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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-21099 Date OCTOBER 19, 1992
THIS CERTIFIES that the building ADDITION
Location of Property 1145.RIITH-ROAD.. MATTITffCK,:N_Y.
House No. Street Hamlet
County Tax Map No. 1000 Sectignt 106 Block 7 Lot IS
Subdivision Filed Map No. Lot.No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated May 4, 1992 pursuant to which
Building Permit No. 26613-Z dated MAY 6, 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 2ND STORY ADDITION & RENOVATIONS TO AN EXISTING ONE FAMILY
DWELLING; AMENDED TO. INCLUDE WOOD DECK OVER EXISTING RAISED PATIO
The certificate is issued to ANTHONY NICOVIC
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT. OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N-253060 - OCTOBER 8, 1992
PLUMBERS CERTIFICATION DATED OCTOBER 7, 1992 - LARRY LISO PLUMB.&HEAT.
B ilding Inspector
i
Rev. 1/81
i
FORM NO. f -
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 AUTHORIZEO)
WN! e 19.4
I 2 QV13Z Date
I
Permission is hereby granted to: 1
I4 to .....plri.d A&d:,.. ~.k :,.1~ ? 0.... cl al.
of premises located at .........../5 .
II
County Tax Map No. 1000 Section ....f..OL Block .....Q... 1 Lot No...1. .
01(A -I-
pursuant to application dated ......V4
19.7 and approved by the
Building Inspector.
I,
Fee $..`{....:.5....
1............
Building Inspector
Rev. 6/30/80
_ Form No. 6
TOWN OF SOUTHOLD
r BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR.CERTIFICATE OF OCCUPANCY
i
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 user
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. $worn statement from, plumber certifying that the solder used in system contains
less than~2/10 of 17 lead.
5. Commercial^builditg, industrial;building, multiple residences and similar 'buildings
and, ins'tal'lations, a certificate of Code Compliance from architect or engineer
h responsible .far the building.
6. Submit Pltanning 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
uxiusual natural or topographic features.
2. X properly completed application and a consent to inspect signed by the applicant.
If ,a Certificaste of occupancy is 'denied, the Building Inspector shall state the
reasons ttrefbr'in writing to the applicant.
Fees
1. Certificate of Occupancy - New duelling $25.00, Additions to dwelling $25.00,-
w Alteration's 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
ew Construction...,... Old Or Pre-existing Bu:ldind< .
vocation of Property: • . • • . • IZ?9/.4.,,~ .
House No. Street Hamlet
+nwer or Owners of Property...,k///L?,%{e'J.GJ
L ) //yy
ounty Tax Map No 1000, Section.. ..Block......: ®l Lot.... 1',~5,/...............
ubdivi-sion...................... (.}Filed Map............ Lot............~.j.........
ermit No,~.~ kr{3......Date Of Permit. .Applicant. ~ ...~I
ly
ealth Dept. Approval 41A ..Underwriters Approva ~ iif r~eA•.~ 7i
tanning Board Approval...}..
equest for: Temporary Certificate.......... Final Certicate...........
ae Submitted: . ........I.. .
lyt k R1
APPLICANT
THE NEW YORK BOARD OF FIRE UNDERWRITERS Rags I
Tar 1600062 BUREAU OF ELECTRICITY s
'g B5 JOHN STREET, NEW YORK, NEW YORK 10098
Date Ocro ift 9$11M Application No. on file 7 18~r9 .rr 2 1 253M
,z
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on. the above app9ication number in the premises of
TIONT MOM, 114E RUTH ROAD, LIL. 28"7940 49e TTITE r R.To
in thefoUou+ing location; ? Basement ist Fl. KI 2nd Fl OUT - Section Block Lot
uns examined ort T4BER 69a1992 ¢rtdfound to be in;cornpliance with the requirements of this Board. i..~
,gL FlXTURE FIXTURES RANGES COOKINGDECKS OVENS DISH, WASHERS EXHAUST FANS
$ ' ECEPTACLES SWITCHES - 'n
CIUTLETS' INCANDESCENT. FWORESCENT OTHER AMT. K. W.. AMi K. W. T. R,W AML K. W. AMT. H. P. 2
24 v 23 24 Z P
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL RECTT TIME CLOCKS BELL, UNIT HEATERS 'j DIMMERS
~
AMT K W. Olt H. P. GAS H, P AMT. NO. 0. W. G. AMi AMP. MAY AMPS TRANS. AMT, H P NpF FEEtTyWAns
6CMtS
SERVICE DISCONNECT NO. OF S E R. V 1 C' E
AMT. I AMP. THE METER Ise YW 1 g 3W 3 % 3W l-Or AW NO.OF CC COND. A,W. G., D . NO. OF Hl LEG OA W. G. ' NO. OF NEUTRALS A W.G.
EQUIP, PER OF CG COND. HI -LEG OF NEUTRAL
~ t 296 c;'~ L s& 1 2P~ §
i
OTHER APPA##RggAA~TUS:®®
,S
MOTORS 14 -
48 FI°B MOT BLVD,
cxAremncivL°g, NY,' 1£ 3.,3. . GENERAL. MANAGER
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. Yi
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
lak .
TEL. 765-1802
TOWN OI SOUTIIOLD
r OFFICE OF
BUILDING
_ ,INSPECTcLrn r P.O. BOX 728 OR
i ~Of O i mot- TOWN HALL
of ~ Q SOUTI OLD, N.Y. 11971
r
C E R T I F I C A T I p N
I
Date
Building Permit No.
owner TYs ~ sff /
(please print)
Plumber
(P e pr,nt)
I certify that the solder) ';used in
contains less than 2 the water supply system
/10 of 1-a lead.
(plumber' signature)
Sworn to before me this
day of ~~i7~~CY L
19
Notary Pu c
notary public, sLf)rwk-
County
Nctaru Oublic, State of New York
No. 4791709
Quj iftd in Suffolk COuntY
Term EVIree: ` ` _
Ob~pd,
J~Zy1I27
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DinoS CORSA21710U/!S
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DESIGN CRITERIA h~000 Degree, DJL"
(FOR NON*ELECTRIC HEAT)
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i Electrical anl`L$ahting STAtemm an ,Egniprjent'.to treet regnira>nentA of ?A15•31 xK +s
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Tb tea bi! of tex Knexledge~
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a~lbrhrntfl ~theAe r1anA arrin 4qs GE Ypy,~ >y
coltpli:nce 'with the cote. Q~c
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765-1802
BUILDING DEPT.
INSPECTION
VoNDATION 1ST { ] ROUGH PLBG.
[ ] FQtJNDATION 2ND [ ) INSULATION
[ 7 FRAMING [ ] FINAL
REMARKS:
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DATE / 1-' G 1? INSPECTOR
1
k.
y
yY
s
765-1802
BUILDING DEPT.
INSPECTION,
[ I FOUNDATION 1ST [ } ROUGH : PL BG.
[ ] FOUNDATION 2ND [ I INSULATION
[ ] FRAMING [ t
2i
I r
REMARKS;
qq~
N;
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r
DATE INSPE R df
j
M-1802
' BUILDING DEPT.
I } SRECTION
FUNDATION 1ST [_j ROUGH PLBG
FOUNDATION 2ND [ ) INSULATIONS
yy gµ}emu { ] F'RAMING [ ] FINAL
1°h l MS'+YY .
F , REMARKS:
' Tic-
1F
~ I
DATE 69 ? INSPECTOR
1
7654802
BUILDING DEPT.
'ImSPECTION
[ ]FOUNDATION BT [ ] ROUGH PLBG.
] FOUNDATION 2ND ] INSt TION
[ 7 FRAMING [ ] FINAL
REMARKS: ~h ~ ~?1~.1,
DATE /O INSPECTO f
of=
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M-1802
BUILDING DEPT.
t ` SPECTION
[ ]:FOUNDATION IST [ I ROUGH PLBG.
i
[ FOUNDATION 2ND [ I INSULATION
[4f"FRAMING [ ] FINAL
;REMARKS:
ry 4,
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t O
DATE Z INSPECTOR
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765-1802
BUILDING DEPT.
i
INSPECTION,
FOUNDATION 1ST { } ROUGH PLBG.
[ ] FOUNDATION 2ND [ I INSULATION
f
[ FRAMING FINAL
G
REMARKS: ,
I
DATE f4/fl AZ,~ INSPECTOR
I
'1 LJ1; k(Dn: J{ L t'4iNTD 0
" O'
H t4l
_rCIUNDATION 1st)
a 70U.,NDATI01 (2nd) 1 I, - v
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I3GU'GH FRAME
PLUMBING
• Il. d .l h DI ~Y.uj, YY 4^ j 3
NSULATIGN PER N. Y.
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STATE ENERGY II'
Imo,.
0
l CODs I _
FILIAL Fi
-Ile
ADDITIONAL COMMENTS:
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7s
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BOdfiD'OF REALM
:FORM No.1 }`SETS OF PL AI
TOWN OF S'OUTHOLD SURVEY
kc BUILDING DEPARTMENT cllrc„i; . .
~e 1 ~ls r SEPTIC i~ovl _ . • . • . • .
TOWN HALL- -
4 SOUTHOLD, N.Y. 11971 _
C t
TEL.; 765-1302 a = F"I
Cc hCL -
i~zam... I ay} lp ! ta/1ZL Trl
0 1??Permit No.
. .
Disapproved a/c 4plroved . -
.
'f-Building Inspector)
1 APPLICATION FOR BUILDING PERMIT
Date 19.. .
i
INSTRUCTIONS
a. This application must be completely filled in by typewriter orin ink and submitted to the Building Inspector, with 3'
~ct sof 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
9r areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli-
batin.
e. The work covered by this application may not be commenced before issuance of Building Permit
I• d. Vpon rapprovai of this application, the Building Inspector will issued a Building Permit. to the appRicant. Such perinit'
mall' be kept on the premises available forinsnectio.: throughout the work.
No biziidmg"s'hall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy
all 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
~ ilding Zone Ordinance of the Town 'of Southold; Suffolk County, New York, and other applicable Laws, Ordinances or
egllatz ns, for the construction of buildings, additions or alterations, or for removal. or demolition, as herein described.
e applicant agrees lopcomply with all applicable laws, ordinances, building cod ousing code, and regulations, and to
mit authorized inspectors on promises and in building for necessary ' pection~ c
c C.~-
f applicant, or name, if a corporation)
y
(Mailing address of applicant) y
hate whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
h t~
,lame of owner of premises .
j (as on the tax roil or latest deed)
applicant is a corporation, signature,of duly authorized officer.
(Name and title of corporate officer
Builder's License No. 44~....,
Plumber's License No. rr3. 5e ..10nU &R S gs.~?
~g pp
i Electrician's License No. ~T ~ . • ~?Af ?
Other Trade's License No. .
Location of land on which proposed work will be done . .
House Number Street Hamlet
!County Tax Map No. 1000 Section i 4...... Block . Lot ,
is
Subdivision Filed Map No. Lot . . . .
(Name)
State existing use and occupancy of-premises and intended use and occupancy of proposed construction:
• .
Existing use and occupancy /..~~/.I~/V
f
b. Intended use and occupancy
I _ ~J
Addition ~ Vie.OAlteration
3. Nature of work (check which applicable): New Building.........
Repair rRemoval , • • Demolition Other Work
q1y (Description)
4 Estimated Cost ..I.... t Fee . `~.•.S??......... .
(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 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 constriction: Front Rear Depth
Height Number of Stories l
9. 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 No
14. Name of Owner of premises Address < Phone No............... .
Name of Architect Address Phone No..... .
Name of Contractor Address . • Phone No. z , .
15. Is this 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.
t
x
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TATE OF NEW YORK, S.S
OUNTY OF ~J .
............lf? .MA f4-1.& being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
>ove named.
}
a is the.......dZ. i. ......:.....................p......
(Contractor, bent, or orate officer, etc.)
said,owner or owners, and is duly authorized to per orm or have performed the, said work and to make and file this
plication; that all statements contained in this application are true to the best of his knowledge and, belief; and that the
j )rk will be performed in the manner set forth in the application filed therewith.
l
r e_E,;.,: tom. r -
orn to before me this
ft'q
E
9 ...........day of del ~ 19 p?s ti ~ s u ~u, x
2
,tary Public, Cdu ty
..?lvt
(Signature of applicant)
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USE IS UNLAWFUL I 9 I I ~ L.-
WITHOU'i CERi1F1CATf
OF OCCUPANCY - _ - t
PLUMBER CERTIFICATION -
J+ i \
ON LEAD CONTENT BEFORE r P-,, SOLDER USED'INWATER h-``,
SUPPLY SYSTEM CANNOT
EXCEED 2110 OF 1% LEAD.
Bcoppertubing is used - for water distributing - - - - - - - -
r,.~ - - - of eVetem;piping shall be
a _
. i; jr, POF NE{yY5 O
amv - -
ALL PLUMBING WASTE _ - _ - _ - - _ - -
& WATER LINES NEED - r - - - - - _ - - - - _ . - i,. ; - _ w I
TESTING BEFORE COVERING ~ - - - - - - - _ - .
APPROVED AS NOTED =r i7-ii_ -
i. 4 Wf1iTIEl s L P1-KIP # P~fESSl9H~~6
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By v WJ VPY dNO DEPARTMENT AT
C ltl~`~ .=11 _ - I
S M9 AM TO 4 PIvl FOR - IfI OWING INSPECTION& I CONCRETE THE
POUNOATION TWOREQ1.11AII
R POURED _ 1 11 • FRAMING & PLUMBING
INCULATIQN
d: PINAL CONSTRUCTION MUST -
RE COMPLETE FOR C.O I . AP TWO Lo I I `
ALL CONSTRUCTION SHALL MEET `
Slot ATE REQUIREMENTS OF THE N.V. mJJ ' CONSTRUCTION & ENEJtO'Y _II~~1 J I'' 1 }.j11 I CODES. NOT RESPONSIBLE FOfl 11 'er
ERSDFIINFlCIDE - ii Ki Jill UNDkNWN: ~ Yk ~ r r i. ~ ~ t:. - - r • REQUIRED ~g• ~ ~ I- Ij J. mi.,~ I i l I 4 14~~
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