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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-22792 Date DECEMBER 15, 1993
THIS CERTIFIES that the building NEW DWELLING
Location of Property 1150 JASMINE LANE SOUTHOLD, NEW YORK
House No. Street Hamlet
County Tax Map No. 1000 Section 69 Block 3 Lot 24.13
Subdivision SOUTHOLD VILLAS SEC. #2- Map No. Lot No. 13
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 2, 1993 pursuant to which
Building Permit No. 21607-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-3I-DEC. 2, 1993
UNDERWRITERS CERTIFICATE NO. N-298192-DECEMBER 7, 1993
PLUMBERS CERTIFICATION DATED NOV. 21, 1993-ARTHUR MALAUSSENA JR.
~~lding Inspector
Rev. 1/81
I*Poeio
FORM NO.3
TOYFN 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)
N Date
21607 Z
Permission Is hereby granted to:
eii~K
`r X1...........././..9..3 s.~....
to ^*V
at premises located at..11 -rr.....~.cn G......, 'z L
................9.....
County Tax Map No. 1000 Section ........l~.s........ Block..................... LotNo...........
pursuant to application dated ........f 19,7 and approved by the
Building Inspector.
Fee S...°~.S<.S•~
..:xr
Aeng 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 12 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 $11~55.00, Comme cciaal $15.00
Date . ~41 . . /.y4/V(3 _
New Construction...... Old Or Pre-existing Build' g....>..
Location of Property ...,1 5D.... /LLU .t t e , ~p-(1 M_&a
House No. Street Hamle:.
/ "T-.
Onwer or owners of Property.
County Tax Map~No10c0O0,, Secti~o/nnv... ~ 1.~/ .Block ~J......... Lot... 74.
Subdivision..t~' 4 /6& ~ /,,/,Filed Map./.:.,13 / . ot.. _ .I
/ /
Permit No..? P .Date Of Permit./g(*/ . ..Applicant
~~•.e
Health Dept. Approval...., ./S .~........./Underwriters Approval..`..,.,..d_,,._,,,
Planning Board Approval. „
Request for: Temporary Certificate........... Final Certicate..
.
fGI~G`^ o~
Fee Submitted: $ 11 C / Akn
C APPLICANT
s
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1000837 BUREAU OF ELECTRICITY
F 85 JOHN STREET. NEW YORK. NEW YORK 10038
Date DECEMBER 07,1993 Application No. on file 82640293/93 N 298192
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the abode oWication number in the premises of
SOUTHOLD VILLAS, 1150 JASMINE LANE, JOB-13, SOUTHOLD, N.Y.
in thefollowing fixation; ® Basement D w Fl. ® Ynd Fl. OUT Section I I Block Lot
was examined on DECEMBER 01 , 19 9 3 and found to be in compliance with the National Electrical Code.
FIXTURE KWTACLES STFITCHES FIXTURES RANGES COOKING DECKS OVENS DISHWASHERS EXHAUST FANS
GUftumo INCANDESCFM FLUORESCENT OTHER AMT. K. W. AMT. K. W. AMT. R.W. AMT. K. W. AMT. H. P.
13 18 17 13
-OUTLET DIMMIES
DRYERS FURNACE MOTORS FUTURE AFFIANCI FfWERS SFICIALREC'" TIME CLOCKS Il LL UNITNEATERS MULN SYSTEMS
Mr. K. W. Oll H. P. GAS H. P. AMT. NO. A. W. G. AMT. AMP. NAT. AMPS. TRANS. AMT. H. F. NO. OF FEET SYST AS
AMT. wArTS
1 F 2 - - 2
SERVICE DISCONNECT NO. OF S E R V 1 C E
TER
AMT. MP. TYPE MWW. 1 u 3W 1 / 3W 3 n 3W 3 w Aw NO. OF CC. COND. A Of NEUTRAL
. W. G.ND. NO. OF HI.LEG OPW A. W. G.jG6 NO. d NFUnAlS A. W. G.
PERa Or CC.CO
1 100 CB 1 X 1 4 1 4
OTHER APPARATUS:
MOTORS:1-F N.P.
G.F.C.It-7
SMOKE DETECTOR:-1
SPUDS ELECTRIC SERVICE LIC.6192-E
175 3RD.ST. BOX 166+
GRAM 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. Rill
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
INSPECTORS ,
o~OgUFFD(k~
OQ
SCOTT L. HARRIS, Supervisor
Thomas Fisher rn ' x Southold Town Hall
p r "r P.O. Box 1179, 53095 Main Road
Building Inspector
Gary Fish Southold, New York 11971
(516) 765-1823
Building Inspector Fax
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. C7
2-_
p~ o / p
Ovner:DFCON/c- 0 , wfAN G1-'-MP -rC0k
(pie se pr?n0
Plumber: JLt~~//~~G~USS~ LL~ y2
(please print)
I certify that the solder used in the wate~ supply system
contains less than 2/10 of IX lead.
Plumbers Signature)
Sworn to before me this
day of19g3 .
Notary Public, Sus~~IK County
No ry Public
MARYANNE E. DOWLING
Notary Public, State of New York
No.5000030
Qualified in Suffolk County
Commission Expires August 3, 1994
r'lELD II:S: EC~:lO;i 11DA E COMML973
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BOARD Olz HEALTH
FORM NO.1 3 SETS OF PLANS
TOWN OFSOUTHOLD SURVEY
BUILDING DEPARTMENT CHECK
TOWN HALL SEPTIC FORK
SOUTHOLD, N.Y. 11971
_ TEL.: 765-1802 t: pT I FY ;
CALL
O . _ .
Examined . . 13 MAIL TO:
Approved . 19,q_&~ Permit No.. a 7 yZ~_
Disapproved a/c . . . . . . _ . . . .
.
(Bu' ing pector)
APPLICATION FOR BUILDING PERMIT
Date .La....., 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 st'ree7
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 the issirarOof a Building Permit pursuant to th
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, aria 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, ordinanc building code, housing code, and regulations, and tc
admit authorized inspectors on premises and in building for neces ry i spection
U 1,
(Signature of applicant, or name, if a corporate . )
(Mailing address of applicant)
State whether applicant is owner, lessee agent, architect, engineer, general contractor, electrician, plumber o builder.
Name of owner of pr mi es .
(as on the tax roll or latest deed)
If applicant is - C o ion ignature of duly thorized officer.
<~1
(Nam itle 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. , .
?cr-o " " " • • • •
House Number trcet Hamlet
County Tax slap No. 1000 Section,. . . .459. Block Lot .
Subdivision ..t,(~ ( Filed Map No. { •
(Name) Ct Lot .
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
-3. Nature ofw&k (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 . ' • ' ' ' ' . ' • • •
Ileight .........Rear Depth
Number of Stories .
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. Date of Purchase " " " " Depth
""'•••••••••••••••••••••...Name ofFormer 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 •
14. Name of Owner of premises • Address Nc
Name of Architect ••••••••••••PhoneNo
" • • • • • Address . Phone No.
Name of Contractor . • Address • • • '
15.' Is this property within 300 feet of a tidal wetland? *
Yes " • Noo. . 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., vP~ ~
~~f
UNDEnN R!TFRS (.WFICATE S.P. # .
REQUIRED _1L--a F
4_J S'
b il.s!!i?C t9Eti",'rt+19:,NT AT
t:= ~r THE
liF 0C"I .
F
PLUMBER CERTIFICATION
ON LEAD CONTENT BEFORE
CERTIFICATE OF OCCUPANCY
SOLDER USED IN WATER
SUPPLY SYSTEM CANNOT
EXCEED 2110 OF 1% LEAD
STATE OF NEW YORK,
COUNT OF S.S
(Name of individual signing contract) being duly sworn, deposes and says that he is the applicant
above named.
He is the .
(Contractor, agent, corporate officer, etc.)
Df 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
.vork will be performed in the manner set forth in the application filed therewith.
Sworn to before me this
..day of . 19
rotary Public, , h!Y11 • , Count
JOYCE M. WILKINS \
Notary Public, State of Now-York . • • • -
No. 4952246, Suffolk Cour}~y , ' ' ' r
Term Expires June 12, 19xS (Signature of applicant)
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