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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-23891 Date SEPTEMBER 19, 1995
THIS CERTIFIES that the building ACCESSORY
Location of Property 3970 RENNYS ROAD SODTHOLD, NEW YORR
House No. Street Hamlet i
County Tax Map No. 1000 Section 54 Block 4 Lot 36
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JUNE 27, 1989 pursuant to which
Building Permit No. 18263-Z dated JULY 6, 1989
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 INGROUND SWIMMING POOL WITH FENCE ENCLOSURE AS APPLIED FOR
The certificate is issued to ORSSTSS & EVSLYN VARVITSIOTES
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N-089184 - AUGUST 30, 1989
PLUMBERS CERTIFICATION DATED N/A
i
Building I Spector
Rev. 1/81
r Fosas 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 ° ~ ~ ~ ~ ~ Z Date ......4f~ 19..:d..~
Permission is hereby granted to:
......A::..~i.~...~s.R~„~.~:~~..., l.~+....c..::.,......
3 ~
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ro ~':V.1r•::~-th3.Q'...4~,!),...,l:~.A::!?-!^.a:irX.....11.:W:~.~..../~.°-„:P~.....~...G~...~.
of premises located of ..,3g~.~....... ...13~:....... ~
County Tax Map No. 1000 Section ...Q...~....... Block Lot Na....~3..~
pursuant to application doted a~ 19.A.~.., and approved by the
Building Inspector,
Fee a..
Building Inspector
Rev. 6/30/80
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form No.
~rol~na of sou7nohD _
6UILDLNG UGPARTEIGN'T dJ~J,~ j~
TOWN HALL. ~J~f
7F~-1802 U(~-UC-{-~, e~rrnn
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APPL7CA'CION F01E CLRIIFICA'fc OF OCCUPANCY 2-S ~ll'1S'/UN~~~
A. This application must be filled in by typewriter OR ink and submitted to th bui d~}'n¢
inspector wil'h the following: Eor new building or new use:
1. Final survey of property caith accurate location of all buildings, propecty lines,
streets, and unusual natural or topographic features.
2. Final Approval from pealth Dept. of water supply and sewerage-disposal(S-9 form).
3. Approval of electrical installation Erom board of Fire Underwriters.
Sworn statement Erom plumber certifying that the solder used in system contains
less than 2/10 of 17. lead.
5. Commercial building, industrial building, multipl_ residences and similar buildings
and installations, a certificat_.of Code Compliant= from archi.[ect or engineer.
responsible Eor the building.
6. Submit Planning Boarcl Approval of comp.t_ted site plan requirements.
8. 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 525.00,
Alterations to dwelling $25.OU, Swimming pool $25.00, Accessory building $25.00.
Additions to accessory building $25.00. Businesses $50.00.
2. Certificate of Occupancy on Pr=_-existing Cuildine - $100.00
3. Copy of Cectifi.cate of Occupancy - $20.OU
4. Updated Certificate of Occupancy - .$50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial 515.00
Date ..q~~~'/.~~j,~~
New Construction....... Old Or Pre-existing Building ~f/
Location of Property.3./.7(L.~~22//g.~/•5..~.'.~?~ ......................wi.".'.'/.G`.".~G~--....
douse No. Q /Street Elarnlet
Omaer or Owners of Property.?.'"~.~.~..l.f~. , ,~!¢-t-~-_ ,r!,s~Z?i`~ A
:;ounCy l'ax Map No 1000, Section....~.r......~I~;1,OAuc,Ic.~.....~........LoC.~~
Subdivision/ ....................................Filed Map............L~ot/.j.......1~..............
Pe nnlt No. l ~ZG~ ~ ...Ua to OE Permit. ~^!E"~ /.r ~.Applicnnc.~~T.'"~~..(!Y-.-•:-!~~~./P.
IlealUr Dept. Approval ..........................Underwriters Approval....................
'la nning Board Approval
'?equest for: Tem.,po/racy Certificate........... Finn1 Certicate...`~...
'ee S_ubmCi~ttsci:~) $.v~.:"~
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THE NEW YORK BOARD OF FIRE UNDERWRITERS ~AC'I'. '
zoLII.3~a.
BUREAU OF ELECTRICITY
85 JOHN STREET, NEW YORK, NEW YORK 70038
Date ALf(,"114°I' 3f.1,2`)£3cl Application No. on file 639737,~~I/~9 :hI flfS~:1&4.
THIS CERTIFIES THAT
only the electricof equipment as described bebra and introduced by the opplicont named on the above application number in the premises of
>r~~RYN VRRJ'f'a"I'AT6;."5, ;t9`h~ ItE#AkiY`~S I2S?ATJ, 1, 4C?(f~~t)trlY, N,Y.
in thefollotcinq location• ? ase e7Et (1If'C
g ? fat F'l. ? 2nd F'1. .Section Blork Lot
s examined oa A[lG9~Y4T 1. [T°t~Pa
Flh and found to be in conrplianee with the requirements q(thia Board.
fl%TURE ECEPTACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS INCANDESCENT FLUORESCENT OTHER AMi. K. W. AMT. K.W AMT. KW. AMT. K W AMi H P.
1. 1 1 L
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS SELL UNIT HEATERS MULTI.OUTLET DIMMERS
AMT. K. W. Oll H. P. GAS H. P. AMT. NO A W. G. AMT. AMP. AMi AMPS TRANS. AMi H P SYSTEMS AMT WAiiS
NO.OF FEET
1 2d1 :t !S(i
SERVICE DISCONNECT NO.OF S E R V I C E
AMi. AMP. TYPE METER I q ]W 1 ,4 3W 3,e 3W 3,6' 4W NO OF CC CONp. A. W G A W G. A. W. G.
EOUIP, PER % Of CC. COND NO. OF HbLEG OF H4LEG NO.OF NEUTRALS Of NEUTRAL
OTHER APPARATUS:
C.E°.C.T:-l.
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Jf31TY PUP37T.LId) 1,CC'nN23f1p~;
PAT L,ANF
MA'i"CTTL7CIt:, NTT, :i'J.9"Yd, GENERAL MANAGER
7.9.
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.
COPY FOR BUILDING DEPARTMENT. THIS COPY OP CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
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765.1802
BUILDING DEPT.
INSPECTION
[ ]FOUNDATION 1ST [ ] ROUGH PLBG.
[ ]FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ NAL
REM KS
DATE f INSPECTO
C~
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765-1802
BUILDING DEPT.
INSPECTION
[ )FOUNDATION 1ST [ ) ROUGH PLBG.
[ ]FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ FINAL
1`"~
R ARKS:
i
DATE ~ ~ ~ INSPECTOR ~y "J
BOARD OF HEALTH
3 SETS OF PLe1NS
FORM N0.1 SURVEY , , • , •
TOWN OFSOUTHOLD CHECK .........1~•,••,••••
BUILDING DEPARTMENT SEPTIC r•oarl
TOWN HALL
SOUTHOLD, N.Y. 11971 NOTIFY
TEL.: 765-1802 CALL
MAIL T0:
L•xamincd W.., 19
t,~~.,
PP t0 ~ ~a (p O'iOH100S d0 NMOl
~ roved 19~.~. Permit No... 7d3q 'OOIB
Disapproved a/c
..(U ,4.t. , ~ a
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date ~1~~......, 150./.
INSTRUCTIONS
a. Tltis app]ication 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 ]ocation of lot and of buildings on premises, relationship to adjoining premises or public streets
ar areas, 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.
d. Upon approval of t]tis 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
Reculations• 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, housin; 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/i1s~ow/ner,~}lessee, a/g+e~nt, architect, en'gpineer, general contractor, electrician, plumber or builder.
'game of owner of premises .....~~4~5 T~~.....~....~r~'S`"'L. (1~"{2l0%T,.r/•®'-~--~_~ • .
(as on the tax roll or latest deed)
If ap tea a corporation 'gnature of duly authorized officer.
(Name and titl of corp officer)
Builder's Liccnsc No. .
Plumber's License No . .
Electrician's Liccnsc No . .
Other Trade's License No . '
I. Location of land on which proposed work will be done. .......:f~,?t,%~~~ y
r
House Number Street,
Hamlet
County Tax tblap No. 1000 Section BI'ock
Lot .
Subdivision Filed Alap No.
(Name) Lot...............
State existing use and occupancy of premises an~d/,intended use and occupancy of proposed construction:
a. Existing use and occupancy /"~~~r?r~.
l~~-
b. Intended use and occupancy /z~i/at-~.7?!a?- W 1 ~ rp L..
? ~~~yvcL--~
( a
3. Nature of work check which 'pplicable): New Uuilding Addition Alteration
Repair Removal Demolition Other 1Vork .
(Description)
4. Estimated Cost ............~i~ ~ Fee .
" g g (to be paid on cling this application)
5. If ~wellin number of dwellin' units . . . . Number of dwelling units on each floor , .
If ara,e, number of cars
6. If business, commercial or mixr?d occupancy, specify nature and extent of each type of use . .
s s.... Nu es, if any: Front . Rear .
Depth...............
ei ht
{ `mberofStorics
r
De.mt
nsions of same nt scturcur' ith alterations or additions: Front . , .
Rear .
P ......i, , .Height . . Number of Stories . .
8. Dimensions of entire new construction: Front Rear , .Depth • •
H~+ 1 3 ,~;I ; . Nutrber of Stories . .
9. Si ~ itt:. ,I
Rear . Depth .
l0. Da'te"o Piirc ase
I1. Zone or use district in which pr ~ ' ' ' ' ' • • • • • Name of Former Owner
~ emisesaresituated......
1.., Does proposed construction vw~ate any zoning ]aw, ordinance or regulation: ~ • • • ~ ~ •
3. Will lot be re"coded ; ~ , , , , , , , , , , , , , , , Wiil excess fi~1 be removed from premiseso- Yes
P
Name of Architect , , , V.l~v.f.7"S~OT.4'$. Address rd 7~x,yJ, , , , Pltone Na .
14. Name of Owner of remises • ,Address . . . .......Phone No. .
r :I......
Name of Contractor LLY,,~.-,f•q,~a.~F , , ,Address . ~?~X .~.,~4. , .!w~,n`,rrphonc No. "~a6
IS.Is this property located within 300 feet of a tidal wetland? *YES....NO....,
*If yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly afll buildings, whether existing or proposed, and, indicate all set-back dimensions from •
property Hnes. Give street and block';number or description according Eo deed, and show street names and indicate whether
interior or corner lot.
t ~ .
I~
I
STATE OF NE1V ORKy
COUNTY OF .r .u/~(,.,,•,,,,L~S
~ f inn idaa~gnm'~y~ ~ ~ • • ~ • ' ' ' ' ' • being duly sworn, deposes and says that ha is the applicant
O g contract)
above named. i
Fie is the C,•~~
'IL/}'+G~~
(Contractor, agent, corporate officer, etc.) • • • • • ~ • •
of said owner or owners, and is duly authorized to p5rform or have performed the said work and to make and file this
application; that all statements contairjed in this application arc true to the best of his knowledge and belief; and that the
work will be performed in the manner het forth in the application Glcd therewith.
Swom to before meTthis
fn .7 . q
~n day of.~. 19~/
Notary Public, , , , ,2,-, , , County
n
HELEN K. DE VDE • .
~No~4707878,S~lkfueuotY~ (Signora applicant)
term Expires Mereh 30,19....[L