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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-22789 Date DECEMBER 15, 1993
THIS CERTIFIES that the building NEW DWELLING
Location of Property 1065 JASMINE LANE SOUTHOLD, NEW YORK
House No. Street Hamlet
County Tax Map No. 1000 Section 69 Block 3 Lot 24.3
Subdivision SOUTHOLD VILLAS SEC. #2 Map No. Lot No. 3
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 2, 1993 pursuant to which
Building Permit No. 21603-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 FLOOR ONLY) AS APPLIED FOR
The certificate is issued to PECONIC PROPERTIES MANAGEMENT CORP.
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 93-SO-2I-DEC. 2, 1993
UNDERWRITERS CERTIFICATE NO. N-298187-DEC. 7, 1993
PLUMBERS CERTIFICATION DATED NOV. 21, 1993-ARTHUR MALAUSSENA JR.
Bu' ding Inspector
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)
N° 21603 Z Date..... IF/ .5.......................................... 19.~~..
Permission Is hereby granted to:
a , l~ s~
~~,s
to .......GErGsr.....
,r- 14r X......................................................................................................
at premises located at..100- - ..i/rr....... Q!L?-e
...........................................~F-11. rl~..W~................................................................
County Tax Map No. 1000 Section ......:.6..? Block 3 Lot No.........r~~,7`r..
pursuant to application dated and approved by the
Building Inspector,
Fee 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, Commercial $15.00
Date l..C~ L .
New Construction.. D,` Old Or Pre-existing Bui ding....
Location of Property. /~.6-V .
House No Street ~Ham~7let
Onwer or Owners of Property ~•e(~~. ?
County Tax Map No 1000 Section ,Y...... Block... ..........Lot..~X J
Subdivision File/ydl Map .14 . , !,3 („Lot. 12 , , , , , , , ,
Permit No~lPQ._? .'Date of Permit. ~.C CIJ.~~/ .Applicant
Health Dept. Approval... te.G! ....................Underwriters Approval......................
Planning Board Approval..../
Request for: Temporary Certificate........... Final erticate..
Fee Submitted: $
~xc 36 0... '
APPLICANT
CD dd D 1
THE NEW YORK BOARD OF FIRE UNDERWRITERS PEGS 1
1
1000837 BUREAU OF ELECTRICITY
83 JOHN STREET. NEW YORK, NEW YORK 10038+
Date DECEMBER 07,1993 Application No. on fife 82639893/93 N 298187
THIS CERTIFIES THAT . .
only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of
SOUTHOLD VILLAS, 1065 JASMINE LANE, JOB-3, SOUTHOLD, N.Y.
inthefollowinglocation; ® Basement ® lnt FL ® 2nd Ff. OUT Section II Block Lot '
was examined un DECEMBER 01,19 9 3 and found to be in compliance with the National Electrical Code. 1
1
NXTURE ECEPTACUIS SWITCHES RXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS INCANDESCENT IIUOIIESCENT OTHER AMT. K. W. AMT. K. W. AMT. K.W. MAT. 9. W. AMt. H. P.
13 18 16 13
DRYERS FURNACE MOTORS FUTURE APPLIANCE REDERS SPECIAL REC'PT TIME CLOCKS MU UNIT HEATERS MUlTI.OUTLET DIMMERS
AMT. K. W. at H. P. GAS H. P. AMT. NO. A. W. G. AMT. MAP. MAT. Mrs. TRANS, AMT. H. P. SYSTEMS AMT. WARS
NO.OF FElT
1 F 2 - 2 -
SERVICE DISCONNECT NO. OF S E R V I C E -
METER
AM .O.
T. AMP. TYPE METER 1 At tW 10 3W 3 9 3W 3.# AW NO. Of R , COND . A. W. G. NO. Of HJAEG A W. G. NO. Of NElmAls A W
PEH Of CC. COND. W HI-LEG OF NEUTPAI
1 I I 100 CB 1 B 1 4 1 4
OTHER APPARATUS:
MOTORS:2-F H.P.
i
G.F.C.I:-7
SMOKE DETECTOR:-1
SPUDS ELECTRIC SERVICE LIC.4192-E
175 3RD.ST. BOX 166
GINI S MANAGE
ST. JAMES, NY, 11780 4
Per
This certificate most not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified. t"ir..credeFif els.
3 INSPECTORS ,
q~OVFFO4c~
SCOTT L. HARRIS, Supervisor
25
0 1
Thomas Fisher ' r { x Southold Town Hall
T
Building Inspector OJ t ~ ~ P.O. Box 1179, 53095 Main Road
Gar 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. ~j
owner: aL-60/VIC R 0 P d LNA/, z Y/Zr NI CO(c
(please/ prin )
Plumber: /LY 'f~G /~/~29?SS~.~v1F
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 1$ lead.
j~
Plumbers signature
Sworn to before me this
1L~ day of d. 19 9
Notary Public, ~ County
No •ry Public
MARYANNE E. DOWUNG
Notary Public, State of New York
No.5000030
Qualified in Suffolk County
Commission Expires August 3,199-ZI
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1ELD I1:S."EC ION •11DATE ~ UUMM€NT°
O H (O,,
7/1-
FOUNDATION (1st)
FOUNDATIO14 (2nd)
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ROUGH FRAME &
PLUMBING
y
3.
INSULATION PER N. Y.
STATE ENERGY
CODE ~p
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FINAL
ADDITIONAL COMMENTS:
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BOARD OF HEALTH
FORM NO. 1 3 SETS OF PLANS .
TOWN OFSOUTHOLD SURVEY
BUILDING DEPARTMENT CHECK _ .
TOWN HALL SEPTIC FORM
SOUTHOLD, N.Y. 11971
_ TEL.: 765-1802 Y.OT I FY
Examined..... 195~3 CALL
MAIL TO:
Approved 19.h.'Permit No.d 3f - - - .
Disapproved a/c
tiea.
(Bing s ctor)
APPLICATION FOR BUILDING PERMIT ~~jj
Date GG L~ihi1 L . 199z
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 street
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 permi
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 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 o
Regulations, for the construction of buildings, additions or alterations, or for removal., Q~'tion, as herein described
The applicant agrees to comply with all applicable laws, ordin ces building code ktoit,}h `eEid and regulations, and tc
admit authorized inspectors on premises and in building for Cary tio s. ;
(Signature of applicant, or name, if a corpdfation)
(Mailing a r6 ess of apWicant)
State whether applicant is owner, lessee, agent architect, engineer, general contractor, electrician, plumber o .builder
Name of owner of premises
(as on the tax roll or latest deed)
If applicant is a corpora sig ture of duly authorized officer. /O k Z L~a,7
(Name an i of corporate officer)
Builder's Lice se No.
Plumber's License No. ,
Electrician's License No. ...9 `
Other Trade's License No. .
1. Location of land on which proposed work will be dol~ Q fa.
House Number Street .......................Hamlet .
County Tax Map No. 1000 Scct'o .~Q• • Block . . . . . Lot
Q .
~-CJL2 ~
Subdivision . Filed Map No. 14. Lot .
(Name)
3: State existing use grid occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy .
.
b. Intended use and occupancy
:
3. Nature of work (check which applicable): New Building . , ~
Repair Removal , , • • • Addition Alteration , '
• • Y • • , , Demolition Other Work .
4. Estimated Cost , (Description)
Fee
5. If dwelling, number of dwelling g (to be paid on filing this application)
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 . , • •
Height Num Rear Depth . .
Number of Stories . • • • • • • • ,
Dimensions of same structure with alterations or additions: Front • • . • • . '
Depth .Height. Rear.....
8. Dimensions entire new constrnctio • • • ' ' ' ' ' , • Number of Stories . j • • •
Height n: Front Rear........... . Depth
Number of Stories . ' ' '
Size of lot: t•ront
5.
. Date of Purchase . Rear Depth
10
11. Zone or use district in which premises are situated , ' 'Name of Former Owner •
.12. Does proposed construction violate any zoning law, ordinance or regulation: • • .
13, Will lot be regraded •
14, Name of Owner e premises , - ' ' ' ' ' ' • • • Will excess fill be removed from premises: Yes ' ANc
Name of Architect ' ' ' ' ' ' ' Address Phone No.
Name of Contractor . , , • • ' ' ' , ' , • • • Address Phone No.. • ........o
•
15. Is this within """''.....Address ,Phone No. . .
property thin 300 feet of a tidal wetland? *Yes..
*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 description according to deed, and show street names and indicate whether
interior or corner lot.
APPROVED AS NOTED
Dn7E: ~B-P ti
By:
UN081WRITERS CERTIFICATE rj ErY t3ui-OENC D IaAR J.ORT AT
REQUIRED r;y-'i.3(32 ARrt TO 4 t' THE
1tjSEcCTECP$SFUR ' .
,y. M4 fifl yq ny a 'S, •
ac/T:0N nn±,ST
r
i _ d rti X t 1, t ~f i L)f
P d 5... i f 10 S s
>FR CERTIFICATION
CONTENT-BEFORE
d v ATE OF OCCUPANCY
SC LDER USED IN WATER
SLIPPLY SYSTEM CANNOT
EXCEED 2110 OF 1% LEAD.
STATE OF NEW YORK,
COUNTY OF . S.S
being duly sworn, deposes and sa pplicant
(Name of individual signing contract) ys that he is the a
above named.
He 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
IPPlication; 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 19 .L
,.otary Public, '
County
JOYCE M. WlLKINS 01
Notary Public, State of New York -
No. 4952246, Suffolk County .
(Signature of applicant)
Term Expires June 12, 1919-.2,3-
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