HomeMy WebLinkAbout29681-Z FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-30773 Date: 02/17/05
THIS CERTIFIES that the building ADDITION
Location of Property: 455 SHORE LA PECONIC
(HOUSE NO. ) (STREET) (HAMLET)
County Tax Map No. 473889 Section 86 Block 1 Lot 4 .21
Subdivision Filed Map No. Lot NO.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated AUGUST 27, 2003 pursuant to which
Building Permit No. 29681-Z dated AUGUST 28, 2003
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 DECK ADDITION TO AN EXISTING ONE FAMILY DWELLING AS APPLIED FOR.
The certificate is issued to ROBERT S & LYNN S JERNICK
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
ELECTRICAL CERTIFICATE NO. N/A
PLUMBERS CERTIFICATION DATED r/7 N/A
Au hori ed Signature
Rev. 1/81
Form No.6
TOWN OF SOUTHOLD 1 lJ I I
BUILDING DEPARTMENT
TOWN HALL B 7
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be filled in by typewriter or ink and submitted to the Building Department with the following:
A. For new building or new use:
L 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 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- $.25
4. Updated Certificate of Occupancy- $50.00
5. Temporary Certificate of Occupancy-Residential $15.00,Commercial $15.00
Date. 2 �11�Ct
New Construction: ak COld or Pre-existing Building: (check one) {�
Location of Property: T5� l�O�e Lane q n)C
House No. Street Hamlet
Owner or Owners of Property: cAl z! l Irl fl J tp Y 111 LV,
Suffolk County Tax Map No 1000, Section 1 Block _ 0CXD Lot QZI
Subdivision Filed Map. Lot:
Permit No. 2g l oEl Date of PermitA/ kpplicant: Inn m
Health Dept. Approval: Underwriters Approval:
Planning Board Approval: /
Request for: Temporary Certificate Final Certificate: (check one)
Fee Submitted: $
.- 30 73 S
G ?� 3 I Ap licant Signatur
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)
PERMIT NO. 29681 Z Date AUGUST 28 , 2003
Permission is hereby granted to :
ROBERT S & LYNN S JERNICK
550 SUNSET AVENUE
SOUTHOLD,NY 11971
for
CONSTRUCTION OF A REAR DECK ADDITION AS APPLIED FOR
at premises located at 455 SHORE LA PECONIC
County Tax Map No. 473889 Section 086 Block 0001 Lot No. 004 . 021
pursuant to application dated AUGUST 27 , 2003 and approved by the
Building Inspector to expire on FEBRUARY 28 , 2005 .
Fee $ 150 . 00
L
rized Signature
ORIGINAL
Rev. 5/8/02
765.1802
BUILDING DEPT.
INSPECTION
[ FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[✓)/FRAMING [ ] FINAL
[ ] FIREPLACE A CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS:
DATE �� U INSPECTOR-
_ -,4-? + _ ,� TOWN OF SOUTHOLD PROPERTY RECORD CARD
OWNER STREET VILLAGE
DIST. SUB. LOT
FORMER OWNER N E ACR.
i.-
kt, Cutmirn n S�hfmbn Ffun�PS S W TYPE OF BUILDING
SEAS. ✓ VL. - FARM COMM. CB. MICS. Mkt. Value
LAND IMP. TOTAL DATE REMARKS
//O/c/7- L l 261L D- �• C l�cR l Cv CC/ma2 �e s v ,
[S -A
.2 116
Tillable FRONTAGE ON WATER
Woodland FRONTAGE ON ROAD
Meadowland DEPTH
House Plot _ i
�H (� BULKHEAD
Total
� q
)LOR /I ',rl �� r l TRIM
i= z
I 3
4 2
i .
S � _
86-14.21 01/03 / /y
M. Bldg. X hg
Ext 'an
Extension
Extension rr��
Foundation C <� Both 1/y Dinette
Basement _ Floors K
Porch LL
Ext. Walls – Interi
Porchor Finish LR.
Fire Place
BreezewayLb Yz< Heat DR.
-15 —7 Type Roof Rooms lst Floor BR.
Garage c'2 X Z = 2
Recreation Room Rooms 2nd Floor
Patio
Dormer Driveway
Total j fl�
r �
I
FIELD INSPECTION REPORT DATE COMMENTS
'a
m
FOUNDATION (1ST) ^� ` oo
(U a
--------------------------------------
FOUNDATION
----------------------------------
FOUNDATION(2ND) m
2
ecO
ROUGH FRAMING& - -- -
PLUMBING --
� aa
r
m
INSULATION PER N.1'. ^1
STATE ENERGY CODE --
FINAL
ADDITIONAL COMMENTS
__ - - -- - O
- - -- - 70 z
n -]
- ul, o
S
m
a
x
0
m
N OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
-DING DEPARTMENT Do you have or need the following,before applying?
'1'N HALL Board of Health_
JTHOLD, NY 11971 3 sets of Building Plans
,L: (631) 765-1802 Planning Board approval /
tX: (631) 765-9502 ^� �J/,Q Survey !/
,ww. northfork.net/Southold/ PERMIT NO. (b U Check $150-00
Septic Form
N.Y.S.D.E.C.
22 Trustees
Examined 12 0 2/ Contac[:
Approved O . ''0 J Mail to:
Disapproved a c
Phone: -3V-73
Expiration 2 2, . 20
I'
Builtdg Inspector
At V21
i APPLICATION FOR BUILDING PERMIT
-- Date
INSTRUCTIONS
a. This application MUST be completely tilled 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 waterways.
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 issue a Building Permit to the applicant. Such a 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 pan for any purpose what so ever until the Building Inspector
issues a Certificate of Occupancy.
f. Every building permit shall expire if the work authorized has not commenced within 12 months atter the date of
issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the
property have been enacted in the interim, the Building Inspector may authorize, in writing, the extension of the permit for an
addition six months. Thereafter, a new permit shall be required.
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 necessary inspections.
(Signature of applicant or name, if a corporation)
P_� Pe( my-, 105A
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
0\-A;mor
Name of owner of premises r )t + S . demLk
(As on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer
(Name and title of corporate officer)
Builders License No.
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Location of land on which proposed work will be done:
i C�5 SYh6 m La e Perm-n c,
House Number Street (� Hamlet
County Tax Map No. 1000 Section NO Block Lot r+ 2—
I t
Subdivision h i(lim and sklat es Filed Map No. (C q:13 Lot 21
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy r{tel - ��((J�)
b. Intended use and occupancy
3. Nature of work (check which applicable): New Building Addition_ [Alteration
Repair Removal Demolition-Other '�'ork
(Description)
4. Estimated Cost Fee
(To be paid on tiling this application)
5. If dwelling, number of dwelling units Number of dwelling uni,s 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
T
Dimensions of same structure with alterations or additions: Front Rear
Depth Height Number of Stories
8. Dimensions of entire new construction: Front Rear Depth
Height Number of Stories
9. Size of lot: Front H5,cr," Rear Ly&oo' Depth 155, 00�'
10. Date of Purchase 3e n z r?)3 ame of Former Owner
11. Zone or use district in which premises are situated
12. Does proposed construction violate any zoning law, ordinance or regulation? YES NO t/
13. Will lot be re-graded? YES NO Will excess fill be removed from premises? YES NO✓
14. Names of Owner of premises , -JP UL4ddress% �S 1lull L LMtr Phone No. -734 `1311
Name of Architect LAMA TLA+b i I I AddressM(LA(1O EnE<tq VhoneNo_ (4-1-1-US78
Name of Contractor 50 Address Phone No.
15 a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES NOyl
* IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED.
b. Is this property within 300 feet of a tidal wetland? * YES NO
* IF YES, D.E.C. PERMITS MAY BE REQUIRED.
16. Provide survey, to scale, with accurate foundation plan and distances to property lines.
17. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey.
STATE OF NEW YORK)
SS:
COUNTI'OF )
being duly sworn, deposes and says that (s)he is the applicant
(Name of individual signing contract) above named,
(S)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 manner set forth in the application filed therewith.
77Z
' 1f
92---f---- >
otary Public Signature of Applicant
NOTARY PUBLIC Stattee ofNew York
No. ois66020932
Qualified in Suffolk County
Term Expires March 8, 20CL7_
BUILDING PERMIT EXAMINER CHECKLIST
DATE REVIEWED: /03
APPLICANT: DATE SUBMITTED: &Q3103
SCTM#DISTRICT: 1,000, SECTION: BLOCK: LOT: SUBDIVISION:
ADDRESS:�56 CITY: ZONING DISTRICT: _CONFORMING?
BUILDING PERMITS OPEN/EXPIRED: PRE CO: Y OR N
Bp-Q& /C/0 Z-0TA 16_3, INFO /BP -Z/C/0 Z- , INFO
BP -Z/C/0 Z- , INFO /BP -Z/C/0 Z- , INFO
SINGLE & SEPARATE CERTIFICATION-REQUIRED /Xy NOTES:
LATS 40,000SF-100-24.Lot recognition.(CREATED before June 30,1983),UNDERSIZED LOTS FROM JAN.1997 100-25.Merger.(A nonconforming at anytime after 7i
REQ. LOT SIZE: ✓ ACT. LOT SIZEEQ. LOT COV. ACT. LOT COV.
REQ. FRONT _PROP. FRONT ✓REQ SIDE ACT. SIDE ✓
REQ. REAR PROP. REAR 15-1 REQ. HEIGHT "-'PROP. HEIGHT
PROJECT DESCRIPTION: Qa a Dom.
ESTIMATED PROJECT COST: ARCHITECT c.Tn-i lel_
WATER FRONT? p DESCRIPTION: PANEL # FLOOD ZONE: XC
APPROVALS REQUIRED
SUFFOLK COUNTY HEALTH T: YES orO, BED #): DTE: / / PERMIT #:
TOWN SEPTIC RECEIPT: Y 04:L
NEW YORK STATE DEC: PRE-DEC 9/l/75 YES O DTE: / / PERMIT#:
SOUTHOLD TOWN TRUSTEES: YES o DTE / / PERMIT#:
TOWN ZONING BOARD APPROVAL: YES DTE: / / PERMIT #:
TOWN PLAN. BOARD APPROVAL: YES _ DTE / / PERMIT #:
_E_
TOWN HISTORICAL PRE (SPLIA): YES o N
NEW YORK STATE CODE COMPLIANCE (SEE PAGE 2): r NO
NOTES:
FEE STRUCTURE: FOUNDATION: SF
FIRST FLOOR: SF
SECOND FLOOR: SF
OTHER: SF INIT OTHER TOTAL
TOTAL: SF FEE FEE FEE
1. (_SF)- ( SF)= SFX $ =$ +$ +$ _$
2. ( —SF)- ( —SF)= SF X $ =$ +$ +$ _ $
3. (_ __SF)- ( _SF)= SF X $ =$ +$ +$ _ $
FINAL TOTAL: $ s—s
NEW YORK STATE CODE COMPLIANCE CHECKLIST
CLIMATIC/GEOGRAPHIC DESIGN CRITERIA: ✓ /
Ground Snow Load: 45 : Wind Speed: 120MPH Seismic Design Category:B
Weathering: Severe -/ Frost Depth: 36" ✓ Termite:M-H ',/ Decay: S-M
Design Temp: 11 ✓ Ice Shield Underlay: YES N �g Flood Hazards: 111 A
USE/OCCUPANCY CLASSIFICATION:
HEIGHT/FIRE AREA:
TYPE OF CONSTRUCTION: W r-C.
DESIGN CRITERIA: ENGINEERED/ SCRIP E WFC#, I
FULL FRAMING DESIGN ELEMENTSO/N
HEADERS: Y/N WALL STUDS: Y/N GIRDERS: Y/N
CEILING JOISTS: Y/N FLOOR JOISTS: YIN ROOF RAFTERS: Y,'N
LUMBER SPECIES AND GRADE: Y/N
DESIGN LOAD CALCULATIONS:ON
LIVE: Y/N DEAD: Y/N SNOW: Y/N SEISMIC: Y/N WIND: Y/N
WINDOW AND DOOR SCHEDULE:
MISSLE TEST REQUIREM NTS: Y/N
EGRESS 5.7 S.F.: Y/N
LIGHT 8%: Y/N U �'
VENT 4%: Y/N
NAILING/CONSTRUCTION SCHED LE: WN
MEANS OF EGRESS: Y/N
PLUMBING RISER DIAGRAM: Y/N
LOCATION OF FIRE PROTECTION EQUIPMENT: Y/N
TRUSS DESIGN: Y/N
CERTIFICATION: Y/N
ENERGY CALCS: Y/N
TOTAL COMPLIENCE? Y/N (RETURN TO PAGE ONE)
SURVEY OF
\YQ LOT 21
�O MAP OF
O RICHMOND SHORES AT PECONIC
(( FILE No. 6873 FILED NOVEMBER 20. 1979
j/ ry,6Mbe SITUATED AT
PECONIC
�s TOWN OF SOUTHOLD
SUFFOLK COUNTY, NEW YORK
9P S.C. TAX No. 1000-86-01 -4.21
SCALE 1"=40'
JANUARY
JULY 25 2000 REVISED WATER SERVICE
.JUNE 26, 2002 REVISED PROPOSED HOUSE
\ \ OCIUBER 29, 2002 FINAL SURVEY
\ AREA = 22,475.47 sq. ff.
'\ 0.516 ac.
` ll.,
090 i
4
a O•. �JYI
CERTIFIED TO.
p5t Q+s j ; COMMONWEALTHLAND TITLE INSURANCE COMPANY
�,0 •0 00< e`4 v: H58C MORTGAGE CORPORATION (USA)
�P`Q P�F,P w \ 1 �2G 'r„ , '\ /� ROBERT S. JERNICK
26 L' �\ LYNN JERNICK
yl�v <
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9� 1� m�11SM mF W T EWI Joseph A. Ingegno
9B' J4 � b^� t2 w n"sumiro s »aa vi of Inc
, �TRUE 00R:. H Land Surveyor
CF]HFIMoprwrtD nik 5Nµ1 M1IN,
My ToO THEE PEFIAND m rob III THE THE
IT rr¢naam. . .n ras A-AC To nc
/. U NNPANr• ION USYp1TK AaHCY AND Iitb Svrreya - Subdniaiona - 9'fe Nana - Cora/rvcfkm tvywt
1`+A\ To ME wsnrurS F THE Irnmx. uro
T. m wsacrrEs ar THE LQtlwlf a¢n-
>\nloxATiaNs Aa xm TnwssEnAaE PHONE (631)727-2090 Far (631)717-1727
RN
E%ISTENCE
THE FR C WAYS
THE EASEYENfW$ OF RECORD, s OFFFQES L"I'M AT NAN.IAC ACORL55
ANY, NOT SHOWN AM NOT GUARANTEED. 133 ROAHOHE AVENUE P.O. hex 1931
RNMEAO, New York 11901 Rnemeco. New York 11001-0965
- D AS NOTED
DAA B.P.
FEE- BY: -
NOTI BUILDING DEP _ AT
765.18N !AN 70 4PM FOR THE
1.1ING
PoUUNND TION . TWO REQUNED
FOR POURED COO a PlE
2. ROUGH - FRAMNfi i.PLIIL�wip
9. INSULATION
4. FINAL - CONSTRUCTION MUST ,l _ - .,; . ._ .
BE COMPLETE FOR C.O. _ ----- ..
' ALL CONSTRUCTION SHALL MEET THE -
YORK REQUIREMENTS OF THECOOSSOF NEW
YORK STATE. N07 RESPONSIBLE FOR - ut- � ..
DESIGN OR CONSTRUCTION ERRORS. - ---'--, _ - _
I Rra• o�
NEW YORK STATE A TOWN CODES hr f�T 1P1
COMPLY WITH ALL CODES OF � �-'- R+`s.�-Rr (rtrt) s,,, ry.,,. ATe«. Ar� t
AS REO RED AS�1O/yN�HD�OI�D �AIONS OF 1 r K g �� exp --
ANIfIW.Y 11Y111r�W�\IrI1 G11111Y y ,.y{' a'� y � - ,���,
[LYS,mc
OCCUPANCY OR
USE IS UNLAWFUL
WITHOUT CERTIFICATE
OF OCCUPANCY
INSPECTKW-
� A
FLOOD ZONE
. . ir
COMPLY WITH CHA . .+�. �-?: 4 '� %'
FLOO'(TDAMAGE PRE ENTION -
SOUTHOLD TOWN CODE. '-
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ALLCONSTRUCTION - Ta " '
MEET THE REQUIREMENTS HE "+ ) Ali i
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'•'`.d¢ br'sxaaelda ounint*4 Ate*do locoolidhar mdf 4m is aped regulafloira,"c �`. , . �S:rsAar�i'vF"'itlnDup�and.aropuiplyr C'Mo su flaor,:Ridehod material t0 be 5 ' .. P '' . '�`4hK :. `SEg.;. :. �` yA�'-',�"e'T,i"`I . ." , '""K- '�:'�, , � .7
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tconsbucdon'means.ih'r I, tdi'dlnliluea;sagUeitCga..orPrticedu6de',or for safety ., - ¢fPa'w.fl ,.,.----- ,•,----,,.-.
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bedroom.verify with local ood m4uitemani par SAO*R38YA460 York Slate , - 14:Provide Appropriate aalflt vemdedon oi,m *"Pi• � :. 4 , _
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GENERAL FOtlNDA'RON NOTES-- .: . . - ,, , ' 9 W redPaMJ,. . fpr h>tfiRgfnad 9!POIWble'aadeand _ - ..�: :.,,r B+tt L P �':',�, . ''r,:a"t ` i . .It
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''�t' - .. 'r - ' + ; `' " . : ', GENERAL HVAC SYaYEtr7 NOTES'
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. safety requwemaree : - ,
, :I 60nends,lWt 4rsandfoPdrevalaig�rohllmum ' r6%6'=noMgwlre hlaeh reinforr�ng.. - L'PANEi "`--'"
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