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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-22846 Date JANUARY 21, 1994
THIS CERTIFIES that the building NEW DWELLING
Location of Property 1450 JASMINE LANE SOUTHOLD, NEW YORK
House No. Street Hamlet
County Tax Map No. 1000 Section 69 Block 3 Lot 24.9
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated OCTOBER 12, 1993 pursuant to which
Building Permit No. 21708-Z dated OCTOBER 19, 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 AS APPLIED FOR (1ST FLOOR ONLY)
The certificate is issued to PECONIC PROPERTIES MANAGEMENT CORP.
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 93-SO-27-DEC. 2, 1993
UNDERWRITERS CERTIFICATE NO. PENDING -JANUARY 14. 1994
PLUMBERS CERTIFICATION DATED NOV. 21, 1993-ARTHUR MALAUSSENA, JR.
iilding 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)
Date October...19.a 19....93...
No 21708 Z
Permission is hereby granted to:
Peconic Properties Management Corp.
P.O. Boa 1143
Cutcho~ue, N.Y 11935
;
to .................GRNS7l~AGT.. A ..ONTi..F.dTTrX.. Ak>I,tixNG..AS.. Ra'R~,xrdR..kA13
at premises located at.... 1450.. J~I?>8..N$ ..............................$..1m ?,P.....N.,Y.,..............................
County Tax Map No. 1000 Section 9 Block ........3................ Lot No..... 2.4...9...............
pursuant to application dated October..12n 19...93,........ and approved by the
Building Inspector.
Fee $........245.00
wng Inspector
Rev. 6/30/80
- Form No. 6
TOWN OF SOUTHOLD
A J 2 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
New Construction........... Old Or Pre-existing Building . . '
Location of Property.. S ~..g ...................5
House No. p~ Street
~i Hamlet
. ft3h%
Onwer or Owners of Property....Q~C4Y'S !~.~'Lt(7~-""'~..?A4 i
County Tax Map No 1000, Section... pp
~l1./....... Block Q.'3.......Lot....-,RL/.:...........
Subdivision ....................................Fillqed Map............ Lot......................
Permit No.~,X 12 g . .Date Of Permit... J~/ I.....Applicant
Health Dept. Approval ..........................Underwriters Approval.........................
Planning Board Approval
Request for: Temporary Certificate........... Final Certicate...........
Fee Submitted: $
.u, Lf7 Ll1 y..... ao-.
INSPECTORS err
o~~gUFFO(k~ ~
O
SCOTT L. HARRIS, Supervisor
. a, t
c
Thomas Fisher ca Southold Town Hall
Building Inspector O~ _ r 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. O 8
Owner: 'ECo VC P,RQp PlgllAGF k9 -nr C'OK~
(pl ase prim
Plumber:_
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of IX lead.
(Plumbers signature)
Sworn to before me this
e6+1--k day of 9-9a.
Notary Public, S Ik County
ftl
Not ry Public
MARYANNE E. DOWLING
Notary Public, State of New York
No 5000030
Qualified in Sutfolk county
Commissusn Expires August 3,199
M-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
REMARKS:
DATE //o, 14~re,12 INSPECTOR/
~JCii9LNT~
OUNDATION (1st) I r(J
. I err
OUNDATION (2nd) r"
O
OUCH FRAME do I
• I O
-PLUMBING QD
N
H
a
NSULATION PER N. Y. II uO
STATE ENERGY
CODE I '
C)
FINAL
ADDITIONAL COMMENTS:
m
' x
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H
7] ~
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? 04.
c*7
r
- - - - - - - - - - - - - - - - -
`-1 0
H
BOARD OF HEALTH
FORM NO. 3 SETS OF PLANS . • .
TOWN OFSOUTHOLD SURVEY
BUILDING DEPARTMENT CHECK; _ _ .
TOWN HALL SEPTIC rOR:I _ . _ • . . .
SOUTHOLD, N.Y. 11971
: TEL.: 765-1802 t:OT I FY ;
t•Xantnted°°~ i M
19 CALL _ . _ .
F Oat ~j........, . .
MAIL TO:
Approved . ~D.f .~.9 19.Permit No.~2) ),6~-.21n . .
Disapproved..a/c _ .
_ r uildinspector)
APPLICATION FOR BUILDING PERMIT
Date . /0 J. 199~r
_ 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 apps:
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 or demolition, as herein described.
The applicant agrees to comply with all applicable laws, rd ances, building code, housing code, and regulations, and tc
admit authorized inspectors on premises and in building f r ec ssaec ns.
(Signature of ap licant, or name, if a core at
0
(Mailing addres f applicar i~
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
NalBuddeir~s er of premises-d2GCT~Q1 .~/./i' GQ .
Val/ {as on the tax roH'or latest deed)
If a a corp ration, signature of duly au rized officer.
a and title of corporate officer)
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....... , , , ,
House Number .....Street
Hamlet
County Tax Map No. 1000 Section ...:.61 ~~tt ~y
f~ Block .....OJ......:... Lot .~S
Subdivision . • • . , , , , Filed Map No.
(Name) Y.3 Lot
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy '
II~GLI~.....
b. Intended use and occupancy
...a,4nna
-3. Nature of work (check which applicable): New Building Addition . . . . . . . . . . Alteration
Repair Removal . . . . Demolition Other Work .
4. Estimated Cost (Descriptior
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 eac}i type of use . • • • • • • • . • . . .
7. Dimensions of existing g structures, if any: Front .
Height Rear Depth .
eight 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 .
Hcigltt Depth
Number of Stories .
5. Size of lot: Front .
. 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 r
14. Name of Owner of premises . Address
Name of Architect Phone
Name of Contractor . ' • ' ' ' • • • • • • Address Phone No......... .
Address . Phone No.
15.' Is this property within 300 feet of a tidal wetland? *Yes.. _
*If yes, Southold Town Trustees Permit may be required. No .x
PLOT DIAGRAM
Locate clearly and distinctly 0 buildings, whether existing or proposed, and, indicate all set-back dimensions fro:
property lines. Give street and block number or description according to deed, and show street names and indicate whetht
interior or corner lot.
r6)1; THE
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k>;c`_. ~•"t N' GA COiN TGii iCTl aSi' ERRO
RS
STATE OF NEW YORK,
S.S
COUNTY OF...,
.
being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named.
-e /V
He is the .....~!~!V ~ A G ....~.G.......................
!
(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.
iwom to before me this
day of.. ,19'
:otary Public,
County G~~~~~~'.~~„
JOYCE M. WILKINS i . .
Notary Public. State of New York
No. 4952246, Suffolk Cou
Term Expires June 12 (Signature of applicant)
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