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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-22794 Date DECEMBER 15, 1993
THIS CERTIFIES that the building NEW DWELLING
Location of Property 930 JASMINE LANE SOUTHOLD, NEW YORK
House No. Street Hamlet
County Tax Map No. 1000 Section 69 Block 3 Lot 24.15
Subdivision SOUTHOLD VILLAS SEC. #2 Map No. Lot No. 15
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 2, 1993 pursuant to which
Building Permit No. 21609-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 FLOOR 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-33-DEC. 2, 1993
UNDERWRITERS CERTIFICATE N0. PENDING - DECEMBER 14, 1993
PLUMBERS CERTIFICATION DATED NOV. 21, 1993-ARTHUR MALAUSSENA, JR.
Z~VAifg
uildin Spector
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)
Date r`` 19.93...
N° 21609 Z
Permission Is hereby granted to:
a,...c........ ~r..~~
. /i73s
to .,0 .,~~L........~ 4 •G
.
at premises located aT. A......... tt~. & dAla' .
County Tax Map No. 1000 Section .......1 .9......... Block .....-5! Lot No....~.~. ~.5........
pursuant to application dated 0 19.....x......, and approved by the
Building Inspector.
Fee $
Ilding 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, CLommeq gcial $15.00
Date /A V..
New Construction.. Old Or Pre-existing Build' g.-.,.o. /
Location of Property... House No. Street Ham le ~
Onwer or Owners of Property.
5~.;!~~(7;7~(;1~~
County Tax Map No 1000, Section... . Block Lot... a-7. 7=a..~.~..
Subdivision.. . Filed Map•1. V3 I ,
ot" S
(J . .
Permit No.o~j/ Qj..Q.Date Of Permit.~~a / .3 „Applicant ~'?L/~.(~(' /f~ lfj1 (
Health Dept. Approval.../.. .s 0;~ 3... ...Underwriters Approval. .
Planning Board Approval.,,,.,.
Request for: Temporary Certificate........... Final Certicate.,
~ n
/1. f
Fee Submitted: $ tTC / D7 /11~cLl I//~
C0 ~ ~~~0 I y APPLICANT
l~...~
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1000837 BUREAU OF ELECTRICITY
F 85 JOHN. STREET. NEW YORK. NEW YORK 10038
Date DECEMBER 22,1993 APplicationNo.onf;le 82640493193 N 299902
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the eb~ application number in the premises of
SOUTHOLD VILLAS, 930 JASMINE LANE, JOBt15, SOUTHOLD, N.Y.
in thefollowinq location; ® Basement ® IAt Ft. ® 2nd Fl. ATTIC/OUT Section 11 Block Lot
Seas examined on DECEMBER 14 , 19 9 3 and found to be in compliance with the National Electrical Code.
FIXTURE FIXTURES RANGES COOKING DICKS OVENS DISHWASHERS EXHAUST FANS
OUTLETS ECBiACIEt SWITCHES INCANDESCENT FLUORESCENT OTHER AMT. K. W. AMT. K. W. AMT. K.W. AMT. K. W. AMT. N. P.
16 28 21 16
DRYERS FURNACE MOTORS FUTURE AFFIIANCE iEEDlRS SPECIAL RK'?T TIME CIOCKS !Ell UNIT HEATlRS I MULTI.OUTIM DIMMERS
AMT. K. W. dl H. P. GAS M. P. AMT. NO. A. W. G. AMT. NAP. NAT. Mrs. TRANS. AMT. M. P. SYSTEMS NO. OF RET AMT. WATTS
1 F ~ - - 2
SERVICE DISCONNECT NO. OF S E R V 1 C E
ALEM
AMT. AMP. TYPE IMP. 1 / 1W t / 3W l / TV ] / AW O RCeCOND. OF CC COND. NO. OF NI.LEG Of N~ NO. OF NEUTRALS OA 'r1lUiGMAI
1 100 CB 1 % 1 4 1 4
OTHER APPARATUS:
MOTORS;3-F H.P.
G.F.C.I:-8
SMOKE DETECTORI-2
2
cro~
SPUDS ELECTRIC SERVICE LIC.t192-E
175 3RD.ST. BOX 166
t 0*M 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
~~~g~f F0(kC
O
o~ Gy< SCOTT L. HARRIS, Supervisor
CA F " z Southold Town Hall
Thomas Fisher y. P.O. Box 1179, 53095 Main Road
Building Inspector O (rte.
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: ll o 93
Building Permit No. ~ 16 o 2
Owner: come 0 /,~{l~~ U/ CO~p
(please print)
Pltmiber:iU/l
(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 ~e r 19
Notary Public, 5~ IK County
No Ty Public
MARYANNE E. DOWLING
Notary Public, State of New York
No.5000030
Qualified in Suffolk County
Commission Expires August 3, 199
1ELD 11.J ::u:i JJUn.c OMM€NT°
FOUNDATION (1st)
~~p(
FOUNDATION _ c
(2nd)
- a,
2.
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ROUGH FRAME &
PLUMBING
3
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3. x
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INSULATION PER N. Y.
STATE ENERGY
CODE
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4. _ in H CJ
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FINAL
ADDITIONAL COMMENTS:
X70. dD • yn _ ~
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BOARD OF HEALTH
FORM NO. 1 3 SETS OF PLA.nS
TOWN OFSOUTHOLD SURVEY
BUILDING DEPARTMENT CHECK
TOWN HALL SEPTIC F0RN
SOUTHOLD, N.Y. 11971
_ TEL.: 765-1802 I:oTIFY•
Examined 199 CALL _ .
,
t•tAIL TO:
Approved 193 Permit No.,. 0.9. .
Disapproved a/c _ .
(Building~14spector)
APPLICATION FOR BUILDING PERMIT
Date ~LLC•,.R~..., 19
INSTRUCTIONS
a. This application must be completely filled in by typewriter Orin 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 pemmi
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 or demolition, as herein described
The applicant agrees to comply with all applicable laws, ordinan es building code, ho sing code, and rem lat' p) d tc
admit authorized inspectors on premises and in building for nece'ssa nspectio s! , f l C
(Sio gnature of applicant, or name, if a cor ration)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent architect, engineer, general contractor, electrician, plumber o builder.
.
Name ofowner4~11-1 remises
(as on the tax roll or latest deed)
If applica t is or ion, signature o duly authorized officer.
( a/ e and title of corporate officer)
Builde/rr's License No . .
Plumber's License No. c?r,,~
Electrician's License No . .
Other Trade's License No. .
1. Location of land on which proposed work will be done.
el'.'73 O o
House Number m
• '
Street Hamlet
County Tax Map No. 1000 Section n~~y
Block tom(... Lot. =z /S
Subdivision .rr:{ n l~L~
Filed Map No. Lot J .
(Name)
3: 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 / . !ti
V
3. Nature of work (check which applicable): New Building
Repair . • , , , , , , , • , , , , Removal • • Addition Alteration .
Demolition , , , , • , • . • . • , , , Other Work
4• Estimated Cost (Description)
Fee
5. If dwelling, number of dwelling (to be paid on filing this application)
b 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
Iicight Number of Stories Depth .
Dimensions of same structure with alterations or additions: Front • • • • • • • ' • ' ' ' ' ' • -
Depth Height. Rear.....
8. Dimensions of entire new construction: Front . • • , • ' ' ' • ' Number of Stories .
Height . Number of Stories . • • . • . • • . ' ' ' ' Rear ...............Depth .
Size of lot: i-ront
5.
10. Date of Purchase Rear................... . Depth . .
............•••••••'••••••...NameOfFormerOwner •
11. Zone or use district in which premises are situated • • • • • • • • • ' ' " ' '
2. 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 Nc
Name of Architect • ' ' ' ' ' ' ' • • • Address .............Phone No.
Name of Contractor . Address Phone No.
Address
15.' Is this property within 300 feet of a tidal wetland? Yes " " " " -Phone.
*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 N*ED
[,'ATE tuy-/0-_ B.P. # x(00 ~
UNDERWRITERS CERTIFICgTE EC 01) BY.
REQUIRED .
. t,:Ut4>=Y 13U>'...'U'1sNG DEfAR ~ SENT AT
`F, t 802 9 Atw TQ 4 Pkn FOR THE
s ,'t's aTlrrtl - t" .Vi7 REQUIRED
5sE('70t+CRETE
r,,U4 G ,4 r LUI I IN G
j;
MIST
F, . : t e c uyx 43's THE IN. Y.
m_' F L t~ON sThl;t;T ON & ENERGY
r +t')T ESPOtdSli?1_E FOR
<s t TRUCTION F-RROP:S
OV UMBER CER7-IRCAT/O/V
LEAD CO/VTEAlT BEFOP, E
CERT/F/LATE OF
SOLD OCCUPAC;,
SUPPLY S ys~ % W~7TF 4
EXCEED 2/1 AA CAA,~Afs
OOF1%' a.
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
,pplication; 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. .
rotary Public, .
County
J YCE M. WILKINS / Z"?" Notary Public, State of NewYgrk ~ ~ .
No. 4952246, Suffolk Cou S- ' ' ' •
Term Expires June 12,19 (Signature of applicant)
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SURVEY OF
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A T SOUTHOLD
lpr CO' TOWN OF SOUTHOLD
lo" SUFFOoLK oCOUN TpY N. Y.
i ® Scale: 1" - 40'
Mar. 23,1993
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FROM DAIr OF MpWAL
The locations of webs and cesspools AREA . 32,055 s ft.
shown hereon are from field observations q 1 r'/
and or from data obtained from others.
%
Prepared in accordance with the minimum The water supply and sewage disposal
s/andads for fift surveys as established systems for this residence will conform
by the L.I.A.L.S. and approved and adopted to the standards of The Suffolk County a NN,
for such use by The New York State Land Department of Health Services.,
Title Associa/lon. / -%t(W NEW k
~N T. MF)*2Q
~664w~ J SAP 0
SUFFOLK COUNTY DEPARTMENT OF WEALTH SERVICES G J i'~i a
FOR APPROVAL OF CONSTRUCTION ONLY
W 3 Q N.Y.S. L/C. NO. 49618
DATE R . NO. 'S VEYOR$, P. C.
N 5020
OX
ELEVATIONS ARE REFERENCED P. 909
MAIN ROAD
APPROVED TO AN ASSIA?ED DATtAA[ SOUTHOLD, N. Y. 11971
NiO~F ~S
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h e SURVEY OF
LOT 15
F&M AUG. 4 NO MEND. A-494
~a A T S6UTHOLD
nor ~lJ
TOWN OF SOUTHOLD
SUFFOLK COUNTY N. Y.
~o 1000-70-01-Pion
X30. T ® Scale: 1" = 40
forma ti
"y 15;. Mar. 231993
~S a
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153 Aug. 17, 1993 (foundation)
rya
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00, P
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190.00,
L7'vl~w' 15.43,
Lq~~
The locations of webs and cesspools AREA = 32 055 sq. ft.
shown hereon are from field observations
and or from data obtained from others.
Prepared In accordance with the m *num The water supply and sewage disposal
standards for title surveys as established systems for this residence will conform
by the L.I.A.L.S. and approved and adopted to the standards of The Suffolk County %,ANDS
for such use by The New York Stale Land Department of Health Services. ~O 1rS,
Title Association.
w Q c
0
SUFFOLK COUNTY DEPARTMENT OF FEALTH SERVICES _
FOR APPROVAL OF CONSTRUCTION ONLY
IC. NO. 49618
DATE - Kc REF. NO. PECONIC , P. C.
(516) 765 - 5020
ELEVATIONS ARE REFERENCED P. O. BOX 909
MAIN ROAD
APPROVED TO AN ASSURED DATUM SOUTHOLD, N.Y. 11971
*/O/P
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~ T~•4sio. F. 414#V
36 9001,
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h SURVEY OF
LOT 15
~`op %WAP OF SOUTH= M AA 9CCmv TWID"
FLED AUG 4 1999 AW NO A-434
~o A T SIDUTHOLD
T s~ TO WN OF SOUTHOLD
SUFFOLK COUNTY N. Y.
Zor 1000 - 70 - 01- Pia
1/0
a X54 h ® Scale: 1"= 40'
'-1 ryh 2,f,;~,. a •',5.,~ cy IMar.
1) P 2311993 15, V e
zo S. Aug. 17, 1993 (foundation)
` " ! 3
11 Nov. 19, 1993 (final)
i 3 SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
\ yy~ 1 ry SINGLE FAMILY DWELLING ONLY
a Approval of Constructed Works
H.D. Ref. No. 93-L
oo• 44
rA v The sewage disposal and water supply facilities at this location
3'S~ •Tj3 z 190 ~`'4r Q have been saustactorily inspected by this Department and are
?tf A s ~O0$ Q in compliance with these as built plans
Al
Js'43j y D3
_I~ ~6¢• ~ l{; ~ DAiE CHIEF OF GENER
ENGINEERING SERVICES
~qNE
f1~~1
The locations of we//s and cesspools tl pg kt '
shown hereon are from field observations AREA = 32,055 sq. ft. E
and or from data obtained from
others. DEC 1 1995
Prepared In accordance with the minimum The water supply and sewage disposal
standards for tit/e surveys as established systems for this residence will conform
by the L.J.A.L.S. and approved and adopted standards of The Su/talk County S C`r for such use by The New York State Land 1 t0 o the lmenl Health Services. 1 ~EAl'!3
Tift Assoclatlon.
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
FOR APPROVAL OF CONSTRUCTION ONLY
N Y. 1C. NO. 49618
93 SO 33
DATE REF. NO. PECOIW VEYGrRS C.
(5/61 76 L Q, sac?..
ELEVATIONS ARE REFERENCED P. O. 86X
MA/N
APPROVED TO AN ASSL46D DATL& MAJIV ROAD
SOUTHOLDr N. Y. if 971
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by
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U4P OF SOU7WW n"A SEiCTXW TWO"
b°i P r FLED AUG. 4 IM FLENO. A-494
a~ A T SbUTHOLD
SOT s~ TOWN OF SOUTHOLD
SUFFOLK COUNTY, N. Y.
SOT 1000-70-01-P/06
® Scale: 1" = 40'
, i° 53a Mar. 23,1993
^"0 53 Aug. 17, 1993 (foundation)
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VOL
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2.64, 10' k•
e/~Y
SAW
The locations of wells and cesspools AREA = 32,055 sq. ft.
shown hereon are from field observations
and or from dote obtained from others.
Prepared In accordance with the minimum The water supply and sewage disposal
standards for title surveys as established systems for this residence will conform
by the L.Z.A.L.S. and approved and adopted to the standards of The Suffolk County AP?
for such use by The New York Slate Land Department of Health Services. O SG
Title Association.
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
FOR APPROVAL OF CONSTRUCTION ONLY \N~ ,r
Uc. NO. 49618
DATE ue REF. NO. PE'- CONIC JUR~Ea'Bl~$, P. C.
15/61 765 - 5020
EL£VA 770NS ARE REFERENCED P. 0. BOX 909
APPROVED TO AN ASSUMED DATUM. MAIN ROAD
SOUTHOLD, N.Y. 11971