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• FORM N0. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-21159 Date NOVEMBER 19, 1992
THIS CERTIFIES that the building NEW DWELLING
Location of Property 775 JASMIN LANE SOUTHOLD, N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 69 Block 3 Lot 15
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated JULY 2, 1992 pursuant to which
Building Permit No. 20793-Z dated JULY 9, 1992
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 (FIRST FLOOR ONLY)
The certificate is issued to PECONIC PROPERTIES MANAGEMENT INC.
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 92-SO-41- NOV. 17, 1992
UNDERWRITERS CERTIFICATE NO. N-258493 - NOV. 1992
PLUMBERS CERTIFICATION DATED OCT. 8, 1992 - ARTHUR MALANSSENA JR.
~¢.7t1~[, d~C
ilding Inspector
Rev. 1/Bl
10EK N0. f
TOWN OF SOUTHOLD
lUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
lUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
NN°. 2079 Z ire ............~..r.~.~c.~...9 t9.`?.L-
Permission is hereby granted to: 1
~~.~...!.l..`~
to ~:s.°..~rRl.S/..`.:41r.~.q,....f~~.~}.... ~.....2.5~:.~....41.N...~.....
of premises located at 7.7~....... a9R~!:!:4~a^:R .
County Tax Map No. 1000 Section ....S~~Q........ Bloek .....0 Lot No....5).P
pursuant to application dated ......~l~r~...~- 19.~.~-; and approved by the
Building In-tspector. 1
Fee S..•~~.ll.:~~?.....
.
ding Inspector
s~,~d
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 OP, 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 Pire Underwriters.
4. Sworn statement from plumber certifying that the solder used in system contains
less than 2/10 of 17 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 ..,,November 18:.1992
New Construction........... Old Or Pre-existing Building
Location of Property...~~~.~,,,..JASMINE LANE SOUTHOLD, NEW YORR
House No. Street Hamlet
Onwer or Owners of Property...........,PECONIC PROPERTIES MANAGEMENT INC: .
g .
County Tax Map No 1000, Section..~a.1........B1ock..e.~...........Lot... ~5
M/0 SODTHOLD VILLAS p.. 9737
Subdivision... ~i. ...................Filed Ma .....Lot..
Permit No.~iQ.Z 9 3 ....Date Of Permit..:T~Y.9a.1992..Applicant.,DONALD,BRACKEN...,....
Health Dept. Approval ..........Underwriters Approval.........................
Planning Board Approval
Request for: Temporary Certificate........... Final Certicate...........
Fee Submitted: $„r~$,.00.,
~?..,K .I~SI y Z APPLICANT
cow a)I~ 9 ~
~ -
_
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAG$ t
1.0@0837 BUREAU OF ELECTRICITY
85 JOHN STREET. NEW YORK, NEW YORK 10038
pate NOVENRSR 30,199^ ApplicationNmunfile 18705192/92 N 258493
THIS CERTIFIES THAT
only the electrical equipment as deacrihed 6efow and introduced 6y the applicant named on the ohooe application numher in the premises of
ti
SiATFRHOUSE-SOUTHOLD VILLA, 775 JASNIN$ LANE, JOBt4, 50UTHOLD, N.Y.
in thefollowinp location: ®Baaement ~ lat Fl. ® 2rtd FY. ~11T .Sertion Block Lut
uws ermnined un r
NOVEHBSR 19 1992 andfound w6e in carnplianre with the requirements of this Buard.
FIXTURE RXTURES RANGES COOKING DKKS OVENS DISHWASHERS EXHAUST FANS
OUTLETS KEPTACLES SWI7CNE$ INCANDESCENTfWORFSCENi OTHER AMT. K.W. AMT. N.W. AMT. K.W. AMT. K.W. AMT. H.P.
10 25 13 10 1 p
DRYERS FURNACE MOTORS FUTURE APNIANC! FlEDERS SPKIAL RlC'PT TIME CLOCKS gEll UNIT HEATERS MULTI.OUTIlT DIMMERS
AMT. K, w. Oll N. P. GAS H. P. AMT. NO. A. W. G. AMT. AMP. AMT. AMPS. TRANS. AMT. H. P. SYSTEMS M1i. WATTS
NO.OF FEET
5 2
5lRVICE DISCONNKT NO.OF 5 E R V I C E
AMT. AMP, TYPE MlTFR 1,e YW 1 ,e ]W 3 $ ]W 3 L AW NO. OF CG COND. A. W. G. NO. OF H6lEG A W. G. NO. OF NEUTRAl3 A. W G
EQUIP. PER 8 OF CC. COND. OF NI~LEG Of NEVTRAI
i 1 100 CB 1 B L q 1
1 OTHER APPARATUS:
3
c.P.c.zl-2
5H0!<E DETECTORr-i
! ' -~~-C
SPUDS ELECTRIC 3EP.YICE LIC.1192 6 i
175 3RD. ST. ROB 1(i6
OWlRAI MANAORR i
ST. JAMES, NY, 11'180 11 , r
Per I _
This certificate must not be altered in any manner; return to the office of the Fbard if incorrect. Inspectors may be identified by their credentials.
Z COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
c~~F F ~L{'` TEL. 765-1802
0~~•,,`• _;y 1. ~l~ TOWN OF S01tTTII0d.D
~ f
• - < OFFICE OF BUILDIPIG INSPECTOR
c°rt ~ ti;~ =~-t.~~+, P.O. BOX 1179
ct? ~ TOWN HALL
%Ol ~b~ SOUTHULD, N.Y. 11971
C E R T I F I C A T I O N
Date ~G'
Building Permit No. a n / 9 3
Owner
(please print)
Plumber ~~~~SS~~
(p ease print)
~Z6 3 /-P~
I certify that the solder used in the water supply system
contains less than 2/10 of 1, lead.
(plumber's signature)
Swo n to before me this
day of '
19~, ,
Notary Public
Notary Public,
County
MARYANNE E. OOWLING
Notary Public, State of New York
No. 5000030
Qualified in Suffolk County
Commission Expires August 3, 199.
ao~g3 ~
765-1802
BUILDING DEPT.
1 NSPECTION
[ ]FOUNDATION i8T [ ) ROUGH PLBG.
[ ] FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING p(] FINAL
REMARKS: rs~E C,c^~ .
DATE 18 q L IN8PECTOR .t:. ~ ,
~ do~~3
768-1802
BUILDING DEPT.
INSPECTION
(]FOUNDATION iST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND p(~ INSULATION
[ ]FRAMING [ ]FINAL
DATE 9 i IN8PECTOR ~L
ao~9~~,
ass-isoz
BUILDING DEPT.
1 NSPECTION
[ ]FOUNDATION 1ST [ls] ROUGH PLBG.
[)FOUNDATION 2ND [ ]INSULATION
(x] FRAMING [ ]FINAL
REMARKS: ~
DATE ~ q'- INSPECTOR U ~ L
'1cL~ L;:S:c-.~;:~ i~9,;:~ I~ ::iilii•1l.Ni^
_ ~ _ ? J
-o
'OUIJDATION (1st) I Q),)
'OUtJDATI0IJ (2nd) _ ~
r~
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T o ~
;OUCH FRki•fE & V
• v'i
PLUMBING
3. ~S l y
y
m
=1JSULATI0;1 PER N. Y. I y
STATE EiIERGY ~I
CODs
u /g C.C9. _~r
m yy
H 1+
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FI;JAL I -
• ~ o
ADDITIOPIAL COMMENTS:
rnwQ S TI I~ A ~ r7~V1 ~ ]L / I ~ 71~ 7
pp V N
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BOARD OF HEALTH
FORMN0.1 } SETS OF PLAtiS
TOWN OFSOUTHOLD SURVEY
BUILDING DEPARTMENT C11ECF
TOWN HALL SEPTIC FORtt
SOUTHOLD, N.Y. 11971
TEL.:765-1802 t:oTIFY; L,6 r. 6Q'/~,
p p CALL 'T
Examined , , , „ 19 9.?-- MAIL TO
Approved . g , 19~?-. Permit No.a9Z 9. ~~t. ~ . .
Disapproved a/c
.................................Y~~........
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date . 19
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3
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 streets
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 permit
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 Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
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, ordinances, building code, housing code, and regulations, and to
admit authorized inspectors on premises and in building for nec ry inspecti s.
(Signature of applicant, or name, rf a corporation)
(Mailing address of a~licant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
,~1
Name of er of mises ~:e4'L44C..~~4Q4..//.?~-~
(as on the tax oll or latest deed)
If pl' is a o ati , signs ure of duly a}~horized officer.
r( a e and title of corporate officer)
i
uil is License No . .
Plumber's License No. j. pP..3 ~..P .
Electrician's License No. ~ ~ .
Other Trade's License No .
n ,A
1. Location of land on which proposed work will be done. ...~-4:44 4+:?"!-~x-: ~,,GL~~... ~'I~~ . .
House Number L Street Hamlet /
County Tax Map,,~~No. 1--770~~0Jy0 Section~~.//.!.47........... Block .....Q. ~..o....7.'.7. Lot .
Subdivision :~~'sr-n:~•c~ch~~ 1:4C~~~'........... Filed Map No. ~:?.1..... Lot .
(Name)
2. Stale existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy .
/ 7
b. Intended use and occupancy l ~~?:4{~~'..C~!Ctr.~~,~?~~ii .
U
3. Nature of work (check which applicable): New Building ...:4..... Addition Alteration
epair Removal Demolition Other Work
(Description)
4. Estimated Cost 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 t
YPeofuse
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 .
eight ...............Number of Stones
9. Size of lot: Front Rear Depth
0. Date of Purchase ..Name of Former Owner
Zone or use district in which premises are situated .
2. Does proposed construction violate any zoning law, ordinance or regulation: .
3. Will lot be regraded Will excess fill be removed from premises: Yes No
14. Name of Owner of premises ....................Address ...................Phone No............... .
Name of Architect ...........................Address ...................Phone No............... .
Name of Contractor ..........................Address PhQge No.
Is t is 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 according to deed, and show street names and indicate whether
interior or corner lot.
STATE OF NEW YORK S.S
COU{N~TY OF ^av7~~~/-~\ .
• • • >~4~/.A.~.t1. • • {-10<.~•~'G~ being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named. [ ~ L
He is the ...................../~~^r-.[.............................................................
V (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 ~
~
fs2... day ~LX... , 19.`2
Notary Public, ~ ~..''.~~--'~~~~,~,,tt ~ sv~ ~
..............'~°:':Ca . ,7`: ,,.,Count
~~dN.C ~
(Signature of applicant)
~
sic,
PLEASt ~vJ i t
P~ Sanitary system is not to be
°P~~ _~'~~E Placed under dr?v ar
-r(- s ~ away ea.
M27 ~
b a10•
4 y
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~u~ , ~ /I 9 ~ ~ ~V~Y OAF
SiN~AMiI~f DVVEI.UPKs QIVIY
EXPIRES 3 YEARS E'ROM OJ1'fF OFAPPROY/I~L '~t+1tp ~ ~ T 4 ViLAS^'
Fl~i 9~C~~iF~MQ
Prepb'ed In oecordarwY wdh /M arAr/mwr? J4 T ~7V V l rai+~.ir
s/rre~?ac far fq/e sarve~s o< ee/eal+aed
ry I.t,~.l..s..~e ewd ane oda~y/ed TaWN'Of S'CXIT~i.D
ra rn. n°~w` ro,~r sro~. ~.?~d S'UFFUILK GC~LN1 f T Y !!L Y.
Tae we%r s~a~ and seweq. al~pora/ 110i0i0 - 70 - 0~ - P/rD
syNerrr for ~s_ ~di+rce w~ caen//irm i
!o s/a,d.?dc of Ta. swfwlt Cow?ly $CJIIIl: 1' =
T~ bcoMau of we/r and ofe~poafr sboMn dawa ore Horn HKO
o8serveJ/oec and a /rom daM o0iatied Han enters. ~~.u, ~ ~
x~oFt~K vA~a~ c~ir ~1~ . M , ~'9~
k1AY 28' 1992 ~ l~Y.~ L~ f+10. 496!8
oA eUF. ~ ~ QRS, P.C.
S. C. GEPT OF
NEFlITN SERVICES
. Y. !l97/
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'mi'l
AREA 1"1,000 aq.f! ~~~1~~~ P Y+v
suRVEr of
7ttE LAM6 .AND SAVNW~S BANK
PECOMC PRARERTES AIANA~NT CARP.. LOT 4
aF s~o~urtaro vuAS~•
Prapa?sd M? accordance wlhti /ha mkilnwm ~~P~~297
slandrds for 11Ns surveys as aala~OMshad A T s'Q~,~]~Q
by fM L.1.A.L.S and Quad and adopted TOWN OF SOUTHOiLD
!or each au by The New Yak SioM Land
rn" Assec/oHon. sUFI ~CXK CQ(~VT Y, I K Y.
Tha wolK supply and sswoq~ aYapoao/ X100 - 70 - 01- P/~ Od
sys/srns Fw M!a rssldanes w!N conlorm
to Jha slaondordr of Ths Sul/afk Caarly 5'CA~~ lrr= 3~r
Daparlman/ o/ Hadlh SarWcss. March 1Z 1992
The /ocollons o/ wags and cesspools shown hsraoa ore from !ls/d Y ~f«wif~t~0I7~
obssrvalhN?s and or liom dole obla4red Jrom olhers.
SUFFOLK COUNTY DEPARTAElIT OF HEALTH SERVICES <A~'~~°~
FOR APMiOVAL OF CONSTRUCTK7N ONLY
~ N.Y.S LIC. N/O. 49618
DATE - wS. REF. N0.
6 ,rte 3 Sr P.C.
0
Q~'~ ~ . 1197/
~1-1070 (4)
SIIfFGLK COU~YTy r,EfARif~:ENi' CF i~if,+'1i3N SER!?mES
V 1~'`~3~~~~~''=~~ , k /~J~(~
(y/M IOCa .v!1 IE)~+c' ~ c:it s ?'.i u;
otYier age ,ups tar
__i~._. ~`r~.y..~.______.
~ASI~r._ ~ f o E3uraau of t^last_~;: ~ ~r Y;?aaagement
J` S's•~~0 E r
O ~3' 00'
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m~~ a ~ ~ SS OQ. '
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moo' ~l ~0 f25• rL'(
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ry Y f-
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N,'S•~ryO~'
~Q 7.S,p0,
Qom.
4 ~ f CQ41~
AREA-= 12,000 sq.ft.
CERT~~O Toy SURVEY OF
Tl~ LONG /SLAAO SAVNVGS BAPN( / O ~
PECONIC PROPERTIES MANAGEMENT CORP. `'r
~~J.%~. ii y3 Cu.~cl,-,~.~- i/9 3 'Xb4P QF SOIJTI,~O~.D VLLAS"
~Ep JlAAE?:f~ !99'1 MAP WQ 9?97
Prepared In accordance wllh the minimum A T SOUTHOLD
standards for title swvsys os es/abUshed
by /M L.L,a.L.S ~d approved and adopted TOWN OF SOUTHOLD
for such use by Ths New York Sla/e Land SUFFOLK COUNTY, IK Y.
Tlik Aasociollon.
Ths water supply and sewage d/sposo/ 1000 - 70 - 01- P/O OB
systems !or his residence wIN conform SCab~ 1~~= 3~~
to the s/ondords of The Sullo/k County
Department of Health Services. March 11 1992
Ju Y 15, 1992 (foudihonl
The locations of wells and cesspools shown hereon are liom !le/d OCt 23,1992 (fi/181~
observations and or tram da/a obtained tram others. '
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES ~
FOR APPROVAL OF CONSTRUCTION ONLY ~ 'ti
S I ~ , ~ . Y.S LIC. N0. 496/8
92 SO 41 1
DATE wS. REF. NO. ~ ? O V RSA P.C.
sG-~ S
4V~ ~S APQrt~
APPROVED H~'~ SOU . Y. 1197/