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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-22788 Date DECEMBER 15, 1993
THIS CERTIFIES that the building NEW DWELLING
Location of Property 965 JASMINE LANE SOUTHOLD, NEW YORK
House No. Street Hamlet
County Tax Map No. 1000 Section 69 Block 3 Lot 24.2
Subdivision SOUTHOLD VILLAS SEC. #2 Map No. Lot No. 2
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 2, 1993 pursuant to which
Building Permit No. 21602-Z dated AUGUST 24, 1993
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 (1ST & 2ND FLOORS) WITH ATTACHED GARAGE
The certificate is issued to PECONIC PROPERTIES MANAGEMENT CORP.
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 93-SO-20-DEC. 2, 1993
UNDERWRITERS CERTIFICATE NO. PENDING - DECEMBER 14, 1993
PLUMBERS CERTIFICATION DATED NOV. 21, 1993-ARTHUR MALADSSENA JR.
Building Inspector
Rev. 1/81
FORM NO.3
TOWN OF SOUTHOW
BUILDING DEPARTMENT
TOWN HALL
SOUTHOID, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
Date 3/7"4 . 19~~....
N°_ 21602 Z
Permission is hereby gr nted to:
old-.........../.....
........I. //S3S
to ...~1!CG......... 41........
.
.
at premises located at...9.r/..vttJ....F~t~rG.....h...Ql
County Tax Map No. 1000 Section ............rrJ..9... Block ........3............ Lot No...V...5`r
pursuant to application dated P-4 19.9 and approved by the
Bullding Inspector. Fee $.,:P./.5!
Building Inspector
Rev. 6/30/80
Form No. 6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
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, Coercial $15.00
ymn
Date ./4q . .
New Construction... xk/ Old 0 Pre-existing B lding.....
Location of Property...~~ Gj.2
House o Street Hamlet y
Onwer or Owners of Property.
County Tax Map No 100 /Section .``.1~.n ......Block...... ..........Lot. ,
Subdivision! r / _-g7. .Fi ed Map ?7..?. ot...
Permit No.G /6A..~.Date Of Permit. ?..Applicantam -1h
~ ~ ~ ~ 17UQ~~
Health Dept. Approval...`\.,,..,,,,,,,,,,,,,,Underwriters Approval... .
Planning Board Approval .
Request for: Temporary Certificate........... Final Certicate.,,.V
Fee Submitted: $ w/ C 0
t~
( e,e `113Q1 APPLICANT
ANT _ ......,,aii:
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1009937 BUREAU OF ELECTRICITY
F BS JOHN STREET. NEW YORK, NEW YORK 10038
Date DECEMBER 21,1993 Application No. on file 92639793/93 N 299723
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the abode application number in the premises of
SOUTHOLD VILLAS, 969 JASMINE LANE, JOB-2, SOUTHOLD, N.Y.
in thefollowinq location, ® Basement ® Ist FL ® 2nd Fl. GAR/ATTIC/OUT Section II Block Lot
Sees examined on DECEMBER 14 , 1. 9 9 3 and found to be in compliance with the National Electrical Code.
FIXTURE FIXTURES RANGES COOKING DICKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS SCEPTACLES SWITCHES INCANDESCENT FLUORESCENT OTHER AMT. K. W. AMT. X. W. T. K.W. AMT. K.W. AMT. H.P.
27 30 29 6 ] 2 F
DRYERS FURNACE MOTORS FUTURE APPUAHC! FINGERS SPECIAL RWPT TIME CLOCKS pu UNIT WATERS MULT14UM DIMMERS
AMT. K. W. OIL H. P. GAS H. P. AMT. NO. A. W. G. AMT. NAP. AMT. Mrs. TRANS. AMT. H. P. NOT F S AMT. WATTS
NO.OF Rot
1 F - 4
SERVICE DISCONNECT NO.OF S E R V I C E
AMT. AMP. TYPE MITER 11 T4 1 X SW S X tW 3 X IW NO.OF CG COND. A. W.O. NO. OF HFU:G A. W' G' NO. OF NEUTRALS A. W. G.
EQUIP. NR X Of CC. COND. OF NI-EEG OF NEUTRAL
1 200 CB 1 X I 2iC~ 1 210
OTHER APPARATUS:
MOTORSI3-F H.P.
G.F.C.I:-9
SMOKE DETECTORI-2
SPUDS ELECTRIC SERVICE LIC.4142-E
175 3RD.ST. BOX 166
GOMM MANAWR
T. JAMES, NY, 11790 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.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
INSPECTORS
O Y fed,. Gy SCOTT L. HARRIS, Supervisor
i
Thomas Fisher to " r• Southold Town Hall
Building Inspector O . r?~ s4 P.O. Box 1179, 53095 Main Road
Gary Fish Southold, New York 11971
Building Inspector Fax (516) 765-1823
Telephone (516) 765-1800
Robert Fisher
Assistant Fire Inspector OFFICE OF BUILDING INSPECTOR
Telephone (516) 765-1802 TOWN OF SOUTHOLD
C E R T I F I C A T I O N
DATE:
Building Permit No. 6 b 2-
Owner: RZ CO/C Rri6p MANA6EAfeNT Conk''
(please p int
Plumber: 421~W ~/AZ ss cC
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 1Z lead. /
Plumbers Signature)
Sworn to before me this
day of ( 19 9 .
Notary Public, S~(rlS L County
"\rLk' 10 4%CD, 0- ~AA 't
Not ry Public
MARYANNE E. DOWLING
Notary Public.S t~030New York
Qualified in Suffolk County
Commission Expires August 3,199A
1. o
00 04 y C3
FOUNDATION _ (1st) N
1
FOUNDATIO14 (2nd) 2. ti
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ROUGH FRAME 8
PLUMBING
y
3. 3 pl
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m _
INSULATION PER N. Y.
STATE ENERGY a
CODE
x
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4. la S 1 T
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FINAL ppb
3
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ADDITIONAL COMMENTS:
;2 45
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BOARD OF HEALTH
FORM NO.1 3 SETS OF PLANS
TOWN OFSOUTHOLD SURVEY
BUILDING DEPARTMENT CHECK _ _ _ .
TOWN HALL SEPTIC F0 RN
SOUTHOLD, N.Y. 11971
TEL.: 765-1802 t:O~ I FY
Examin 7' lY :3. CALL . .
ed MAIL TO:
Approved ...°~.L.T 19 ¢ Permit No.1.4%~ P _ .
Disapprovcda/c
(Buil7I spe or)
APPLICATION FOR BUILDING PERMIT
Date
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with
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 st'ree:
or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appl
cation.
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 issued a Building Permit to the applicant. Such perm:
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 Occupanc
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for theAssuaAce of a Building Permit pursuant to th
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and.-other applicable Laws, Ordinances o
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, ordina s, building code, housing code, and regulations, and tc
admit authorized inspectors on premises and in building for ne ss inspect' ns.
(Signature of applicant, or name, if a corporation)
(Mailing addre Vof applicant
State whether applicant is owner, lessee, agen , architect, engineer, general contractor, electrician, plumber o builder.
Name of owner of prem' fl~LGP • •
Islas (as on the tax roll o tes-id;: If applicant is a 4aai , s' nature of duly~a thorized officer.
....GY4 T!? t . xµ
}ri q "v
(Namof corporate office r)
Builder....../ .
Plumber's License No. . A.o~/; ' P - - • • • •
Electrician's License No. • • • • • • • • • • • •
Other Trade's License No. . .
1. Location of land on which proposed work will be don.~~4~~ !`F '
House Number .......................Street .......................Hamlet
County Tax Map No. 1000 Scctio . ~ Block co Lot
Subdivision ..\`L~r~ ~!t? .{'.C~iC.*{ Filed Map No. 14. ~ ~L.-?. Lot .
(Narne)
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 r.... .
•3. Nature of work (check which applicable): New Building Addition Alteration
Repair Removal Demolition Other Work .
4. Estimated Cost (Description)
Fee
5. If dwelling, number of dwelling (to be paid on filing this application)
b
If garage, number of cars units Number of dwelling units on each floor .
.
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. Height Number of Stories . Depth .
Dimensions of same structure with alterations or additions: Front • • . . . ' ' ' . ' ' '
Rear
Depth . Height. Numb
8. Dimensions of entire new construction: Front . Number of Stories J,
cig}tt Number of Stories . .
Rear
H Depth
y. Size of lot:l•ront . . . . Rear .
10. Date of Purchase Depth .
IL Zone or use district in which premises are situated , • 'Name Former Owner , ,
12. Does proposed construction violate any zoning law, ordinance or regulation: . . . . . .
13. Will lot be regraded . Will excess fill be removed from premises: Yes Nc
14. Name of Owner of premises . Address
Name of Architect _ ~•••••••••••Phone No
Name of Contractor . ' ' ' ' ' . ' ' ' • • • Address Phone No......... . dress 15. Is this property within 300 feet of a tid lawetland? * " Ph e No............
*If yes, Southold Town Trustees Permit may.be required,... No.
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 de iption =rding to deed, and show street names and indicate whether
interior or corner Iot. c .
y7
APPROVED AS NOTED
UNDERWRITERS CERi1FICA7E DATE: _ a r~ 7L7L _ B.P. i9 a 1600.
REQUIRED S, rr
FEE: BY:
_ NOTIFY BUILDING DEPART
'r6b- 1802 9 AM TO 4 PM FOR THE
6~E)LLC'^li~C P2,,SPECiIONS:
t. =£iiE+i7~T1t31E - rV(,) REQUIRED
R pot
!RED 1:70NCRETE
F F6 ,
r ~~~e y gr'U& PLUMBING
F:' s Im I~ c Pcaw~3 E
10
G PA NSTRJCTION rOUST
BF 1();.1: ~ ZTE FOR C.O.
ALL CONSTRUCTION SHALL MEET
?'HF "ic 'UIt•EMenNTS OF THE N.Y.
:,\T[ CMJ1STRL1C'1 ON & ENERGY
PLUn48ERCERTIFICATION NOT RESPONSIBLE FOR
ON BEAD CONTENT BEFORE n:- stn (~R CONSTRUCTION ERRORS.
CERTIFICATE
SOLDER USED OCCUPANCY
D IN WATER
SYSTEM CANNOT
10 O 1% LAD.
SUPPLY EXCEED 2/
STATE OF NEW YORK,
COUNTY OF S'S
' ' ' ' ' ' ' . ' ' • ' ' ' ' • • • • • • • • • • • • • being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named.
fie is the .
(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
....day of ....l.L........, 19 3
Jota Q~.~
ry Public, = ~w• County
JOYCE M. WILKINS
\ .~4~ tGaC/"
N
Notary Public, Statri of New York
No. otary 4952246, 522X, Suffolk Cour~y ' ' ' . ' ' ' .
Term EViresJurie 12,1 (Signature of applicant)
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