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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-.1,6990....... Date ....June..l4.,..1,988
THIS CERTIFIES that the buildin ADDITION
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Location Of Property 400 Conklin Road Mattituck N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section ....1 3.9 .....Block 4.........Lot 6 .
Subdivision ...............................Filed A4ap No. ........Lot No. .
conforms substantially to the Application for Building Permit heretofore filed in this office dated
May 1 0 , ] 9 8 8 pursuant to which Building Permit No. ~ ~ 04 6 Z
dated June ] , , , 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 .
FIREPLACE ADDITION TO EXISTING ONE FAMILY DWELLING AS APPLIED FOR
Tlie certificate is issued to , , JOHN R. & JANET E . FLOWERS
(owner, ld?~YbirX~~r~t3;rX
of the aforesaid building.
Suffolk County Department of Health Approval N { A . . . . . . . . . .
UNDERWRITERS CERTIFICATE NO N,/A , , , , , , , , , . , . _ _ . , ,
PLUMBERS CERTIFICATION DATED: N{A
Building Inspector
Rev. 1/81
]PO8d1! NO. 19
TOWN OF SOUTHOLD
Bli1LDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUI6DING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
No 017046 Z Date ...&:./1 ~9rf..~
Permission is hereby granted to~
.............................................r
to ..~ar®...~.e~(F.:C~...~U... j~f.....(,~Gi;~tlt'YJ..........
~1~.......~ .r~~sf.::r3Y/"."'
of premises located at ......~'(2.Q....... ....'......~m'/.~
...............................................CeY~G~
.~..'.~`.~lrf-................................................................................
..........................................................................Q.....................................................................................
County Tox Map No. 1000 Section Block Lot No ................5°....
pursuant to application dated a...................., 19.~~, and approved by the
Building Inspector.
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Fe ~.r)I
` ildin or
Rev. 6/30/80
FORM NO. 6 ~ ~ ~ ~ ~
.JWV " I TOWN OF SOUTHOLD ~ ~ r-~
f
# Building Department f~\f
Fil-DG.
DC''"~
t:y"'°°y Southold, N.Y.111971
TOWN OF ^sOUi'HOl.I) 765 - 1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted to the Building Inspec-
torwith the following; for new buildings 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 of Health Dept. of water supply and sewerage disposal-(S-9 form or equal).
3. Approval of electrical installation from Board of Fire Underwriters.
4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa-
tions, acertificate of Code compliance from the Architect or Engineer responsible for the building.
5. Submit Planning Board approval of completed site plan requirements where applicable.
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing"
land uses:
1. Accurate survey of property showing all property lines, streets, buildings and unusual natural or
topographic features.
2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings.
3. Date of any housing code or safety inspection of buildings or premises, or other pertinent informa-
tion required to prepare a certificate.
C. Fees: Additions $25.00 POOLS $25.00 ALTERATION $25.00
1. Certificate of occupancy New Dwelling $25.00, Accessory 10.00 Business $50.00
2. Certificate of occupancy on pre-existing dwelling $ 50.00
3. Copy of certificate of occupancy $ 5.00, over 5 years $10.00
4. Vacant Land C.O. $ 20.00 Vc~
5.Undated C.O. $ 50.00 Date.~..4~h~e~..~. 1~~~?....
t.......
NewConstruction,,,,,, OldorPre-existin Buildin
g g ~ Vacant Land,r
Location of Property .............~.C1117.~:~.,I.N...!~V'.........MCJI:L'4!~(f~~~...
House No. Street Hamlet
Owner or Owners of Property , , ,
County Tax Map No. 1000 Section Block Lot................
Subdivision .................................Filed Map No. ..........Lot No. .
Permit No. ~.7~. ~ . Date of Permit ..........Applicant .
Health Dept. Approval ........................Labor Dept. Approval .
Underwriters Approval ........................Planning Board Approval
Request for Temporary Certificate .....................Final Certificate .
Fee Submitted $
Construction on above described building an ermi't//m,, ee~ts all applicable codes and regulations.
ApPlicani... ..~4!....~.
Rev. 10-10-78
R~ 3y~aq
cb~l6g9'D
~E
785.1802
BUILDING DEPT.
1 NSPECTION
[ ]FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [~INAL
REMARKS: b./ ~ ~ e ~
U
DATE INSPECTOR
~2
7G5-1802
~ BUILDING DEPT.
Z INSPECTION
[ ]FOUNDATION 1ST [ ] ROUGFI PLBG.
FOUNDATION 2ND [ ]INSULATION
[ ]FRAMING [ ]FINAL
REMARKS:
DATE ~ ~ INSPECTOR
r'1ELD IGS:'~~T=U;i ~~UA'iE ~01`iMGNT~ ~
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outJDnTZON (tst) ~~pS
FOUNDATIOW (2nd) _ ~ ~A
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ROUGH FRAME &
.PLUMBING
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3.
INSULATION PER N. Y.
STATE ENERGY
CODE
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ADDITIOPJAL COMMENTS: ~
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~ i~tA:~+~,~.r~'r t..~t~:,i1CrIC7Ci~1`~, i1VC. • ,
1 P.0. BOX 412
""'vU''' ~ - ~ SOUTHOLD, NEW YORK 11971
~/1'yy'" y (516) 765-3312
Cf. t ,~~~=;.~1 ~ C~~mn~~tu~~'1--m~r~. of
2' el:aova l0' Perpetic~iculai
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E+cis~~n~ Houle.
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S`4 ~n.m ~m Solid kvb.60=nry b~kleer~'T ~r C~J O~c '
wood '~rar.:~'nq~, a ~A ~
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Floor 'Eo b.4o5.~~ei2~,q?,~a~^;„bb.,l~"~'s~i'd~ewee~.°ti~F'~or wu°.
d~a{'n~nc; ~'o su~or'E- hewr}~.
• 8 G18~~ BOARD OF HEALTH
3 SETS OF PLANS .~•.K_ .
~OU~ I ( A~ FORM N0. 1 SURVEY .
vOU TOWN OFSOUTHOLD CHECK
~~1~ BUILDING DEPARTMENT SEPTIC FORM
n ~l c TOWN HALL 1 p GG~~
„OUTEOLD65-18021971 NOCALL a~(~...`:f1~D.1........
r ~•f{ MAIL T0:
Examined 19 ~yyY
Approved ,/p~ 19Q~Permit No............ ~1 o-~ Ad
L W
Disapproved a/c ~f6"Wn,
(Buil ing Inspector)
.APPLICATION FOR BUILDING PERMfT _
Date f 19 c~~
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 an . in building for necessary inspectio p
a~..?.
f~.'.. c~.~a..~'...... .
(Sig re of applicant, or name, if a corporanon)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
. .
Name of owner of premises .4. !~!`I:~ ~ ~'•1•` • T • • • • • • •
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
OCCUPANCY OR
(Name and title of corporCa~te officer) USE IS UNLAWFUL
Builder's License N ' i!~ .
Plumber's License No . ~~A 1®U~ CER~~~~CA~~
Electrician's License No . O~ OCCUPANCY
Other Trade's License No . .
Location of land on which proposed work will be done. ...~a.~ .
~S C ~ /U /c L r ~wJ t2 v cL.'p - .
House Number Stgreet Hamlet
County Tax Map No. 1000 Section Block Lot•S .....y........ .
Subdivision ~>'h~ p.~ ~ ...~e N• Filed Map No. . ~ 7 Lot .
(Name)
2. State existing use and occupancy of p/r~emises and intended use and occupancy of proposed construction:
.
a. Existing use and occupancy ! ~3. ~''r
b. Intended use and occupancy .......~.~.I~ >~'.4.5 k~ • • • • • F. 6 V`• r-. ~Z: .
i
1.5, Ri~i~ X
3. Nature of work (check which applicable): New Building Addit~pij,.~.. , y..l ~atio~ f~_~........ .
P Rem',, , , ,
Re air oval , Demolition ' " Other Work .
(D~s~ription)
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 mixe
7. Dimensions of existin structur d occupancy, specify nature and extent of each type of use
g es, if any: Front .....y~ Rear Depth ~f~ .
13eight Number of Stories .
D pensions of same structure with alterations or additions: Front Rear .....~l.d'......... .
De th .....~a. ; ..Height Number of Stories
S I;emhntsions of entire new c Num ction: Front . Rear Depth ,
g ber of Stories ,
~ ~ ..r
9. arze of lot: Front ~4 ~ Rear d.o Depth (a?s1.~ .
10. Date of Purchase e? 4 , , , ,Name of Former Owner L $,¢uNO~/, /{~tt, Tenth •
1 1.done or use district in which premises are situated . . .
12. Does proposed construction viojate any zoning law, ordinance or regulation: !Y
.
Will lot be re raded
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Name of Architect ' ' ' ' ' • Will excess fill be removed from premises: Yes No
14, Name of Owner of remises.: a ~t"sAddress ..!':`ff7 i'.~.?~{~ , , .Phone Noa-.9~.".Y! 69 .
P
Address .....Phone No.. . .
Name of Contractor 7`•%!?4 , , .C-j ,r y', • , , • , , , ,Address . c5'd. !~(p.~.9, ,Phone No. '7.6 iS 3,3 ~ ~
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and, indicate all set-back dimensions from
property lines. Give street and blocknumber or description according to deed, and show street names and indicate whether
interior or corner lot.
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ce ~ ~~,o~ose.
C oN /~~i W ~o ~ti1"J 1 ~V'wN-la ~V~~
' ` 3 ` ~At is ~ r~ ~ ~ i~ i ~ ~ .
5
STATIiO)~ TV)W~1~0'R`I~,a`"f~F`a.t` s q~.,~. ~
COUNTY OF r:,._. s a..n.;~g+ , , -
A:
• • • • • • • • • • • • • • ~ • • • • • • • _ ~ • • • • • • being duly sworn, deposes and says that he is the applicant
(Name of individual si ning contract)
above named.
He 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 manned set forth in the application filed therewith.
Sworn to before me this
................r~ daffy/of,......!:r!~........,19~~
Notary Public, ~ . q ; .'i!.(-. Y.~'; County ~
No.47079 R Suflo~lk~ nb ~ ~ . ~ ~!:-O.`":"""'...... .
NOTANYPUBUC,StateofNe ~ Si nature of applicant)
Term Eapires March 30,19