eor the building.
6. Submit Planning Board Approval of complc[ed site plan requirements.
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 comple[ed application and a consent to inspec[ signet by the applicant.
' If a Certificate of Occupancy is denied, the Building Inspector shall scare [he
reasons [herefor in writing to the applicant,
Fees '
1. Certificate of Occupancy - New dwelling :;25.00, Additions to dwelling $25.00,
A1[erations to dwelling $25.00, Swimming pool $25.00, Accesso n~ building $25.00,
Additions to accessory building $25.00. IIusir.esses ,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 - 550.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
Date .~-5~~....~;,..~~.T.~
Construction..,,,...,,, Old Or Pre-existing Bu~ldi •••-•g•~7-:~•-•-" " e
ocacion of Property.......~:,~.. i~-..,~??ati:y ~!~•1.~32C~.L':k:~YG~
Ilousc No, Street Hamlet
-7 _
E 1-LZ • PJ,
:wcr or Owners of Property..'`:~!rr ~C~-s_.~G , JC.:~+G~':'.~y.~
aunty Tax Pfap No9(•L000, Suction.~l.~ ........B1uck,.1
.............Lot....
:bdivision ....................................Filed i`tap............Lot...........
rmit No...~.lf.(r.J~.L1....Datc Of Pcrmi.t ................Applic:ant.............................
alth Dep[. Approval ..........................UnUcrwritcrs Approval.........................
;nning Board Approval
nuest for: Temporary Certificate........... Final Certica[c....'Z.......
Submitted: S „ _
APPLICA..T '
C 0 ? bb,~ 97
=1ELD I::S:'6C::U:J ~~U;,:E ~ :;U!YMENT° ~
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FOUt7DATI0N (1st)
- ~ 9 ,
FOUNDATIOfJ (2nd) m
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P,OUGH FRAME & o
PLUMBIIJG
. y
X89
3. - m
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IIJSULATION PER fJ. Y.
STATE EflERGY
CODE
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ADDITIOf1AL COMh15NTS: ,p
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1oonll THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTREICyKITyYpgg
MAY 31 , 199I 85 JOHN STREET. NEW YORK. NI t03UL`tl 1~~D38 pt S: 't?~11 ~ ,
Date Application M1'o. on file
THIS CERTIFIES THAT u
only the electrical equipment to deacri6ed below and introduced by the opplicant named an the above applitrtion number in the premiaea of
RICHARD KUBIAK., HD, 5355 RAIN RD., MATTITUCK, N.Y.
ATTIC/OUT
in thefollowinp lnca~~T: ~(~~ment ~ la[ Fl. ? Ynd F'1. Sertian Block Lot
una examined on and found to be in cmnplianre u~i1h the reyuiremenU of thin Board.
! gXTURE RXTURFS RANGES COOKING DKKS OVENS DISN WASHERS EXXAUST FANS
OUTD!TS INGNDE]CENT FLUORESCENT OTHER AMT. K. W. AMT. K. W. qMT. K.W. AMi. K. W AMT. M P.
1•
DRYERS FURNACE MOTORS FUTURE AMOANC! REDEIIS SFECIALRKTT TIME CUXKE REli UNIT HEATERS MUITIAUTIET DIMMERS ^
AMT. K, W. Oll H. P. WS M. 4Ni. NO. A. W. G AMT. AMP. ANi. PMPS TlANS. AMT. N P SYSTEMS NMi. wATT$
NO.OF RET
E SRRVIC! DISCOlNEECT NO.OF S E R V 1 C E "
_ t
AMi. AMP. TYPE b
RK I l ]W 1 ,p ]W ] d ]W ] / KW NO' DpER aCOND. Of CC. COND. ~ HI~LEO ~'H'~ NO OF NEUTEAIS Off'
EUTRAL "
OTIM ANMIIKEUS:
4 1.50 TON.A/C UNITS-1 0
FR.AIR NANDLER'i w.
G.F.C,I: 1 n
SMOKE DETECTOR:-1 0
n
TRACK LIGHTING:-16
t
n
a
E I
PAUL R. BURNS I~IC.IE282E ~ ~
275 TONN HARBOR LANE o
SOUTHOLD, NY, 11971.
11 o.EUAI. AIARIAOiI n
~J
Per
This certificate mLM not be oNered in any manner; return to the office of tM Board if incorrect. Inspectors may be identified by tlryir credentials.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED UI ANY MANNER.
I~
G
765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ]ROUGH PLBG.
[ FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ ]FINAL
REMARKS:
2
µ
DATE 3 INSPECTOR
9G~~
rss-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ]ROUGH PLBG.
[ ]FOUNDATION 2ND [ ]INSULATION
FRAMING [ ]FINAL
R/EMARKS: ~
~~Z ' ~t °
DATE ~ J l ~ INSPECTOR ,
/(O~~
765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION i5T [ ] ROUGH PLBG.
]FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING INAL
REMARKS:
w
I
~ ..1 -~~cev
DATE ~ INSPECTOR ~
765-1802
BUILDING DEPT.
INSPECTION
[FOUNDATION 1ST [ ]ROUGH PLBG.
]FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ ]FINAL
REMARKS: l~~-iG"r~..r2i%~
E
snlrt,~
DATE ' IN8PECTOR
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~'~'~~"~~.J f.~'r'' ~"~(1l'~'F..I,~71Izac,'snTd
(qu-rzd as~aTd) (/l/
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SZL XOQ'O'd ~ r~~~i '`'j c°
2IO.L?HJSNI OI•lIQ7IIIII 30 8JI330 ' ,~1~ ~ '
Zd8I-S9L '7H.L
rr ~ ~ ~ BOAFO OF HEALTH
~`--"GJL~!-.~,~!`: J SETS OF•PLdYS•_•........
FORM NO. 1 •
SURVEY
. T.r,._x.x,.=V i`, T04vN OF SOUTHOLD CUCCK . .
FGD~'44~~~ BUtLDINGOFPAf1TMENT SEPTIC FOR:1
p TOWN HALL
BLDG. OFp>';, tl $OUTHpLp_ C~l_Y~ 1tII71 t.OT I FY ;
70WfUdf=SO j~~9t7G,c~)w„„.<a / TEL,:7G5~1II02 CALIJ ~~f'~'.~lfa`30
Exatnincd o< .~J. l9 ~J MAIL TO : . _ • • • • .
Approvrd . 19i
f Permit No..~,%,~t~~j ~J . .
Disapprovcda/c
rng In ~ ctor)
APPLICATION FOR BUILDING PERIv11T / q
' Datc .....'1.
j/.- L....... IS~~
. INSTRUCTIONS
a. T1tis application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, wiL`
sets oC pLzns, accurate plot plan to scale. Fee accortting to schedule.
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public sire:
or areas, and giving a detailed description of layout of property must be drawn on the diagram which is Bart of this apr
cation.
e. The work covered by this application may not be commenced before issuance of Building Permit,
ti. Upon approval of this application, [he Building Inspector will issued a Building Permit to the applicant. Such perr.
'shalhbe kept on the premises available for inspection throw=bout the work.
e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Oceupa:.:
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Pe,^it ptrrsant to t'
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Is~vs, Ordinances
Rc_ulations, Cor the construction of buildings, additions or alterations, or for iemaval or demolition, cs herein describe:
The applicant a:rees to comply with all applicable laws, ordinances, building code, housin; code, ann regulations, and t
admit authorized inspectors an premises and in building for necessary : sp
ctt~ _ _
(Signature of applicant, oc name, if a corporauon)
(114ai1ing address of applicant) • •
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or buiIde:
...-~~.:'L.~~ ~Cf2
i`tameofowneroCpremiscs•..'S.r.~:Ltyi2~ ~ ~l~/S~ ~~i/'Si ABC-
. • (as on the tax roll or latest deed) ~ ~ ~ • • ~ ~ ~ • • • ~ • -
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate yyofliccr)• •
S uildci s Licc nsc No...... ! :3 d f_ S~ _ Z-... .
Plumber's Liccnsc No .
Electrician's Liccnsc No . '
Other Trade's Liccnsc No . .
Location of land on which proposed work will 6c done; _
Ilousc Number ~ .Street. ~ ~ ~ • • • •
_ .Hamlet
County Tax ,11ap No. 1000 Section ~ S......... IIlock ,
Lot......_...
Subdivision . ~ • • • • ~ •
F.i1cJ Alap No.
Lot.............
(Name)
0
State csistin~ list and occupancy of premises and intended use anJ occupancy of proposed construction:
A. Existing list and occupancy.....~M~~/~-/~/iJc-~ S//, ~~.l~ ~
/J•.
8. Intended use and gccupaney.:.~~Q.~~.::-i:.~;t...~!v,~~•~!l~.~. ~~.~c~S~.d.t;~••:•
3. Nature oCwork (check which applicable): New tlriilding Y ,Uteration
Repair RFmoval Addition
Tennis~Court~, " Demolition ........Swi;nmin~ poet.
~ece/ssory Buildin~....., .Fence .......Other~tJ ~
4. Estimated Cost . .Z~oQ.. •Fe• or ,1.r....... .
e
5. IC da•clling, nurnbcr of dwcllin^ 'nits A (tn be oaid on filing this application);
• • Number of dwelling units on each floor , ,
If ^ara^c, numbc ' 4 • • • • • .
a = r of cars
6, If business, commercial or•mixeJ occupancy, specify na•urp and extent of cacti ty c of use • • • • ~ •
7. Dimensions of existing structure;, if any: Front • " '
Hcicht , , , , , Number of Stories , ~:ij~. • ' •Rcar , F? Depth , d • • • • • •
DimensionsgC a sjructurc wi~h alterations or additions: Front ~ , G6•~' / / • • ~ • •
Depth.,3a,~,~Z• Rcar V.K7.;,....•...
. , . Height , , , , ,Number of Stories . .l.~~Z.,
8• Dimensions of entire new constn~ction: Front . • r ~ ~ ~ " " '
Hcigltt r Rcar f r...... Depth
• -~`•f•..•. 1`1um~erofStorics. ,l,
'9. Size of let: Front 1. ~ P.ca:. . `1~w
. : .
10. Date of Purchase l~e?~e • %y, • . • • Depth . ~ZS .
1 Docs ra osed construction viol t • • • • • • • • • • ...Name QQf Former Owner h>. ~z.t(~ra-2 .~Q:~ f195.e.~ .
11. Zone or use district in whiclt premises arc situated , /1~~; .gyp
l3. 1Vill lot be 3tc any zoning law, ordinance or regulation: C~ .
reeraded , , tiVill excess fill be removed from premises- Yc.
14, Name of Owner of prcmis • ~rf:
q C. • • • • • • ~ • • '
Name ofArchitcct ?`~~~,~F,J~ f' "•""'--Address C~~s:!~It?~':! „/,LL~11~!1P?f/Pltonc No.~l~:'.~~,~1.......
Name of Contract ' ' ' ' • • • • • • • Address , , , , ...Phone No..
or .~I~1.`~.~{~•C,u.,,e e!:"~ ....Address /,s'~?,s;cC,!rl~r N~; • • . , .Phone No. S,d7/,~.. '
l5_Zs this property Located within ~3pq feet of a tidal wetland? ^YES....210.4!": •
*If yes, Southold Town'ITrustees Permit may be required.
• I PLOT DIACRAivt '
Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimer.:ior:' t:
property lines. Give street and block number or description according to deed, and show street names and indicate a;:c::.
interior or comer lot.
. ~I
. I,
. II
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STATG OF NEIV YORf:,
COUNTY OF Sj5
~ ti rG
• • • ~ ~ '
`~.~~~`~7' ' ' ' ' ' ' • • • • • • • • • • • being duly sworn, deposes and says that he is the appli.^ar
(Name of individual si,niuig contract)
tbovc named.
fc is the ............~~~1~:`:>~ .
• I , • ~ (Contractor, agent, corporate officer, etc.)• • • • • • ~ • • • • • ~ • ~ • • ~ • • • ' • '
~f said owner or owners, and is duly ~~uthorizcd to perform or have performed the said Work and to make and file tl:
'pPlication; that all statements contaitjed in lltis application arc true to the best oChis knowledge and belie(; and that L':
vork will be perforntcd in the manner s;et forth in the application filed therewith.
itvom to bciorc me this ,
+ ..............~.......dayof.~,e~-- ....,1~~~.
n' ublic ~i
iota : • ,
County
HELEN IC 4
tAtO Ol tdeW York • .
7e7rm~Expirea March VOE ej~,/~yj
NoA7W87S,Su{f30 29u~ • • • • • • • • • • • • '
(~ture of applicar+'
_ .
°
SUFF. CO. HEALTH DEPT. APPROVAL + H. S. NO.I~"='(r(A
OWNCR:
WAfGt`.CiN c_!-~!'~±:%. Y'~%/`~l._LJb`~.X'7/_t.
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AREA: ?O,~ti~`"+;s:~,{'/-.
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DEED: L,69~i~ ~ Ca.27~3 (t-"e%) '
~re s i drv+ees)
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TITLE s ;r:1 t[b !::PI:?'.^:, rl rv: fir.++; m,5r•
CEli71 F. C~wr Ja7t. % I I`:T,Pi
~ : P,P;CtG G:U~i x171 _j )r,r r;q t¢r:~r„
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STAMP
M14~ G>f= Przor~~=~-rY T~ty_,TI"W~ GC.+alArilf~e ~rlI~KNT<' SEAL' •
<a7"
Gym StJrVC~9:71 Javf. I`~~j'1
MAT7"lTUCp~ RODERICK VAN TUYL. P. C.
T~rvrv rx= xx.~:r_~~d,..tatJ.Y. ~ jy/, ~ , ~ .
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LIC~. LAND 3UR`v'EYO^n5•v REE PORT. N. Y,
5v a(!~Co.TaxMa~C.~gi lfcrFion-CJisf:tOU'7,~cl.lf`~,F31ack1,F?rl,H.
7E9T HOLE SUFF. CO. DEPT. OF HEALT'.i SERVICES STATEMENT OF INTENT
O' '
~'O a0if FOR APPROVAL OF CON$TRU('TION ONLY
IOONf THE WATER SUPPLY AND SEWAGE
DATE: _ DISPOSAL 3YSTEM9 FOR THIS RESI•
,SpHOV,.cfrbVRl „f' DENCE WILL CONFORM TO THE
H. 3. REP. NO.: _ r~ ` ~ ~ STANDAR D9 OF SUFFOLK CO. DEPT,
$dry~, OF HEALTH. SERVICES.
APPROVED:
' (3)
AppLICANT
~ 17 -
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