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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-19795 Date MARCH 14, 1991
THIS CERTIFIES that the building ADDITION
Location of Property 890 COX NECK ROAD MATTITUCK, N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 113 Block 14 Lot 7
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JUNE 28, 1989 pursuant to which
Building Permit No. 18266-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 DECK ADDITION TO EXISTING ONE FAMILY DWELLING AS APPLIED FOR
The certificate is issued to JEFFREY & LAURIE EVANS
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N/A
PLUMBERS CERTIFICATION DATED N/A
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Building nspector
Rev. 1/81
roam 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° ~ 8? ~ V Z Dote ...........~......`Y 19.~•I•
Permission is hereby granted
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to ..~~ia.`.^:3~'....P.,..........44.,~!A~t~etFha....11~?....a-r.1...~~~1'rfrv.~II....JZ?:lRa,.....
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rvk,.Q.eq.....i..~.j.... sue?
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at premises located at ....Q.. .Q......l.N..,g'•..~.A:4~...:F.:..:?.c.........~..G'I.. kt.tJ:G
Caunty Tax Map No. 1000 Section Block Lot No....Q.7
pursuant to application dated .......~..r4''':~K,......:~.g 19.A..9., and approved by the
Building Inspector.
Fee
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Buil ng Inspector
Rev. 6/30/80
Form No. 6
p ~ C J , t~l ~ ,
TOWN OF SOUTHOLD
~ BUILDING DEPARTMENT
MAR ! 4I99i TOWN HALL
765-1802
TOWN OF
SOUTHOLD
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 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.
3, 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.
v. 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 - Residen~tjial $/15.00, Commergcial $15.00
Date ,/~~~?l.Cl7~,.~~~.~/.~~~J
'yew Construction..... ((,,11 Old Or Pre-exi ting BuildingO„ ~y/
Location of Property.. d.9Q ~:QX..~'tiC.~ ,flQ~f-f............!!L/.,4,~~i~U~..
House No. Street
Hamlet
Onwer or Owners of Property... YC'sF~l~(~ll ~g{it~~~ . ~(fLLfJ~i/,j~/, • • , . , '
County Tax Map No 1000, Section.... 1.~~......B1ock.....,~T.. „Q„~
.....Lot...
Subdivision,~,g~ ..........................Filed Map...........,Lot.,
'ermit No. .Date Of Permit., / Gp ,C9.~~~e. ~ ~
•.~~P~Q?.....Applicant. ~7~~i.
lealth Dept. Approval ..........................Underwriters Approval „
Tanning Board Approval
lequest for; Temporary Certificate........... Final Certicate „
'ee Submitted: $.....4,~
C' O ~ ~Q1q~j APPLICANT
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BUILDING DEPT.
1 NSPECTION
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B0.1RD OF HEALTH
t!1 ~I~ FORMN0.1 3 SETS OF PL.1NS
~A Q~ ~ SURVEY
f. V ,i TOWN OF SOUTHOLD CHECK
BUILDING DEPARTMENT ~ ~ ~ ~ ~ ~ ~ ~ ' '
....n.-~.. SEPTIC FORPI
BLDO.DE:1'7 TOWN HALL
TOWN OF SUO"~~'01.! , _ _ ' EOUTHOLD, N.Y. 11~J71
NOTIFY ~ s~3~.,
nQ~ ~ pp TEL.: 705.1802 CALL , yD. ; .
Examined . ! .~p. , 19 .b. } MAIL TO:
.\pproved 19g5', Permit No.~ :~.b~~,
Disapproved a/c
(Building Inspector)
APPLICATION FOR BUILDING PERMIT ~j q
• Date . ~!vN~ ....°.f.rO....., 15 g/.
• 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.
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 pan of this appli-
.:ation.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Buildin; Inspector will issued a Building Permit to the applicant. Such permit
shall be kept on the premises available for inspection throu2ltout 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 Buildin; Department for the issuance of a Building ~ermit pursuant to the
3uilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of bui]dings, additions or alterations, or for removal or demolition, as herein described.
Tite applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to I
mtt authorized ins ectots on remtses and ut building for necessa Ins a tt
P p n, ~ p (
(Signature of applicant, or name, if a corporatron)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or bull"der.
~Il!lOE.~ .
\'ame of owner of premises ..~E~FRF,y;t . ~,Av(Rl~ .~yQ~.s•. , , ,
(as on the tax roll or latest deed) ~ ~ ~ ~ ' ~ ' ~ ~ ' ' '
fCapplicant 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 . .
OtlterTradc'sLicenseNo,
Location of land on which proposed work will be done. „`~~,'~~C/: lPogb - ~o~?'Ff of W~s'r(~ja,/~~
.~aRrlf of ,.`'~8.......... X90.. ~oX'.!;V~C~K.. !Pagel F-lad•frfvc~'..!?~.!(gs.~...........
House Number Street. ~
Hamlet
County Tax ,1fap No. 1000 Section Bluck , , , I~. , Lot ,7
Subdivision Filed Afap No. .
(N:tutc) Lot...............
' State c~isting use and occupancy o(/p~remises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ....".d US S(b f/~~
R.'e....e~.... .
b. Intended use and occupancy S.F~M ~ ..a . ~ • • • • . .
i
.
- ~ a~' $ ~
3. Iv'ature of work (check whit a licable N .
Re air ~~":r
s•
P Rdmopal • cw I3uildin Addition V tp{t~ n •i•` .
' ' ' ' • • • • • • • Demolition Othct 5 or ~ ` •
.a. _
4. Estimated Cost . ~'ZOO•OO %t(IOIriON 7-0 (Dcsi1o4t'p~ron)
I Fee r;'XrSrlwFr'pBCK...~.....~...
5. If dwcllin~ ' (to be paid on filing this application)
If ~ arc, numbcrof ca Swelling units , , , , , , , . Number of dwelling units on each floor.. , , , •
oar ^
6. If business, commercial or mi Iced occupancy, specify nature and extent of caclt type of use . • • • • •
7. Dimensions of existing structures, if any: Front . ' ' ' '
Height . Nrlmbcr of Stories • • • • Rear Depth .
Dimensions of same structure',with altcratio • • ~ ~ • ~ ~ ~ " " • " " " " " •
Depth ns or additions: Front Rear .
. Iicight . , , ,Number of Stories . . • • • • • • • • • •
8. Dimensions~a~~tirc new construction: Front , • ~ • ~ • ~ • • s~
Hei,ht Nu'mbcr of ...~)..F~i~.?".. Rear ..~.1• ~~rCT..... Depth ...r..7 p ~L~'I'.
9. Siae of lot: Front I5fJ.D}}~ Stories , , , , , ; , • ,
10. Date of Purchase . ~Gly ~ 9~8 • Rear 6:~ D pth • • .
1 1. Zone or use district in which plremises are situated , Nam ~O~Former Owner . ~fy~~e sr,46.. ~^?~'S• . , •
12, Does proposed construction ciplatc any zoning law, or~n nee or~ gulation: , ,
13. Nill lot be regraded ,/•~(p• I .
l4. Name of Owner of premises ¢ p • • • • 1Vd1 excess fill be removed from premises: ~suti~ • Nc
Name of ,architect ~ ~ ~V9~ • Address .~O,trgxN~{,K • • • • ,Phone No. X98 ~
Name of Contractor . , • ~ • • • ~ ~ ~ ~ ~ ~ ' ' ' ' • • • Address ...................Phony, No.... ~ •
IS.Is this property lot#rted within •'•Address.. Phone No.....
*If yes, Southold Tow!In TrusCees Pe0rmi[emay bearequiredetland? *YES....270...:••
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate ail setback dimensions from
property lines. Give street and bloc}; number or description according to decd, and show street names and indicate whethc:
interior or corner lot.
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T,~TE OF \EN a• I~',
OUtiTY OF SAS
,
• • • ' ' • • • • • • • • 6cing duly sworn, deposes and says that he is the applicant
• • . • . • • • (lame of indiro~idual si
rove named. p contract)
:istltc
(Contractor, agent, corporate officer, etc.) ~ • • • • " • " " "
said owner or owners, and is duly ]uthorixed to perform or have performed tltc said work and to make and file this
~lication: that all statements contain;cd in this application arc true [o the best of Itis I:nowledgc and belief; and that the
rk will be performed in the manner spa forth in the application filed therewith.
ern to before me this t,
~..........°Z r~. ..day o f . .~'r:4C_.......'... 19 t~/
ar,i Public. C..!l i:.. ~'L.//~ . County
HELEN K OE VOE
NOTARY PUOl1C, State of New ork • • • . , . , , ,
No. 4%0T8%A, Suffolk Coon ' ' ' ' ' ' ' ' '
TormExpiresMerch30,19 (Signature of applicant)
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