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i FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-20529 Date FEBRUARY 13, 1992
THIS CERTIFIES that the building ADDITIONS
Location of Property 5420 MAIN BAYVIEW RD SOUTHOLD, N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 78 Block 4 Lot 35
Subdivision Filed Map No. Lat No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated APRIL 23, 1990 pursuant to which
Building Permit No. 18988-Z dated APRIL 26, 1990
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 2ND FLOOR ADDITION WITH DECK & GARAGE ADDITION TO EXISTING
ONE FAMILY DWELLING AS APPLIED FOR.
The certificate is issued to GEORGE F. & EILEEN A. MOORE
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N-223277 - FEBRUARY 4, 1992
PLUMBERS CERTIFICATION DATED JULLY 19 1991 - K&K PLUMBING & HEATING
B ilding Inspector
Rev. 1/81
soaa>< xo. s
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~ ~g~~g Z Dote 19.9v
Permission is hereby grant/e~?d to: C
to ...~.t?':!-~M:t.t~-..4.~1....r~N~....~::~!?-~-...~'^-$:...~:.~a:~:9.:4....."-~.41~!:irD'+1....
at premises located of ..~~~?.....1~...::~1~.:cP.M? .
Caunty Tox Map No. 1000 Section .......Q.Z.~..... Block ......Q~....... Lot No.....,~. 5
pursuant to opplication doted ...........~.n.ii 19.~V, and opproved by the
Building ins2pector.
Fee $..a~gw?:~ V.....
ciTua"
Building Inspector
Rev. 6/30/80
j•'orm No. fi ,
ti
TOWN OP SOUTIIOLD ~
BULLDINC, D6PARTPIGNT
TOWN BALL
765-1802
APPLICATION POR CGRTIPICATE OP~OCCUP.\NCY
ti
1. This application must be filled in by typewriter OE inlc and submieted to the building
inspector with the Eo1lo~aing: Eor 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-Q form).
3. Approval of electrical installation from Board of Fire Underwriters.
G. Sworn statement from plumber certifyins that the solder used in system contains
less than 2/10 of 17 lead,
5. Commercial building, industrial build ins. multiple residences and similar buildings
and installations, a certificate of Code C~;mpliance from archi'_ect or engineer
responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.
For e:isting buildings (prior to April 9, 1957) non-conformins 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 scare the
reasons therefor in wrieing co the applicant.
Fees '
1. Certificate of Occupancy - New dwelling 725,00, ,\dditions to dwelling $25.00,
Alterations to dwelling 525.00, Swimming pool $25.00, Accessory building $25.00,
Additions to accessory building $25.00, Businesses $50.00,
2. Certificate of Occupancy on Pre-existing BuilclSng - $100.00
3. Copy of Gertificatc of Occupancy - .$5.00 over 5 years - $10,00
G, Updated Certificate of Occupancy - $50,00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial 515.00
Date
ew Construction...: Old Or Pre-exisLinp, building
ocation of Property~V,~.~C~~„~~E'A.4~..~AS~.t,..~E?~-i~~..........,
liousc No, Street Hamlet
ewer or Owners of Property. ~.'~K(J~. ~ ~~4\ .(.~f~1'~A.S~2fi~.. , : , :'e; , , , , . ,
,unty Tax Pfap No L000, Section.../. :?........Bloclc...7.,' .......Lot...
bdivision .Filed itcip......... .Loc...
pp QQ r~ ~l ~ Out\G~
rmit No, i•4~$.V.~.....Date Of PnrmiC.~:'Gt10.:7~....Applicant. <~Ca~C'Y31.t~..(YI~J',~-~s....
alth Dept. Approval ..........................Underwriters Approval........,..............,,
Inning Board Approval ~~t
i
;uest for: Temporary Certificate........... Final Gerticate..,.~.
i~Y,
Submitted: $..~v;~(,~..
6Zae., y 33'3 ~ _ ~.s~-~~=~ca~~~(;
~e~^
:-:~.../~'Y~,~~.
ArrLICaNT
~:ar~~~~q
~ r ;k,
TEL. 7G5-1802
pS~F~~(x~p 'T'OWN OF SOYJTHOI.D ~
` ,mil'.^' :t OFFICE OF IIUILDII~IG INSPECTOR
~ ~ :=Y, P.O. DOX 728 '
F.
,v ~ .z TOIVNHALL
.,0~~~1 ~ ~~0`r- SOUTHULD, N.Y. 11971
C E R T I F I C A T I O N
x~'
Date ~ 4~~\~~
i
• R
Suildin~ Permit No. 1~dg43`BZ
Owner '~'7oce-
(please print)
Plu.;.ber ~ k '~~vrY.bZr.~.hd ~a~.rc~
(please print)
ti:c,erye~' ass ~ - g
I certify that the solder used in the water supply system
eontains Less than 2110 of 1$ lead. ,
+
iplumber'sQsignature)
Sw~ol~rg to before me this ~Y ~K0~1 1IbAt
7-L,~_dsy o~ ~ r
r
19~, Notary Pu lie
notary Public, County
1
I
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1 '
1001071 BUREAU OF ELECTRICITY
65 JOHN STREET. NEW YORK, NEW YORK 70038
pare FEBRUARY 04,1992 gp(A(iro[ionNo.anfi[r 76024192/92 N 223277
THIS CERTIFIES THAT ~
only [he electrical equipment as descrihed 6e/ow and introduced 6y the applicant named on the ahooe application numher in the promises of
GEORGE & IRSNS MOORS, MAIN BAYVIEW WEST SIDE, SOUTHOLD, N.Y.
in thefa(louing (oration: ? Bate+nent ? (.Tt F(. ~ 2nd FT. GAR/ATTIC/OUT sertian Bork Lot
uas examined art JANUARY 30,1992 and found to be in canLplianre with the rryuirement.e o(tieia Board.
FIxTURE ECEPTACIE$ SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISN WASHERS EXHAUST FANS
OUTLETS INCANOESCENi FLUORESCENT OTHER pMi K W. AMi W. AMi K W AMI. K W AMT H P
17 39 19 14 2 g
DRYERS WRNACE MOTORS FUTURE APPl1ANCE FEEDERS SPECIAL REC'PT TIME CLOCKS RELL UNIT HEATERS MULTI-OUTLET DIMMERS
AMi K. W. On H P. GAS H P. AMi NO. A W G. AMi AMP AMi AMPS TRANS. AMi H P SYSTEMS AMT WATTS
NO. OF FEET
3 F
SERVICE DISCONNECT NO. OF 5 E R .V _I C E
AMT. AMP. TYPE METER L 9, 1W I ~ ~W J 8 3W 3,e AW NO OF CC COND. A W G. NO OF HLLEG A. W G NO OF NEUTRALS A W G
EQUIP. PER .P OF CC COND Of HI LEG OF NEVYRAI
1 200 CH 1 % 1 2/0 1 2/0
OTHER APPARATUS:
G.F.C.Ie-5
SMOKE DETECTORt-1
~~z~ -c~~
G & S CONTRACTOR LIC.#578-E GJj~~
BO% 215
SOUTHOLD, NY, 11971 GENERAL MANAGER /
Per. 11
This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their credentials.
I~ S'~~
THE NEW YORK BOARD OF FIRE UNDERWRITERS ~nf;~ 1
1®x1071 BUREAU OF ELECTRIGITY '
BS JOHN STREET, NEW YORK, NEW YORK 70038
Date ~~i~lll~h~i' ~~,1992 APPfirgtionNo.onfile 7~~74192/92 ~ 22.3177
THIS CERTIFIES THAT
only the electrical equipment os described 6elou+ond introduced 6y the applicant named on the gbove gpplicgtion number in the premises of
Y
c~o~tcc ~ z~b~aa ~~Qlt~;, ~~rl~r a~uvxear w~s~~ ~r~~k, s~c~~az~ll, rr.x,
in thefollgwinq location; ? Basement ? 1st Ff. ~ 2nd FT. GA.f2 JFlT'SIC~Qf)rA' Section Bloek Lot
tuns ezornined m/ 171t1Un~7 al~11!?~`° arzdfound to 6e in cornplfanre with [he ret{ulrer/ients of this Board.
~ FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISHWASHERS EXHAUST FANS
~ SOUTLET$ ECEPTACLES SWITCHES INCANDESCENT FWORESCENi OTHER AMT K W. AMT. K W AMT KW. AMi K W PMi ytH P
17 39 .1" ? L
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS BELL UNIT HEATERS MULTLOUTUFT DIMMERS
AMT. K. W Oll H. P GAS N. P. AMT NO A. W G. PMT. AMP AMT. AMPS TRANS. AMi H. P SYSTEMS pMt. WATTS
NO.Of FEET
SERVICE DISCONNECT NO.OF S E R V I C E
AMT. AMP. TYPE METER Imo, 4W i,B 3W ~,e' 3W JA' dW NO. OP CC COND A W G. NO OF HbIFG A W'G NO Of NEVTRAlS A W G
EQUtP. PER .e OF CC.COND OF HLLEG OR NEUTRAL
1 ?,@0 C[S 9, K 1 Zip 1 2!0
OTHER APPARATUS:
~ fi.~. ~.lt^3
~I~la~~'i D~'C7;C'Pplt t
c ~ cor~al[inc~o~a iAr.c, ~s;7s-~
/
fox zl~,
$~JU4rHEMS,[~ t qly t ~ 1571 GENRRAL MANAGER
~~.1 ~ 1f
Per
This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by their credentials.
i COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
INSPECTORS
PrincipaltBuilding Inspector O~pSUFFO(~CO
Curtis Horton SCOTT L. HARRIS, Supervisor
Senior Building Inspector w x Southold Town Hall
Thomas Fisher P.O. Box 1179, 53095 Main Road
Building Inspector ~ •
Garq Fish ~?J~l ~ ~~0~ SouFth~l
516) 765- 823 71
Building Inspectar 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
August 14, 1991
George & Eileen Moore
5420 Main Bayview Rd.
Southold, N.Y. 11971
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
XX An application for Certificate of Occupancy is
not on file. (Enclosed)
XX No Underwriters Certificate on file.
XX The check is (XXXXXXXX/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 being
issued after,April 1, 1984).
BUILDING PERMIT # 18988-Z {ADDITION}
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
r'lELD It:SPEC;TU;7 ~~UATE ~ COMMENTS
1. ~ ~
„t _ - _ y off
FOUI3DATION (1st) ~
N
FOUNDATIOIJ (2nd) _ ~
~
2. `
` z ~y
o .G
P,OUGH FRAME &
PLUMBING
t N y?p~
D H -1
3. ~
c~~7 C
H
I77SULATION PER N. Y.
STATE ENERGY I
CODE
x
a
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4. y ~
FIi4AL
~ z
ADDITIONAL COMMENTS: ~
x
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x
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~ss.iso2
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ] ROUGH PLBG.
[ ]FOUNDATION 2ND [ ]INS TION
[ ]FRAMING FINAL
REMARKS:
DATE ~ ~ INSPECTOR
r
(d
765.1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION i5T [ ] ROUGH PLBG.
[ ]FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ INAL
REMARKS: ~
~ ~
DATE dINSPECTOR ~ Icy
` V`~
..r . _ ~ ~
rss-isoz
BUILDING DEPT.
INSPECTION
1 T ROUGH PLBG.
[ ]FOUNDATION 5 [ ~
]FOUNDATION 2ND [ INSULATION
[ ]FRAMING [ ]FINAL
REMARKS: ~ a~
DATE ~ INSPECTOR ~
765-1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ]ROUGH PLBG.
]FOUNDATION 2ND [ ] iN5 CATION
[ l FRAMING [ FINAL
REMARKS:
4
DATE ~ 5 / INSPECTOR
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BOARD OF HEALTH
D ~-~•-a 3 SETS OF. PLANS...,
~IC r FORM N0. 1 SURVEY
TOWN OFSOUTHOLD CNECK
~z3(~ ~ BUILDtNGDEPARTMENT SEPTIC r•oRrt
' TOWN HALL
L $OUTHOLD, N.Y. 11rJ71 NOTIFY ;
BLOC. DEpp TEL.: 765.1F302 CALL .~10. .-~~y.C-?, , , , ,
To OF s urw~lp
Examined . . a~":':; I g~ MAIL T0:
Approve 194~.PcmtitNo.~.~9~~;~°, .
Disapproved a/c .
i
" ~ (Building Inspector)
APPLICATION FOR BUILDING PERPr11T
Date ..."t 1~
INSTRUCTIONS
a. Tltis 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.
h. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets
ur at•eas, and giving a detailed desct!iption of layout of property must be drawn on the diagram which is part of this appli-
cation.
o. The work covered by this application may not be co.rnmenced before issuance of Building Permit.
° d. Upon approval of this application, the Building Inspector wit! issued a Building Permit to the applicant. Such permit
shall be kept on the premises available for inspection throughout the work.
e. No building shalt 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 th.e
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.
Tile 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 it ecti ns,.
(Signature o[ ap licant, r name, if a corporauan)
' S ~o r~nau~c. Rocad
" ~ou~~o\~.i:n:~..l~q:~1.
(Mailing aTtdress of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises ~9s~CC~s.L.. ~~'4~~.. :~~Qd~, , , , , , , , , , , , , , , ,
v (as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of core ate officer) `
"Builder's License No.C~.fi-~}~:n~.'. .
Plumber's License No. 1`::.~.. ~ . /..Pi
/ ,
Electrician's License No. ~.cy ,
Otter Trade's License No. •
I, Location of land on which proposed work will be done; •
',~y~,P... 5~c~ata..~~~~i~.. Rom: , Sov:`~P'c~~,,C~ .
House Number Strue//t~~~~ Hamlet C
County Tax ,,\fap No. 1000 Section ..d~~.~.~1~J..: B1Dck ~y..:OQ, , , , LotQ~ :.1:.~~Q ~ , ,
Subdivision Filed plap No. .Lot i
..(Namej•
3. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ...3
~ ~.~~~T.~-X:~ .
Intended usegndoccupancy ...........L,.......
i
3. Nature of work (check which applicable): New l;uilding , Addition , • • . Alteration : .
Repair Removal Demolition ..............Swi:aning pool........... .
Tennis Court Accessory Building..........Fence .......Other ~o
4. Estimated Cost Fee • .
(to be paid on ti]ing this application)
5. 'If dwelling, number of dwelling units ...C~f~~'.~...... Number of dwelling units on each (loot ...C:~~$,-, , . •
If garage,numbcrofcars .T~~•••
6. If business, commercial or mixed occupancy, specify nattue and extent of each typetof use fl~~..!~..~.~.t....... .
7, Dimensions of existing structures, if any: Front . Rear Depth L,7sy,~. , • , , • , • ,
Hcighf-Slt~•~c.e~c~S Number of Stories ....~~-C.~......... i a t......... . .
Dimensions of same s ~ructurc with alterations or additiorts: Front ...S.O........... Rear ~ . .
Depth Height ....~:-11~.'~. i'~~a~. S . Number ofjStories ..~1.
~.C,~ r .
8. Dimens;ons of entir~e,new constnuction: Front Rear ...C:~........ Depth ...r~. .
Hci;ht~~~:rc'~RoC:~2„ . Number of Stories .I: Q'nE'.' 1 .
9. Size of lot: Front ....~.J\,f:.Q............ Rea- ~ b0 pe th t~~ 14~...>~.1~1-~ ,
L0. Date of Purchase ...~~.~(J ....................PdameofPormcrOwner .C~.t.~`~`~.~'`?.4~Yoe;~c~•c;~-~q~,-~
11 • Zane or use district in w}ticlt premises are situated . .
IZ. Does proposed construction violate any zoning law, ordinance or regulation: ...C>O..... • • • • • • • • • • • • • • . • • • • .
13, Hill lot be regraded r1CJ Nill e ~~ao 11 b~c rec~~n,o~v,e~,d~fr~o~! premises: C Yes , No~
14. Name of Owner of premises ~}~ee~ . {'!S.cx:
~AAddress ...~.,~x~.,Fg~~ l'~one No.'~.to ~ :`a:}'}~!... ,
Name of Architect .Address ...................Phone No................ .
Name of Contractor .................:........Address ...................Phone No..... ,
IS.Is this property located within 100 feet of a tidal wetland? *YES....NO~~•
*If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM •
Locate cleazly 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.
t
i STATE OF NEtiY, YORK,
COUNTY OF ~FF.oci<„ • , . • S.S
. • , , , , , , Cl.L1~,~? /'f :.?.~°L~C being duly worn, deposes and says that he is the applicant
(Name of individual signing contract)
above named.
Hu is the........ ~~~1,9~,_
(Contractor, agent, corporate officer, etc.) '
oC said owner or owners, and is duly authorized to perform or have performed the said work and to make and Gle this
application; that all statements contained in this application arc true to the best of his knowledge and belief; and that the
work will be performed in tltc manner set forth in the application filed therewith.
Swom to before me this
....day of . ~~L . 19 ~U
N'ota Public . Count
rY Y
NOTARY PU ,State of New Yotk ~
46b2675
Qualified In Suffolk County (Signature of applicant)
Commisaian rxpves Jan, 20, 19~ 1 '
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765-1802
BUILDING DEPT.
1 NSPECTION
[ ]FOUNDATION iST [ ]ROUGH PLBG.
[ ]FOUNDATION 2ND [1~M1$ULATION
[ ]FRAMING [ ]FINAL
REMARKS:
~ ,
DATE ® INSPECTOR
41^ ~
V
765-1802
BUILDING DEPT.
1 NSPECTION
[ ]FOUNDATION iST [ ] ROUGH PLBG.
[ ]FOUNDATION 2ND [ ]INSULATION
[~RAMING [)FINAL
REMA °~~..,c-~ 17~-- s
DATE E~ INSPECTOR