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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-22790 Date DECEMBER 15, 1993
THIS CERTIFIES that the building NEW DWELLING
Location of Property 1155 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. 4
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 2, 1993 pursuant to which
Building Permit No. 21604 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-22-DEC. 2, 1993
UNDERWRITERS CERTIFICATE NO. N-298184-DECEMBER 7, 1993
PLUMBERS CERTIFICATION DATED NOV. 21, 1993-ARTHUR MALAUSSENA, JR..
l/ Building g Inspector
Rev. 1/81
FORM NO.3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOM HALL
SOUTNOLD, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N° 21604 Z Date ...V /7.27e/ 19..9
Permission Is hereby granted to:
46A.51....~! 3
.........a.. J~
to..4~
.ALA
.
at premises located at...Zz~ l~RG....~a~!A G
r~y..
County Tax Map No. 1000 Section .........4.{......... Block .......0 Lot No..... 3%.
pursuant to application dated Q. I. 19....1.. and approved by the
Building Inspector.
Fee $..a`.7`.... I..~~....
. r 1 , f ' f ! 1,~% 4
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 $,1.!5.00, CLommme ccial $15.00
Date .
New Construction...... Old Or Pre-existing Build* }g....
Location of Property. .1.1 5Zi Ua41_(X_(At . -
House No. Street Hamle ~C
Onwer or Owners of Property.X
County Tax Map No 1000, Section......!.. Block ....~f.... . Lot O,., y,
Subdivision..t 'koFiled Map./. V1 el
3 ot... .
'j?/ / (J ..r..
Permit No.Gd ~0u 7. ..Date of Permit./Oq(* .3 ..Applicant {
Health Dept. Approval
.Underwriters Approval..`' _ _
Planning Board Approval.
Request for: Temporary Certificate.........., Final Certicate..
Fee Submitted: $ tTvflC / ffL~l~
C~ I-c/ 1 1 APPLICANT.......... _ .rt
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1000837 BUREAU OF ELECTRICITY
85 JOHN STREET, NEW YORK, NEW YORK 10038
Date DECEMBER 07,1993 Application No. on file 82639993/93 N 298184
THIS CERTIFIES THAT
only the electrical equipment " described below and introduced by the applicant named on the above application number in the premises of
SOUTHOLD VILLAS, 115-75, JASMINE LANE, JOB-4, SOUTHOLD, N.Y,
inthefollowinglocation' I Basement 0 IAIFI• 2 2nd Fl. OUT Section 11 Block Lot
was examined on D E Ll E N B E R @1,1993 and found to be in compliance with the National Electrical Code.
RXTURE FIXTURES RANGES COOKING DECKS OVENS DISH WASNlRS EXHAUST FANS
oUNMMS BTACUES SWI7CNES INCANDESCENT FLICOESCENT OTHER AMT. K. W. AMT. K. W. AMT. K.W. AMT. K. W. AMT. H. P.
ld 17 17 13
DRYERS FURNACE MOTORS RITURE APPLIANCE FEEDERS SPECIAL REC'IT TIME CLOCKS pu UNIT HEATERS MULTI.OUTIET DIMMERS
P. SYSTEMS AMT. WATTS
MT. K. W. at H. P. GAS H. F. AMT. NO. A. W. O. AMT. AIM. AMT. AMPS. TRANS. AMT. H. NO. OF
RET
1 E 2 - 2 -
SERVICE DISCONNECT NO.OF S E R V 1 C E
MEM
AMT. AMP. rot EOWF 10 tW 10 3W 3 a 3W 13.9 - NO. KR O "DOF CC. COND. ~OF HIAEO a ~W G NO. OF NEUTRALS of NEU ,
L 100 CB 1 X i 4 ] 4
OTHER APPARATUS:
MOTORSI2-F H.P.
G.F.C.It-7
SMOKE DETECTORe-1
SPUDS ELECTRIC SERVICE LIC.9192 E
175 3RD. ST. BOX 166
OR40M MANAGER
ST. JAMES, NY, 11780 11
Psr
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.
L/
INSPECTORS
S)~~gllFFO(ke
O
SCOTT L. HARRIS, Supervisor
C++ z Southold Town Hall
Thomas Fisher 'F. , t++
B P.O. Box 1179 53095 Main Road
Building Inspector
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 : I G~ J
Building Permit No. Q
Owner: lC b1ZOP, WN46,c wNr c09P
4 (ple se prin ))~~JJ
Plumber: f ie 11~A'
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.
(Plumbers signature)
Sworn to before me this
(D-_ day of. 193
Notary Public, County
No ry Public
MARYANNE E. DOWUNG
Notary Public, State of New York
No.5000030
Qualified in Suffolk CounCommission Expires August 3,799-q
JJUA:E I ~OMMENT° ~1
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wow 6~04
FOUNDATION _ (1st)
FOUNDATION (2nd) 2.
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PLUMBING
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INSULATION PER N. Y. ?
STATE ENERGY
CODE
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FINAL P
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ADDITIONAL COMMENTS: x D
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BOARD OF HEALTH
FORM NO. 1 J SETS OF PLANS
TOWN OFSOUTHOLD SURVEY
BUILDING DEPARTMENT CIIECK _ . , , , ,
TOWN HALL SEPTIC FORK
SOUTHOLD, N.Y. 11971
_ TEL.: 7G5-1802 NOTIFY:
Examined /G 'Y........ • 1159 x. CALL . .
MAIL TO:
Approved 1(/....., 19,~2'? Permit No..~~a~
Disapproved, a/c/ _ .
Build' Inspector)
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'reet
or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this apph
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 thf
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, ordinane uilding code, h using code, and regulations, and tc
admit authorized inspectors on premises and in building for nec i spectio s 4ar (Signature of applicant, or name, if a corporati6)
(Mailing address o pplicant)
State whether applicant is owner, lessee, agent architect, engineer, general contractor, electrician, plumber o builder
...Ar
Name of owner of premises % ~~Q........ .
(as 0-q tthe l or I~test deed)
If applicant is a corpo ati re of duly authorized officer.--±--'
(Name and t' 1 corporate officer)
Builders License No.
Plumber's License No. • • .
Electrician's License No. /..7. ,
Other Trade's License No.
1. Location of land on which proposed work will be done. .LQ/C~~Q, 9/. .
Iiousc Number .......................Street .:.........Hamlet...............
County Tax Map No. 1000 Section Block .......Q ' . , Lot / . , , , • ,
Subdivision ..c'~~-~'~~<!'~~ /
. Filed blap No. /1... Lot .
(Name)
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 .
•.'3Ai
•3. Nature of work (check which applicable): New Building / Addition . Alteratio
Repair Removal n
Demolition Other Work .
(Description)
4. Estimated Cost Fee
5. If dwelling (to be paid on filing this application)
d, number of dwelling units Number of dwelling units on each floor
If garage, 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
Height Number of Stories Depth .
Dimensions of same structure with alterations or additions: Front . • . • . • . . ' ' ' ' '
Depth Rear.....
Height . . Number of Stories .
8. Dimensions of entire new construction: Front . Rear .
Height Number of Stories ..............Depth .
y. Size of lot: l•ront . • Rear .
10. Dale of Purchase Depth
11. 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 No
.14. Name of Owner of premises Address
Name of Architect ~•••••••••••Phone No
. • • • . Address Phone No.
Name of Contractor ~ " " " • • • • • • • • • .
15.• Is this property within 300 feet of a tidal wetland? * ' " " " " " Ph No
Yes,....... No......
*If yes, Southold Town Trustees Permit may. be required.
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. i . .
C~~
• 16PP.C91E13 AS NOTED
51
d 3 B.P. #
UNDERWRITERS CERTIFICATE DATE:
21 190
REQUIRED FEE a 01 8Y:
tIOTIFY BUILLNNG. DEPART ENT AT
765-9902 9 ANN TO 4 PM. FOR THE
FOLLOW iNG INSPECTION&
9. £ UNDATION - TWO REOUIRED
FoP rP(?f1SED CONCRETE
"e p r),,!CjH - FRANflr~;G & PLUMBING
31, .;RiJCTION.fb`UST
ALL t t3?,'`'FHl?C'flON SF-!d'LL MEET
s ICE Rrs;'lllR£ A.- UTS OF THE N
~x, aSTRUCTION & F EFGY
P, IFICATION NOT RESPONSIBLE FOR
C.' » EIVT BE¢C, OFS. c;Cta: (RUCTION ERROPS
F OCCu.
aEQ/N OW
'STEM CAh.
l0 OF 1% L,.
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.
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
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
..........l6 c.. . .
...day of. ......J~n
rotary Public, r1nVr t CounE M. WIIJCINS /
Notary Public, State of New York . .
No. 4952246, Suffolk Cou (Signature can .
Term ExptreaJune 12,19 of applicant)
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