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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-22791 Date DECEMBER 15, 1993
THIS CERTIFIES that the building NEW DWELLING
Location of Property 1220 JASMINE LANE SOUTHOLD, NEW YORK
House No. Street Hamlet
County Tax Map No. 1000 Section 69 Block 3 Lot 24.12
Subdivision SOUTHOLD VILLAS, SEC. #2 Map No. Lot No. 12
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 2, 1993 pursuant to which
Building Permit No. 21605-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) 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-30-DEC. 2, 1993
UNDERWRITERS CERTIFICATE NO. PENDING - DECEMBER 14, 1993
PLUMBERS CERTIFICATION DATED NOV. 21, 1993-ARTHUR MALAUSSENA, JR.
uilding Inspector
Rev. 1/81
FORM NO.3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOW HALL
SOUTHOLD, N.Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
Date ......V81 19.3..
No 21605 Z
Permission Is hereby granted to:
ter. f ..Va..,.Q,~rf
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to.. . x'x/ !.l 1tC..... ~.....rA~1i
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of premises located at...l.~~...?ZAi.. xiA
.
County Tax Map No. 1000 Section 6..9......... Block Lot No... a..~ KImo.....
pursuant to application dated 0~ 19..E and approved by the
Building Inspector.
Fee
'Y...
B !ng 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.y 5.00, Coommmeyyc~ial $15.00
Date /Y././ . < .
New Construction.. Old Or Pre-existing Build" g....
Location of Property ...~t~aQ,.,,,•, .
House No/.//~ C/JI Street Hamle ~l
Onwer or Owners of Property. • • .
County Tax Map No 1q000,Section M.66 . , Block ..../J......... Lot...
Subdivision. .e ~r..' • • Filed Map./7.
!yJJ~~0 t. .
Permit No.~?RA[S ./y.7Daa7te of Pernmit.'/Ca j, Applicant&..rra.O*aAA(~l[?'.0, ~
Health Dept. Approval.../. ;.;7 0........ Underwriters Approval.................
Planning Board Approval.,,,.,.
Request for: Temporary Certificate........... Final Certicate.,
Fee Submitted:
c6 all ql APPLICANT
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1000837 BUREAU OF ELECTRICITY
85 JOHN STREET. NEW YORK. NEW YORK 10038
Date DECEMBER 22,1993 ApplicationNo.onfile 82640193/93 N 2^.99904
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, 1220 JASMINE LANE, JOB-12, SOUTHOLD, N.Y.
in thefollominq location; ® Basement 7 Ist Fl. ® Ynd Fl. GAR/ATTIC/OUT Sertionll Block Lot
urea examined on DECEMBER 14 , 19 9 3 and found to be in compliance with the National Electrical Code.
FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS ECBTAL'AES SWITCHES INUNDE]CEM FlU0RE5CEM OTHER AMT. K. W. AMT. K. W. AMT. K.W. MIT. K. W. AMT. N. P.
34 37 30 34
DRYERS FURNACE MOTORS FUTURE APPLIANCE REMERS SFWAL RK'?T TIME CLOCKS na, UNIT HEATERS MULTWUTLET DIMMERS
AMT. K. W. OH H. P. GAS H. P. NAT. NO. A. W.G. T. AMP. AMT. AMPS. TRANS. AMT. H. P. SYSTFMS
NO. OF FEET AMT. WATTS
1 F 1 2/12 DISH 2 i
SERVICE DISCONNECT NO. OF S E R V 1 C E
AMT. AMP. TYPE (,e TW t / ]W ] / TV 3 / AW NO' O"RC,COND. OF CC COND. NO. M HIAEG OA Np. OF NEUTRAIS Oi 1EUAAl
1 200 CB 1 X 1 2i0 L 2/0
OTHER APPARATUS:
MOTORS(2-F H.P.
G.F.C.II-7
SMOKE DETECTOR:-2
SPUDS ELECTRIC SERVICE LIC,4192-E
175 3RD.ST. BOX 166
ODOM MANAGER
ST. JAMES, NY, 11780 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 ,
~~~gOFFO(,~ O
SCOTT L. HARRIS, Supervisor
Thomas Fisher Southold Town Hall
p ! P.O. Box 1179, 53095 Main Road
Building Inspector Southold, New York 11971
Gary Fish 1{fd _7
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:// a 93
Buildingy Permit No. ~6()~ /
Owner: iJE(O~fJ l L fJROT~i>r1gAW'C-lti1t-N-' COU'
(please print)
Plumber:
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 12 lea*Plumbers re)
Sworn to before me this
(per day of, \K]95~.
Notary Public, SCounty
d
'-rat
Not ry Public
MARYANNE E. DOWLING
Notary Public, State of New York
No.5000030
Qualifietl in Suffolk County
Commission Expires August 3, 199
r
I E L D IN S" CT1UN COMMENTS
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INSULATION PER N. Y.
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BOARD OF HEALTH
FORM NO.1 3 SETS OF PLAYS
TOWN OFSOUTHOLD SURVEY
BUILDING DEPARTMENT CHECK . .
TOWN HALL SEPTIC FOn:I
SOUTHOLD, N.Y. 11971
TEL.: 765-1802 NDT I FY ;
CALL
Examined .c) ........9y,3 MAIL TO:
Approved 19'9:3Permit No.. `v OS . _ .
Disapproved. a/c .
(Building In~Ector)
APPLICATION FOR BUILDING PERMIT
Date L' y~' r!:C?~.. C7~...., 19!
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 appli
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 Occupancy
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Buildin Pe uant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and ot$ll~~k`~e'.dinances or
Regulations, for the construction of buildings, additions or alterations, or for removal or demAWV s herein described.
The applicant agrees to comply with all applicable laws, ordinapees, building code, housing code, and regulations, and tc
admit authorized inspectors on premises and in building for necessaryl inspections.
, f
/ ~~~%~/~1L1!'~-~ .C:~?. ~.Cl ~~;_2iG~.,i'1-.4GG~~tfQi !,~el'4~.~ .
(Signature of applicant, or name, if a corpora(ion)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent architect, engineer, general contractor, electrician, plumber o builder
Name of owner of premi s
-($S,on the tax roll or latest deed)
If applicant is a c rp t• anature of duly uthorized officcer/.
l~t~,t(..... Z X Zc) 1 d. -
(Name a 'tle of corporate officer)
Builder's License No .
Plumber's License No. , . , , :
Electrician's License No . .
Other Trade's License No .
1. Location of land on which proposed work will be done. .
l/
. • . • . • i • • • •
House Number Street Hamlet
County Tax Map No. 1000 Section
Block Lot i
Subdivision C ? i t / n
Filed Map No. l i..~./ Lot . .
(Name)
1 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 / . '~!n!f Cf • • • • U^ f
:f .
' V v
3. Nature of work (check which applicable): New Building Addition Alteration
Repair Removal Demolition.............. Other Work
4. Estimated Cost (Description)
Fee.......
(to be paid on filing this application)
5. If dwelling, 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 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 Rear . . Depth
Height Number of Stories .
y. Size of lot: I~ront Rear Depth .
10. Date of Purchase . Name of Former Owner • . . .
11. Zone or use district in which premises are situated . ' ' . '
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 . Phone No.
Name of Architect Address • • • • Phone No.. • • .
Name of Contractor Address Ph ne No,
15. Is this property within 300 feet of a tidal wetland? *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 acco ing to deed, and show street names and indicate whether
interior or corner lot.
1~RQlED AS ra®TED
uNOERwR1rERS cOrrFrq~ 1 2 .i E, $ a y 13.E a
REQUIRED F-F 4 S, if L) BY:
PfC",Y Fitill LMNIG CDE~A 11 ENT AT
f `iti-'1802 9 AM TO 4 PM FOR. THE
r,,, k r !',;e II::p-CTli..NS*
~ S ~ tl C s p,f1
SSED
if \it~l~Tlq. ~lt ? - vs EQUIn
MING
PLUM
x0161° ",6 CY OR Ia:.ItTIOhl rnllsT
lUISE IS UN" AWFUL
[ t,'•;u i t n~?t;Tl!'~6~I SHALL Pu9EET
".'ITHOUT CERTIFICATE ti P:NTS OF THE N.Y.
OF OCCUPANCY -"^-TG c;,Rl,ICMON & ENERGY
OF r - ;PO NSIBLE FOR
PLUMBER C RTIFICATIC " rTRUCTION s RROPs
ON LEAD CONTENT $EFO,
CERTIFICATE OF OCCUPY
SO[ I rER USED IN W .
Silf'i? LY SYSTEM CA'
EXCEED 2110 OF 1 °
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.
Ile 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 , 19 .2--3,
rotary Public, V" ~LYY`
\ County
J0 LE M. WILKINS
Notary Public, State of New York , , , • .
No. 4952246, Suffolk Coin • ' ' ' •
Term Expires June 12, 19 - (Signature of applicant)
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