HomeMy WebLinkAbout26898-Z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-28107 Date: 12/10/01
THIS CERTIFIES that the building NEW DWELLING
Location of Property: 1620 REEVE RD MATTITUCK
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 100 Block 3 Lot 15.9
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated SEPTEMBER 28, 2000 pursuant to which
Building Permit No. 26898-Z dated NOVEMBER 2, 2000
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 ONE FAMILY DWELLING WITH COVERED PORCH, REAR DECK AND ATTACHED TWO CAR
GARAGE AS APPLIED FOR.
The certificate is issued to KAREN & HELEN & PEGGY STAGIAS
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL R10-00-0216 11/23/01
ELECTRICAL CERTIFICATE NO. N 564275 07/13/01
PLUMBERS CERTIFICATION DATED 07/12/01 LISO PLUMBING & HEATING
t
Au orize Signature
Rev. 1/81
FORM NO. 3
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)
PERMIT NO. 26898 Z Date NOVEMBER 2 , 2000
Permission is hereby granted to:
KAREN,HELEN & PEGGY STAGIAS
30-79 48TH STREET
ASTORIA,NY 11103
for
CONSTRUCTION OF A NEW 3 BEDROOM SINGLE FAMILY DWELLING WITH
ATTACHED TWO CAR GARAGE, COVERED PORCH & WOOD DECK AS APPLIED FOR.
at premises located at 1620 REEVE RD MATTITUCK
County Tax Map No. 473889 Section 100 Block 0003 Lot No. 015 . 009
pursuant to application dated SEPTEMBER 28, 2000 and approved by the
Building Inspector.
Fee $ 816 . 80
Authoriz Signature
COPY
Rev. 2/19/98
Form
TOWN OF rHOLDBUILDING k? 6 2001
TOW HA
765 1$U SLOG. pT.
avrwo,m F S UTHOLD
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 1% 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 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 - Residential $15.00, Commercial $15.00
Date fl1a�1
l .�./ . . . . . . . . . . . . . . . . . . . . . . . . . .
New Construction. . . . . . . . . . . Old
Or Pre-existing Building. . . . . . . . . . . . . .
Location of Property. . . .o�� . . . . . . . .4� G !/E . . v.. . . . . . . ..[!��tJ.���C!/ .�. .ly'.l
House No. Street Hamlet
n GG
Onwer or Owners of Property.
Cy, L,� n( ,/'� y, .MalS. . . . . .. . . . . . . . .
County Tax Map
es�No 1000, Section. . 16:P . . . . . .Block. .: . . . . . . . . . . .Lot. �.5:9. . . . . . . . . . . . . . .
Subdivisioh!5.1F-. : . �S les5. . . . . . . . . . .Filed Map. .G.?A'�. . .Lot. .! . . . . . . . . . . . . .. . . . . .
Permit No:. .Date Of Permit.///a,fo? . . .Applicant. '`''-��� .G�' . S. . . C uR lot .
Health Dept. Approval IF'IF' , , . , , , , ,Underwriters Approval. .7h--J!v. . .. . . . . . . . .
Planning Board Approval. . . . . . . . . . . . . . . . . . . . . . . . .
Request for: Temporary Certificate. . . . . . .. . . . Final Certicate.
,S .
Fee Submitted: C . . . . . . . . . . . . . ..
�"� APPLICANT
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE '
1135021 BUREAU OF ELECTRICITY
F 40 FULTON STREET, NEW YORK, NY 10018
Date JULY 13,2001 Application No. on file N 564275
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the above application number is in the premises of
KAREN STAGIAS, 1620 REEVE ROAD, SEC.1000-100-3-15.9,
in the following location; ® Basement ® 1st Fl. ® 2nd Fl. GAR/.,ITI!_-r 0 1' Section Block Lot
was examined on JUNE 28,2001 and found to be in compliance with the National Electrical Code.
FIXTURE RECEPTACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS INCANDESCEto FLUORESCENT OTHER AMT. K.W. AMT. K.W. AMT. K.W. AMT. K.W. AMT. H.P.
42 57 43 39 1 3 1 10.0 1 1.2 3 F
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL RECTT. TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET DIMMERS
SYSTEMS
AMT. K.W. OIL H.P. GAS N.P. AMT. NO. A.W.G. AMT. AMP. AMT. AMPS. TRANS. AMT. I H.P. NO.OF FEET AMT. WATTS
3 F 2 - I
SERVICE DISCONNECT NO.OF S E R V 1 C E
METER NO.OF CC COND. A.W.G. A.W.G. A.W.G.
AMT. AMP. TYPE EQUIP. 1!2W 1 0 3W 303W 304W
PER 0 OF CC.COND. NO.OF HIAEG OF HIAEG NO.OF NEUTRALS OF NEUTRAL
1 200 CB 1 X 1 4/0 1 2/0
OTHER APPARATUS:
CO DETECTOR-1
WELL PUMP F-1
PADDLE FANS F-2
WHIRLPOOL BATH-1
AIR CONDITIONERS 1 2.5 TON,1 3.TON-2
MOTORSr1-2.5 H.P. ,1-3 H.P. ,2-F H.P.
PANELHOARDSe2-1 CIR. 60
G.F.C.I:-7
TRACK LIGHTING:-2 L
<<< Continued on Page 2 >>>
GENERAL MANAGER
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 OF CERTIFICAT MUST NOT A ERED IN ANY MANNER.
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 2
1135021 BUREAU OF ELECTRICITY
F 40 FULTON STREET, NEW YORK, NY 10038
Date JULY 13,2001 i '. .1;'<� N 564'275
Application No. on file
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the above application number is in the premises of
KAREN STAGIAS, 1620 REEVE ROAD, SEC.1000-100-3-15.9, ";�i`t's TT`3C?,, P Y
in the following location; ® Basement IN 10 Fl. ® 2nd Fl. GAR/'Ar"T111 'CE''.' Section Block Lot
was examined on JUNE 28,2001 and found to be in compliance with the National Electrical Code.,
FIXTURE RECEPIACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS INCANDESCENJ FLUORESCENT OTHER AMT. K.W. AMT. K.W. AMT. K.W. AMT. K.W. AMT. H.P.
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PF. TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET DIMMERS
AMT. K.W. OIL H.P. GAS N.P. AMT. NO. A.W.G. AMT, AMP. AMT. AMPS. TRANS. AMT. H.P. SYSTEMS
NO.OF FEET AMT. WATTS
SERVICE DISCONNECT NO.OF S E R V I C E
METER NO.OF CC COND. A.W.G. A.W.G. A.W.G.
AMT. AMP. TYPE EQUIP. 1/21Y 1/JW 3/3W /LW PER• OF CC.COND. NO.OF NI•lEG OF HIAEG NO.OF NEUTRALS OF NEUTRAL
OTHER APPARATUS:
THREE "C" ELEC.INC. LIC.#3327E L L
21 ZDUNKO LA.
RIVERHEAD, NY, 11901 GENERAL MANAGER
11
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.
RNW
f
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NPTRED IN ANY MANNER. {
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Town Hall,53095 Main Road y = Fax(516)765-1823
P. O. Box 1179 - . Telephone(516)765-1802
Southold, New York 11971
OFFICE OF THE BUILDING INSPECTOR
TOWN OF SOUTHOLD
C E R T I F I C A T I O N
DATE
Q?� 9S*
Building Permit No. //,� �
owner: f 7 W 0-oC� � i`-�` -X 6>tl
(please print)
Plumber: Z2'So �L 8iy6' -• f�q���G'
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.
Plumber S nature)
Sworn to before me this
7Z-
�G� day of cTUG y 'W:�o 0
Notar Public, �5�,/�{ G,� County
OLORES L. USO
Notary Public,State of New York
Suffolk County-No.4841022
Commission Expires Oct.31,.?'o°i
J u 1.`!
L t-> - t4
o w tq o f
To W "Ori tiT ►"l t��! � o�L o-�!�
17l/ L= L p► r4 c iL P L t-�"T' A L a w f.L o hl o v Q.
1Q R o o 04T Y /S;—% /(p? U -
A S IT 1 S S s-t e- +- A_ *4 5 ac L i 1-4, e u i; c
p o S o
w E %-.-- I,L,L. 1-� w►zv8-tom ja v-- �'� L.. .�.N
BUILDING PERMIT REVIEW CHECK LIST
DATE REVIEWED: o° 1-3e /ad
APPLICANT NAME: 4s DATE SUBMITTED:
PROJECT LOCATION �t
STREET: /626 Aee o 16.4-0 CITY: .tTri�ur r SUBDIV. NAME:
ARCHITECT/ENGINEER:
FAST TRACK: E R NO
SCTM# --- DISTRICT: 1,000 SECTION: /00 BLOCK: 2 LOT: /.5.?
ZONING:
ZONING DISTRIC : R4 R80 AC CONFORMING YES R NO REQUIRED LOT SIZE: 404 SQFT.
WHERE ACTUAL LOT SIZE FROM? 1 ftn rY C— 1.36gAr5 - ACTUAL LOT SIZE:SSS90 SQFT.
REQ '-�a �' REQ. REQ.
FRONT:'PROPOSE : 46' ,' SIDE YD: 1 T'l 3S' PROPOSED: 46 V 9-3 ' REAR:tjyo
' ROPOSED&L'
LOT COVERAGE: ALL : ,20 % EXISTING: sf-- % NEW:2a� TOTAL: sf %
CORNER? YES o O WAT ER FRONT'? YES o NQ_y DESCRIPTION:
SINGLE & SEPARATE CERTIFICATION-REQUIRED: YES ORO NOTES: (nom J.362- Arec
LOTS 40,000SF --100-24. Lot recognition. (CREATED before June 30, 1983), UNDERSIZED LOTS FROM
JAN.1997 100-25. Merger. (A nonconforming at any time after July 1, 1983.)
sel '°mo'y`
PROJECT DESCRIPTION: ADD ALT ACC o N/D:' 2Ca� �nr n�� �ny�r�� 2rc�►,
AGENCY PERMITS REQUIRED FOR REVIEW
GE�DED
TOWN SPETIC PERMIT: NO � 2 /a0
SUFFOLK COUNTY HEALTH DEPT: r NO, (BED #): DTE: 712.9100 PERMIT#:R10-C30-C32-16
NEW YORK STATE DEC: PRE-DEC 9/1/75 YES
SOUTHOLD TOWN TRUSTEES: YES IPL
TOWN ZONING BOARD APPROVAL: YES
TOWN PLAN. BOARD APPROVAL: YES
FLOOD COMPLIANCE ZONE: PRE-FIRM 3/Is/8 #: 3 ,
NYS ENERGY. YES R NOT: LIGHT: `tj
NOTES: )S000 -T�,..,r,�
r-d Crn iq l u F cr i s a. .sf-^
�7
�� 5� a o1/ /0 ' Pr
FEE STRUCTURE: FOUNDATION: /_ SF
FIRST FLOOR 26 9 6 SF
SECOND FLR / 32a SF INIT OTHER TOTAL
TOTAL: 4259 SF FEE FEE FEE
TOTSF)- ( 0 SF)= 320 SF X $--?t) =$ 1141-8-0+$ +$�__$ /4•
Town Of Southold
P.O Box 1179
Southold, NY 11971
* * * RECEIPT * * *
Date: 09/28/00 Receipt#: 0
Transaction(s): Subtotal
1 Septic Permit- Construct- Resid. $10.00
Total Paid: $10.00
Name: Stagias, Karen
39-79 48th Street, Astoria NY
Clerk ID: LIZS Internal ID:18437
STATE OF NEW YORK )
ss:
COUNTY OF SUFFOLK ) l
being duly sworn, deposes and says:
That deponent is over the age of 18 years and resides at
21 Alel Ao,ti ►CGApOr/
That on the 2n day of S'1le4l ` , 2000 deponent ar ,t/engineer,
licensed by the State of New York, hereby states that, /he accepts full
responsibility for the accompanying plans compliance with the New York State
Fire Prevention and Building Code (9 NYCRR); said plans pertain to property
located at SCTM# 1000- !0 b ' 3 �3• S
,
street address 1�«vcveh�c �'fo,�j�f y
6101.
Architect/Engineer
Sworn to before me this
20 day of_&- VwwX000.
EILEEN$.SANTORA
NOTARY PUBLIC,State of New xpd
No. 30-4916018
Qualified in Nesseu uet
Commission Expires_ / Cs�sC
Notary Public
cc: Applicant
M-1802
BUILDING DEPT.
NSPECTION
[ FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS: ZAP�f-
L-10
,DATE ( INSPECTOR
M-iso2
suiLDiNc oar.
INSPECTION
[ ] FgkINDATION IST [ J ROUGH PLBG.
[ vj' FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS: � �----
,DATE f /o r0 INSPECTOR
14 /
l
yrs-iso2
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION IST [ ROUGH PLBG.
[ ]
FOUNDATION2ND [ ] INSULATION
[
L4 FRAMING [ ] FINAL
[ ] FIREPLE 8 CHIMNEY
C �-
REMARKS:
SLIP,
d., -) A'
c _
DATE O INSPECTOR
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION iST [�GN PLBG.
[ ] FQUNDATION 2ND [ ] INSULATION
[ / MING [ ] FINAL
[ FIREPLACE & CHIMNEY �
REMARKS:
G
RLL j
0141
T
R
,DATE � INSPECTO ' , D
suiLDiNa DE".
INSPECTION
[ j FOUNDATION 1ST [ j RO H PLBG.
[ ] FOUNDATION 2ND [ INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS: �S� 6AI-7-7 t.7J
,DATE � 2^' � � INSPECTOR
7W-ieo2
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION IST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INS ION
[ ] FRAMING FINAL
[ ] FIREPLLj�F & CHIMNEY
RE MA KS:
AA
V��Jj-,4
,DATE INSPECTOR
765.1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION IST OUGH PLBG.
[ ] FOUNDATION 2ND [ INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLACE 8 CHIMNEY
REMARKS:
DATE INSPECTOR
V
FIELD INSPECTION REPORT DATE _ ' COMMNTS
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FOUNDATION (2ND)
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ROUGH FRAMEp-vtl4alt 913
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INSULATION PER N. Y. II C�i
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ADDITIONAL COMMENTS:
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BOARD'OF 111ALTH
FORM NO. 1 3 SETS OF PLANS . . . . . . . . . . . . . . .
2 8 TOWN OF SOJ5T9OL1P SURVEY . . . . . .
BUILDING DEPARTMENT CHECK .. . . . . . . . . . . . . . . .. . . . . . . .
TOWN HALL SEPTIC FORM . . . . . . . . . . . .. . . . . . .
cUi"JGJV�'��i
TOWN °�SI 4SOUTHOLD, N.Y. 11971
L.� t
~" TEL: 765-1802 NOTIFY:
CALL .�: : . . . . . .
Examined.../D . <t ......'x+04 MAIL TO: . . . . . . . . . . . . . . . . . . . .
/p yy
Approved..��. 31........ C1 Q Permit iib 174. .7.:.... ...................................
Disapproved a/c .................................. ...................................
............................................... .. ...
zex
• - •
(Building inspector)
APPLICATION FOR BUILDING PERMIT
Date:`E-07� . .. .2 c • , 2p .o Q
INSTRUCTIONS
a. this application oust be completely filled in by typewriter or in ink and submitted to the Building Inspector wi
3 sets of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan showing location of lot and of buildings an premises, relationship to adjoining premises or public
streets or areas, and giving a detailed description of layout of property must be drawn an the diagram which is part of
this application.
c. The work covered by this application may not be eannenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issue 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 MAIL 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.
)150 GoN51.. G%vA P .
.....................................................
(Signature of applicant, or name, if a corporation)
. a p� , two 3 .�:3�... 1.1h ... .. �.
...................... .. . ......../...
(Mailing address of applicant) !Iy'}7�
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Lfj L C o µt R- ^ `t� Q
............. ........... .....:................................................
Name of owner of premises ..............................................................................................
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer-
.........................................................
(Name and title of corporate officer)
Builders License No. .......�.... ......
Plumbers License No. .7.4.3... ............
Electricians License No. A.'F7. Z........
Other Trade's License No. .. 7 .............. /
Rb-
1. Location of land on which proposed work will be done. .. ....
.....1.��:Q
................ �.�:..�.......................:.T�i.. ��.......!:..:�'..............
House Number Street Hamlet
County Tax Map No. 1000 Section /O O .... Lot
................ Block ..•�....... l.g
Subdivision .. ..... .h � p 4-' 5 l°t ....... Filed Map No. �.7R A...... Lot ..1............
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ..............................................................................
b. Intended use and occupancy ..� u'1 L I=.-- 'L � ••. � t..�..t N
...........................................................................
p1HTA's2 A H"--AMP
..,_OS.B ys►:.,L
w
3. Nature of work (check which applicable): New Building .. Addition .......... Alteration
Repair ............ Removal ............. Demolition ............ Other Work ..................................
., '••(Description)
4. Estimated Cost
....�...y,o..� o......... fee ......................... ...............
(to be paid on filing this application)
5. If dwelling, number of dwelling units ....9...... tkrber of dwelling units on each floor .4/.............
Ifgarage, number of cars ....................
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use......................
7. Dimensions of existing structures, if any: Front...:—......... Rear .'.::.......... Depth =.............
Height ......................... Number of Stories ................
Dimensions of same structure with alterations or additions: Front ............... Rear ...............
Depth ......... ......... Height ..................GG.. Number of Stories .:7 .........
8. Dimensions of entire new construction: Front ...: .f......... Rear ..• .g.f....... Depth .:.......
�.}]eight ..... ..../............. Number of Stories .... ..............
9. Size of lot: Front ...l Jam.d.......... Rear ...�.r�.l�............ Depth .3 1.R.f....... ..
10. Date of Purchase ...Z 9.9:�......... Name of Former Owner :777....................................
II. Zone or use district in which premises are situated ..............................................................
12. Does proposed construction�viiolate any zoning law, ordinance or regulation: ..i d.................
13. Will lot be regraded ......�1,.AA . ........ Will excess fill be removed from premises: YES
14. Names of Owner of premises#.A—W k.:S/.910�!i S a,oA� Address 3�`7�.� f r./�Sl�!Q/�. Phone No.�F 714_914
Name of Asdnitect �-:+"'a o-e . b-. .LL ....... Address (o a 0-r '�-'.K�°`�Q: .......... Phone No.
Name of Contractor ��ss D. e""!;s:t:...L A a�:`.�.... Address X0.43. No.
15. Is this property within 300 feet of a tidal wetland? * YES .......... NO
*IF YES, SQTIlIa1D MM MMMS PERMIT MAY BLS IMJIRED.
PLOT DIAGRAM
Locate clearly 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.
SfA1E OF N3J YC7[ZK,
SS
0"ly or .......................
... .... ..n..................................being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named,
lie is the ..........G'O/tiI P-44 -7L t! /-................................................................
(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 contained 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.
Sworn to before me this
Z o o p
..... ......day of .?Wl...........T9 ....
Notary Pub .. .. 07
r
MAIM ........
ARY PUBLIC,St8W 0f N9W Yb4 (Signature.
Si gnature.of•Appl.i cant)
N0.01STSWein Suffolk C,ounq
Tam ExPkesS.20W.
BOARD'OF HEALTH . . . . . . . . . . . . . . .
FORM NO. 1 3 SETS OF PLANS . . . . . . . . . . . . . . .
2 8TOWN OF SOUTHOLD SURVEY . . . . . . . . . . . . . . .. . . . . . . . .
f t BUILDING DEPARTMENT CHECK . . . . . . . . . . . . . . . . . . . . . . . . .
i---�--- — ~ — 3 TOWN HALL SEPTIC FORM
SOUTHOLD, N.Y. 11971
TEL: 765-1802 NOTIFY:
CALL ./. � - . . . .
Ermined.. C- ......LOCI // MAIL TO: . . . . . . . . . . . . . . . . . . . .
Approved.. °. 3 L.......,� G1 OPermit Nn.(W.9 i.2a-r ... ...................................
Disapproved a/c .................................. ...................................
............................................... .. ...
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
a. 'Deis application mast be eampletely filled in by typewriter or in ink and submitted to the Building Inspector wi
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 application.
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 issue 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 whale 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
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein
described. The applicant agrees to eamply with all applicable laws, ordinances, building code, housing code, and
regulations, and to admit authorized inspectors on premises and in building for necessary inspections.
hl So GoNST, . GaAP ,
.....................................................
(Signature of applicant, or name, if a corporation)
.
. ..k t.k P��- inn 3 .'�3�..s r�rn ns P•a t.
........... ..
(Mailing address of applicant) Al~f
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
6o�r;z-n-a L c o t, t R- c `a A- .
.......�......................................................
Namof owner of premises .............................................................................................
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
.........................................................
(Nam and title of corporate officer)
Builders License No. .9.3 E 4 is......
Plumbers License No. 1!. ...P............
Electricians License No. e........
Other Trade's License No. .."...... _ C
��J vLN.. F�� 3�S /7/Q S L/4N 1
I. Iocation of land on which proposed work will be done........'..
..............................................................................
Hoarse Number Street Hamlet
County Tax Map No. 1000 Section ....... Black ........... Lot
SubdivisionS
............la -r,.....l ti l ...... Filed Map No. (e.7ef�d lot ..[............
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ..............................................................................
b. Intended use and occupancy O r`-N L nN k L� D ...tee c.L i N
.............................................................................
81HTAT2 A H",1AStIq
*Veyw em It,n`,;tc,7t.dr' t <YPATOM
e
BNERGY CODE CALCULATIONS
(For Noir-Electric IIeat) Design Criteria G , 000 Degree' Days
' l r O.A. 100E I .A. 7U°F
FOR: V Q P), tj / 4s PE It: i�S �CH d U - - 2
DA'Z'ED: �ev �._ 8- pV
DESIGN TI113RMEL
SUBSYSTEM AREA If U" ILT'TlNG REMARKS
Lxtcra.ol: Walla (Opaque)
2-201 0 ,5' Z
:.�1 a Z 111 y Qi ') P'"s a�, /�'-1 J".►t Il _
3S� . 32 - 70 CPU 47
Doors �u ^ Z3
Ceil.iny/hoof (Opaque)
Skylights _ %
Floor
P oundation Walls
Slab Insulation
TOTAL
[lutes:
Building Envelope Systems to ineet• requirements of 7015. 2
IIVAC Equipement to meet requirements of 7U15. 11
11VAC Systems to meet requirements of 7015. r2
Ducat Systems to meet: requirements of 701.5 . 1.3
Ventilations Systems to meet requirements of '1015 . 19
Insulation of Pipiny Systems to meet requirements of 7U15 . 15
Service Water Heating Systems & Equipment' to meet- requirements of '1U15 . 21
l,lect•.rical & Lighting Systems & Equipment- to meet• requirements of 7U1.5 . 31
f NEW
To the best or my knowledge, E t J
belief, & prolessional
Judgement, these plans are iii
compliance with the code . , w
a
F� 032254-1
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Y
3. Nature of work (check which applicable): New Building .Y<.. Addition .......... Alteration ..........
Repair ............ Removal ............. Demolition ............ Other Work ..................................
(Description)
4. Estimated Cost ....1!.y c.�..0....
...... fee ..............................................
(to be paid on filing this application)
5. If dwelling, number of dwelling units ....9...... Number of dwelling units on each floor 7.'.............
If garage, number of cars ..ca�..�r.A.Q.-...
.................
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use......................
7. Dimensions of existing structures, if any: Front...:—......... Rear .......... Depth .-..............
Height ......................... Number of Stories ....................
Dimensions of same structure with alterations or additions: Front ............... Rear ...............
Depth ...... ........ Height ........ ....... Number of Stories ..—.
8. Dimensions of entire new construction; Front .. .f. ....... Rear ...j.g.f....... Depth ...........
Height .....1;-;?. ............. Number of Stories .....................
9. Size of lot: Front ...lS d.......... Rear .. l�1�........... Depth .3 f.fY...........
10. Date of Purchase ...Ztel.99......... Name of Tomer Owner :77:....................................
11. Zone or use district in which premises are situated ..............................................................
12. Does proposed construction violate any zoning law, ordinance or regulation: ..Aa.................
��
13. Will lot be regraded ...... g-S........ Will excess fill be removed from premises: YES
iL B� S /H s o oas 34t--701 cLf.... T aQi �..
14. Names of Owner of premises�/C........�9............ Address .................�1....y.. Phahe No. .:....
Name of Archi tect L Fh-,0.wytr1►l..l. ....... Address a j=-,a 4 Phone No.
....
Am
1-t►'i�K�1� �.1v
Name of Contractor Lt� . `u u L, A AIt-t.... AddressS`/9HaF��!!.Phone No.
15. is this property within 300 feet of a tidal wetland? * YES .......... NO Y........
*IF YES, S(XAIM IUA M)S EES PERMIT MAY BE MARRED.
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions
from property lines. Give street and block amber or description according to deed, and show street names and indicate
whether interior or corner lot.
SfA1E OF NS) YORK,
SS
OOIICIT OC .......................
`I
a-
.......................n...................................being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named,
lie is the G O /ti1 pa ` L d
.. ..................../.�.-
................................................................
(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 Lhis
application; that all statements contained in this application are true to the best of his knowledge and belief; and
Lhat the work will be performed in the manner set forth in the application filed therewith.
Sworn to before me this
-1<-/ 2 0 0 0
...... p........day of.5 i9' ......
Notary Pub FV�I - . .:(�`�N�2u�:t/!...
"
ARYPUSUC,StatsofNewYeM (Signature of Applicant)
NO.019T8008173,SUffdk Cwj*
Tenn ExpiresAM8.ZO2il
Tli/e No. GNA 3063 S
NOW OR FORMERLY GRACE GRANDY 4 HENRY DRUM (MAP
' VA c.aAJT
S. 160 32' 40" E. No
0 2� 6c'•6s'9 Ec•6s J
it is the plica�rt's responsibttlty to
0 malntai n equate s itarr distance
9
between waupplY and sewage
VACANT - WooDEO
EL.GSS UNABLE 7
AREA = 59.592t' S.F. °v GOCRTE CP WEA
B�,S ENTS AND/OR SUBSURFACE STRUCTU'Nt_: tt"\
�pF NE�I
.^,6G0 O UNRECORDED ARE NOT GUARANTEE ��``yQ411L M YD
UNLESS PNYSIG �nf�ru- -uc +prpnlA�c -``_ W
+..noir nr ea m•.-
'-1
A^.e .P A Art
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Iftsa .MFi ,'v as�riti8 ^+ne ARRC nrw -�R .ems. r.. d
EL.GG•S D -.�x.- . t FO.STK. d x
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0 0 0 zso \Pc X8.3 p o M
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N N O PROP Ep O I ti� / use Iia t 7 / 5�yi�
N G7j OF 70,�'� '• �p o
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Fo.
20'WIDE DRAINAGE EASEMENT ��j h
Mont. �-67.Z r 3AD
25.00' 14
=� 150.00' N. l50 22' 40" W.
//Ar2 Bot viEW
r AvE E° Co7•SO 7.
if EP 67.3
(a85b Iv' �COf!•So ( REEVE X40 ROAD Yrrig 1- 67-303
CA cP 5750' W/ E
SO S• WELL-
ORVEY OF LOT # 9 MAP OF SEA -A/RE ESTATES
FILED : FEB. 5, 1979 - FILE # 6780
SITUATED AT MATTITUCK, TOWN OF SOUTHOLD, SUFFOLK COUNTY, N. Y.
GUARANTEED TO : GNA ABSTRACT CORP.
iIIF�o�t Coultrr COMPANY
A ST /A PEGGY STAG/A.5
SIMCL9 FANAX ftslD9W=M.Y S RVEYED JAS/" G, 2600
.r•" P v r PeAni Au&. 30/ Z[2007
oft q-zg-odl Ks.Rtf.No. ID --D
A/wrts S �A)E /" 50'
salt MAxINUM OR �„�,,, HARRY P. H/L L EBRA ND=
�ESt"MIll YEARS FROM DATE OF AMROY LAND SURVEYOR
wmmwTOLK COUNT TAX AP 11 CHURCHILL LANE - SMITHTOWN, N.Y.
DISTRICT SECTION BLOCK LOT TEL. 543-5139
1000100 3 /5.9
Fl/e 99292
Title No. GNA 3063.5
5 20M NOW iOR FORMERLY GRA CEGRAND Y 4 HENRY DRUM
4 16. 32' 40" E. 166.20' 4�OiA AVl1 E
oN COQ,UEQ
N of NEHr�,o
AREA = 59592 ' S.F. d
r\
49004
e
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N h
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Fo.
20'WIDE DRAINAGE EASEMENT
:MOW.
�� 325.00'2-9 46:f �
150.00' N. 150 22' 40" W. Mme.
E D/07.50 EP 67.50 NYT.L3 E_R e,7.33
t- 6,7 S0 ( REEVE ROA D ) 4 67.30
REEVE ( 50-WIDE ) AVENUE
SURVEY OF LOT # 9 MAP OF SEA -A/RE ESTATES
FILED : FEB. 5, 1979 - FILE # 6760
SITUATED AT MATT/TUCK, TOWN OF SOUTHOLD, SUFFOLK COUNTY, N. Y,
GUARANTEED TO : GNA ABSTRACT CORP.
STEWART TITLE INSURANCE COMPANY
KAREN STAG/AS)HELEN STAGIA5,PEGGY STAG/A5
;;.ENl z ANWOF SUBSURFACE STRUCTURES,
aoRD®OR INIREOORo®ARE NOT CIIApNUM SURVEYED JAN- 6, 2COO
'ESSPN AILY FftMT ON THE Fi1ENS00 AT U.LJ r
na e
OP Y:.Nii ISS TO TW BRDMIN NNRlDN FRok
. PROPERTI'LEIS 70 TME 0 POs
aw vo SCALE /" = 50'
1lIES OR To OINDE THE aIlON OR
ODITIONAL f1TNF' =HARRY P. HILLEBRAND=
LAND SURVEYOR
SUFFOLK COUNTY TAX MAP 11 CHURCHILL LANE - SMITHTOWN, N.Y.
DISTRICT SECTION BLOCK LOT TEL. 543-5139
1000 /00 3 /5.9
NASSAU SUFFOLK BLUEPRIN ING
F!/e 99292
Title No. GNA 3063.6
NOW OR FORMERLY GRACE GRAND 4 HENRY DRUM (MAP
S. 16. 32' 40" E. 166.20'
ov Co E2
FD. �
02N/
O p
s
�ZS. w�apo
n AREA = 59.592 ' S.f. '� �W ~�
wwuwia--F¢¢-a
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�.� - - — - - — - - - — Z- -
FD.
20'WIDE RA/NAGE EASEMENT
STvNeiyo,l. c�cc. r.eTe¢ 325.00'
150.00' N. 150 22' 40' W.
V
EP fo7.50 EP(o7-SONYT 3 6PG.7.3j
h 4 6,7So ( REEVE e ROA DQ�-G7.30
REEVE ( 50-WIDE) AVENUE
SURVEY OF LOT # 9 MAP OF SEA -AIRE ESTATES
FILED : FEB. 5, 1979 - FILE # 6780
SITUATED AT MATTITUCK, TOWN OF SOUTHOLD, SUFFOLK COUNTY, CY -Ell,GUARANTEED TO : GNA ABSTRACT CORY? - kSTEwwr �Y'1 e"/ A*E COMPANY
KA= S TAWAjhdEL EN S NG/A 5,PEG GY 5TAGIA5
SURVEYED : JAN- G 2 ? r
C;c>C, 2-1 U o
.' J �`�v .. UivUE,QCON$ : DEC./3 Z
F/N,aL JULY S, 20
PEV SAN.At-r, a/2zo,�P A
SCALE " /" = 50'
=HARRY P. HILLEBRAND=
LAND SURVEYOR
SUFFOLK COUNTY TAX MAP 11 CHURCHILL LANE - SMITHTOWN, N.Y.
DISTRICT SECTION BLOCK LOT TEL. 543-5139
1000 /00 3 15.9
N
NASSAU SUFF01K BLUE PRINI ING Flle 99292
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= I 'uyllw[u.. N - •.'., yWgYrq,Kli:�r' -^�'�
APPROVED AS NOTED
DATE: � -
FEE: BY: � :h��� ISLAWFUL
r
NOTIFY BUILDING DEPARTMENT AT
765-1802 9 AM TO PM FOR THE E"TI 1-I CAT
4
IT
,
F � U� 1
FOLLOWING INSPECTIONS:
1. FOUNDATION - TWO REQUIRED
FOR POURED CONCRETE
2. ROUGH - FRAMIP�3 & PLUMBING
3. INSULATION
PROVIDE ANTI-SCALD AND/OR I r{
4. FINAL - CONSYRUCTION MUST ,
BE COMPLETE FOR C.O.
ONSTRUCTION SHALL MEET THERMAL SHOCK PREVENTING
ALL C
THE REQUIREMENTS OF THE N.Y. DEVICES AS TO PART. 902.6(K) -
STATE CONSTRUCTION & ENERGY N.Y. STATE BUILDING CODE. ' -
CODES. NOT RESPONSIBLE FOR r`
f
DESIGN OR CONSTRUCTION ERRORS `
IL
DO NOT PROCEED WITH
-.
. PROVIDE OPENINGS FOR FRAMING UNTIL SURVEY
EMERGENCY ESCAPE AS OF FOUNDATION LOCATION
REQUIRED BY PART. 714 OF HAS BEEN APPROVED. x
N.Y. STATE BUILDING CODE. P��oF
' S'� ��CE
PERMlT REQUIRED FOR PLUINkel, iNG",' T w y
ALARM SYSTEMS UNDER ALL PLUMB ATE
ALARM LACY &WATER LIEz EEi�
PROVIDE SMOKE-DETECTINGTESTING FE'°ORE COVERING
ALARM DEVICES I� 03 �•'
AS TO PART. 721.1 If copper tub' 0 Is used .� fi ! o-ESSIGA
N.Y.S BUILDING CODE. for water distributing
system; piping shall be PLUMBER CERT/�Y.CATI6!"J
E
Of types ON LEAD CONTE1ii ;BEFDRE ,
UNDERWRITERS CERTIFICATE UNDERWRITERS CERTIFICATE CERTIFICATE OF OCCUPANCYa
REQUIRED REQUIRED SOLDER USED IN, WATER
SUPPLY SYSTEM�ANNoT
EXCEED 2/10 OF 1%LE�4D. -.,._..-.__
PROVIDE % HR. FIRE
RATED SEPARATION.TO
..
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N.Y. STATE BUILDING CODE.
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