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30378-Z
FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY NO: Z-30832 Date: 03/28/05 THIS CERTIFIES that the building NEW DWELLING Location of Property: 4406 OLD NORTH RD SOUTHOLD (HOUSE NO.) (STREET) (HAMLET) County Tax Map No. 473889 Section 55 Block 2 Lot 8.6 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JUNE 4, 2004 pursuant to which Building Permit No_ 30378-Z dated JUNE 4, 2004 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 WITH DECK AND ATTACHED TWO CAR GARAGE AS APPLIED FOR. The certificate is issued to ROBERT A & MARGARET S GRIGONIS (OWNER) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 86-SO-198 04/25/01 ELECTRICAL CERTIFICATE NO. H 070995 03/30/01 PLUMBERS CERTIFICATION DATED 03/24/05 ROBERT GRIGONIS Authorized Signature Rev. 1/81 S SCr ?0 ro Form No.6 TOWN OF SOUTHOLD Ili II �; BUILDING DEPARTMENT �, Li'tJ TOWN HALL 1 765-1802 G�ii'•; DEP'. ToA- .5rv_THD!.D APPLICATION FOR CERTIFICATE OF OCCUPANCY This application must be tilled in by typewriter or ink and submitted to the Building Department with the following: A. 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. ?. 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. Swom statement from plumber certifying that the solder used in system contains less than 2/10 of 1°u 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. _ -:1 _ New Construction: Old or Pre-existing Building: _(check one) Location of Property: 4t4 0 r, 0 4- p NB +LTi-r in/k f� u i ri o t'y House No. Street Hamlet Owner or Owners of Property: .;�_. kS Suffolk County Tax Map No 1000, Section S Block 0 Cr 0 -2— Lot u o $, ooh Subdivision_ Filed Map. _ Lot: Permit No.3AeL 7 b .L Date of Permit C�/gip ,applicant: Health Dept. Approval: Underwriters Approval: x Planning Board Approval: Request for: Temporary Certificate _Final Certificate: (check one) Fee Submitted: $ 303 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. 30378 Z Date JUNE 4 , 2004 Permission is hereby granted to : ROBERT A GRIGONIS PO BOX 4406 SOUTHOLD,NY 11971 for CONTRUCT ONE FAMILY DWELLING AS APPLIED FOR. THIS PERMIT REPLACES BP#18036 . at premises located at 4406 OLD NORTH RD SOUTHOLD County Tax Map No. 473889 Section 055 Block 0002 Lot No. 008 . 006 pursuant to application dated JUNE 4 , 2004 and approved by the Building Inspector to expire on DECEMBER Lzed Fee $ 781 . 50 ORIGINAL Rev. 5/8/02 Foxes NO. 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) N° 18036 Z Dote .......... .....1...3............... 19. 1. Permission is hereby granted to: .......C�. .............................. 3� ...... . o. ............................................ ......u.. :...! 9Z.�.............. to .... .....4.....0.yW6.. ............... . ... . 24.0..A. ~ ..Y. s...'�9i ...... . .. . l..-:e.e................. .......................................................... at premises located at ... ..... . ... . ....... .................... ........ . ........................................................... ................................................................................ ...1..9...... ........ . . .. ........................ ........................... . . .......................................... County Tax Map No. 1000 Section .... -4?. ....... Block ....©.L........ Lot No. .. ...... pursuant to application dated ... 4e ......../An................. 19XI., and approved by the Building Inspector. U Fee S•• 5 75�•• .... ..................... .. . ........................................... Building Inspector Rev. 6/30/80 FORM N0. 11 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) � N° 15431 Z Date ....sem a ,.....� ................. 19.2.6 Permission is hereby granted two: . ►-...l!. Oyu.v........................... ......................... .......... .......... �. 1.�.4.. .�......... to ... .................. . .....o,.....1M?4... ....I ... ,. .?.. .... ..... ..I; ...... ... .. ..... .,.K,.fi...Y. ....�. .�.� ... ... .. .. ..... !ZA=d�........... at premises located at ...3.` 4. ... ... ......... ....... ..... ......... ... ...... ............................ ................................................................................ ................................................................................ ................................................................................................................................................................. County Tax Map No. 1000 Section ..... ...... Block ........ ..... Lot No. ....9...f............ pursuant to application dated ..Q..` rw?'`''4r....... ................ 191(;1, and approved by the Building Inspector. Fee S..a4. �.:.. i G !/L Building Inspector Rev. 6/30/80 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 AUTHORIZED) N9 12893 Z Date .. ,t� !'✓ .f ......... ...... 19.d.y Permission is hereby granted ........../s-0. Xa .�1., /rnGlf.. ,crr'ctrc�"G . ............ am..... . .2.................................. �-.. . . . ......... 7/ to ........ .......... ........ x- . .� j.......... ................................................ ... .............. ......................... ................ ..................I............ .. . . .... ....... ....... /' c at premises located at ... ./� ..........,YC7GJit/ .. 0 /........ d.�-�C>-1v� ................................................................................ ................................................................................ ................................................................................................................................................................. County Tax Map No. 1000 Section ?...... Block ..I)6G,......... Lot No. Q.U.>7.Y. pursuant to application dated J.........1 ..... 19. 7; and approved by the Building Inspector. od Fee S..... ........... t Building Inspector Rev. 6/30/80 THE NEW YORK BOARD OF FIRE UNDERWRITERS - `' J`?_-'" BUREAU OF ELECTRICITY F 40 FULTON STREET, NEW YORK, NY 10038 Date IwT'.� ,._':u;i Application .No. on file THIS CERTIFIES THAT only the electrical equipment as described below and introduced by the applicant named on the above application number is in the premises of KBEP1' C`r,]:G)VIS , 7906 CH.,D NORTH ROP-L . 0_ITIiI-J.- in the following location; P Basement 11 !st FL El 2nd Fl. "'I`` Section Block Lot Hr,CH 23. =Gm1 was examined an and.found to be in compliance with the ,National Electrical Code. FIXTURE RECEPTACLES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS OUTLETS SWITCHES INCANDFSCENA FLUORESCENT I OTHER AMi. K.W. AMT. K.W. AMT. K.W. AMT. K.W. AMT. H.P. DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS ISPECIAL REC-PT.1 TIME CLOCKS I BELL IUNIT HEATERS MULTI-OUTLET DIMMERS SYSTEMS AMT. K.W. OIL X.P. GAS H.P. AMT. NO. A.W.G. AMT. AMP. AMT. AMPS. TRANS. AMT. N.P. NO.OF FEET AMI. WATrS SERVICE DISCONNECT NO.OF1 S E R V I C E METER NO Of CC GOND. A.W G A.W.G. A.W.G. AMT. AMP. TVPF EQUIP. I 0]W 1 0 lW J 0 JW J 0 AW PFR 0 OF CC.CONO. NO.Of XI-lEG Of HIAEG NO.Of NFUTRAIS OF NEUTRAL OTHER APPARATUS: :�urvc Ilas 1-i,>_an mad'_- .ir the lectrv- _ e uirmcnt, in the ra:e7n s a it i::; Se ,.q, . h•.-.,, s ,_+ ("2:C�._ ,'.G Xa10[t l'i5 f."d"I:1�:. \ R. '_nI'_CI7It Ldl, _ 1... 'I��L'�. 41?E OLD yCr,-.�T! '?OIJTHOLL', N7. 11 GENERAL MANAGER Ii 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. i;OPV FOR BUILDING DEPARTMENT THIS COPY OF CERTIFICATET NOT VE ALTERED IN ANY MANNER. o�gUFFOLIC N Z Town Hall, 53095 Main Road O Fax(631)765-9502 P.O. Box 1179 y�ol 0� Telephone (631)765-1802 Southold, New York 11971-0959 y In BUILDING DEPARTMENT 9---= TOWN OF SOUTHOLD MAR 2 4 2005 I U I . L_ grE.T I CERTIFICATION L _T ___ Q'NN Q'.Sr._THO:.J- _1 Date: Building Permit No. 3 d 3 7 g z= Owner: (Please print) Plumber: 0 D� /✓ e-�/?- (Please (Please print) 1 certify that the solder used in the water supply system contains less than 2/10 of 1% lead. (Plumbers Si "attire) �. Swots to beforcce ..me this day of , 2065 Notary Public, JC O \lL _County BONNIEJ.DOftOSIO Notary Public,State Of New'brk No.OID06095328,Suffolk uaq Term Expires July 7,20 TOWN OF SOUTHOLD PROPERTY RECORD CARD GI OWNER STREET VILLAGE DIST. SUB. LOT ol FORMER OWNER N E ACR. S W TYPE OF BUILDING RES. (� SEAS. VL. FARM COMM. CB. MICS. Mkt. Value LAND IMP. TOTAL DATE REMARKS 121 ccr U Z S Z 4 0 - r EvE�m �5 k:Rc--1Q ---Ascot, to (0 00 .4 .5 s 1 L 1 oWM 3;23 A. C r'c , s + , r; N jc, Urr - ''� _ �' 4* S tic, 4 0 303 rw aces S-03 Tillable — FRONTAGE ON WATER Woodland FRONTAGE ON ROAD Meadowland DEPTH House Plot BULKHEAD Total ` ( '05 ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■GGii■■■ ■■ ■■■■■■■■IL■ I ■■■ ■■ t YY ■■■■■■■■■■■■■■■■■■■■ M. Bfdg. ■■■■■■ ■■■■■■■■■■■■■ ., s► Sb Foundation Bath FloorsBasement Extension Extension Fxt. Walls Interior Finish ® Extension Fire Place Heat Porch ,i■■ Breezeway �■�■ ■�� Deck ® .. . . . .. se _ ® ■ Garage �■■�■■■■ ��■ �■■■ 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND INSULATION [ ] FRAMING [ ] FINAL REMARKS: s�ij 1 DATE./c56 G INSPECTO �/ 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [1 ROUGH PLBG. [ ]]/FOUNDATION 2ND [ ] INSULATION [G�" FRAMING [ ] FINAL REMARKS:. �� G4/ l DATE '' " ZI INSPECTOR�� 765-1802 BUILDING DEPT. INSPECTION [ ] FO DATION IST [ ] ROUGH PLBG. [ FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL r REMARKS: DATE // //10 /f-6 INSPECTOR 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1 ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] IN ULATION [ ] FRAMING [ FINAL [ ] FIREPLACE & CHIMNEY [ } FIRE SAFETY INSPECTION REMARKS:--.. DATE �'L �� 'too INSPECTOR v pF SO 303 7Y Z ©} oum, TOWN OF SOUTHOLD BUILDING DEPT. 765-1802 INSPECTION [ ] FOUNDATION IST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULAT ON [ J FRAMING / STRAPPING [ ] FINAL [ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECfT�ION REMARKS: DATE 3 ��� os INSPECTOR ��' � _ FIELD INSPECTION DATE C014MENTS _ ma 1 . 3\r FOUNDATION ( 13t ) J Glo c FOUNDATION ( 2nd ) / o 2 . o ROUGH FRAME & PLUMBING 3 . 4 INSULATION PER N . Y. 3 STATE ENERGY CODE s a 3 4 . / a Gr H .b� . FINAL • ow(l z ADDITIONA COMMENT$ : c� � -7?- 52 mlH a H ) H O Z s a • r H S d m H En 3 'OUNDATION ( 7st ) -� C "1419T4 ddEL c Z N 'OUNDATION ( 2nd ) 47 m U O R7U i TOUGH FRAME & �y PLUMBING 3 . mH � � m CN$ULATION PER N . Y. y STATE ENERGY c. CODE x A y �J , FINAL s z ADDITIONAL COMMENTS : m ` ' x . y ro M _ y H d� O Z ov 1 �• x oC, m s A r ri: H � r - Z m r. ro � H FORM NO. 1 I TOWN OF SOUTHOLD OU : BUILDING DEPARTMENT ; AUG I I I10J36 TOWN HALL SOUTHOLD, N.Y. 11971 !Ute, 3-1 TEL.: 765-1802 ' 1L Examined 19 ��? ��� t.t �t 13 '7V Received . . . . . . . . . . . , 19 . . . Approved � ?�`!ti. . .1g. ., 100? Permit No. 1.S.q.?41-7 Disapproved a/c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ysr_, 8)Z.�I '1b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . �... . . . . . . . (Buil ingInspector) 3U�' APPLICATION FOR BUILDING PERMIT C 973 / 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 a Bui ment for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Sou nty, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, ions, or for removal or demolition, as herein described. The applicant agrees to comply with all applicab es, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buil inspections. a. � . . . . . . . . . . . . . . . . (Signature of ap ' ant, or name, if a corporation) � � . . .lv .. .x/17,/. . . . / (Mailing address of a4plicant State whether applicant is owner, lessee, agent, architect, ens neer, general contractor, electrician, plumber or builder. . . . . . . .lc�,3u( . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of owner of premises . Jvvva. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Name and title of corporate officer) Builder's License No. . . . . . .1W . . . . . . . . . . Plumber's License No. . . . . . . . . . . . . . . . . . . . . . . . . /v"S ffZ&C7e V_ Electrician's License No. . . . . . . . . . . . . . . . . . . . . . . Other Trade's License No. . . . . . . . . . . . . . . . . . . . . . 1. Location of land on which proposed work will be done. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3y 10 - Iavm 0 X-L - !?'bk'%.. . 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . House Number Street Hamlet County Tax Map No. 1000 Section . . . . .q ?� . . . . . Block . . . . . . 2 . . . . . . . . Lot . . . . . .3 . . . . . . . . . . Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filed Map No. . . . . . . . . . . . . . . Lot . . . . . . . . . . . . . . . lNmnel 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. Intended use and occupancy . . .nj,;-'Y7f. !t'— . . . . . • • . • • • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Nature of work (check which applicable): New Building . . . . . . . Addition . . . . . . . . . . .Alteration . . . . . . . . . . Repair . . . . . . . . . . . . . . Removal . . . . . . . . . . . . . . Demolition . . . . . . . . . . . . . . Other Work . . . . . . . . . . . . . . . U- yDescription) 4. Estimated Cost . . . . . . . . . . .1V 0 ori Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ` (to be paid on filing this application) 5. 5. If dwelling, number of dwelling units . . . . . . X. . . . . . . Number of dwelling units on each floor . . . .7. . . . . . If garage, number of cars . . . . . I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 ofStories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimensions of same structure with alterations or additions: Front . . . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . . . . Depth . . . . . . . . . . . . . . . . . . . . . . Height . . . . . . . . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . . . . . . . . . S. Dimensions of entire new construction: Front . . . .3. U . . . . . . . Rear . . . ... 0. . . . . . . Depth . . . . . . . . . . . . Height . . .4v� . . . . . . . Number of Stories . . . . . . . 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Size of lot: Front . . . . . . f o.. ���. . . . . . Rear . . . . . Yt�7 A 6 y . . . . . Depth . . C$.,.� . . . . . . . . . . . 10. Date of Purchase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of Former Owner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Zone or use district in which premises are situated . . . . . !z� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Does proposed construction violate any zoning law, ordinance or regulation: 13. Will lot be regraded . . . . . . . . . . . . . . . . . . . . . . . . Will excess fill be removed from premises: Yes 0 14. Name of Owner of premises . . . . Address YT`s.44e_A•CM.'C>. Phone No. . . Name of.Architect . . . . . . . . .P . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . . . Name of Contractor �d11. . �k��J�s. . . . . . . . . . Address 1e*>;15. V?�? �. . Phone No. .Z�- SC fo . . . 15. Is this property located within 300 feet of a tidal wetland? *Yes . . . . . No Js . . . *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. >TATE OF NEW YORE, S.S '.OUNTY OF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) .bove named. Ieis the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Contractor, agent, corporate officer, etc.) ,f said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this pplication; that all statements contained in this application are true to the best of his knowledge and belief;and that the pork will be performed in the manner set forth in the application filed therewith. mom to before me this � r . . . . . . . . . . . . . �� . . . .day of. . . . . .Ctu . . . . . . . ., 19 . . . otary Public, . . . . . ./ . . . s� . . . . . .�! County ^� . . . . �L: 9. . ` . . . . . .'. . . . . . . . . . . . . . . . . MWfNsdK#Nw York Signature of applicant) Tenn Exxpira Afimb 30,19W�� FORM NO. 1 U TOWN OF SOUTHOLD BUILDING DEPARTMENT FS 1510 TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined .`7_,-y . . . ., 19 F Application No.. . . . . . . . . . . . . . . . . . Approved[. .r?L,? . . . . . . ., 1 . . . Permit No. Disapproved a/c . . . . . . :-.— -'f- . . . . . .�. . . . . . . . . . . . . . . . . . . . . . . . . . . . (Building Inspector) APPLICATION FOR BUILDING PERMIT Date . . . . . 19 r�. 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 necessary inspections. L^ (Signature of applicant, or me, if a corporation) �k 1x32 � . . . . . . N . (I.`t. . . . (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. . . . . . . . . . . . . .�C//�/�CR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of owner of premises . . . . . .ffN.?oy . . . ���!w�.^ . .✓.�... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Name and title of corporate officer) Builder's License No. . . . . . .1.45. . . . . . . . . . . . . . Plumber's License No. . . . . . . . . . . . . . . . . . . . . . . . . Electrician's License No. . . . . . . . . . . . . . . . . . . . . . . Other Trade's License No. . . . . . . . . . . . . . . . . . . . . . I. Location of landonwhich proposed work will be done. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � ,-7. . . . . . . . . . . . . . . . J�[[NGS. . (l�d✓G. . . . . . . . . . . . SO.K ?y olr./7. . . . . . . . . . . . . . . . . . House Numb r Street Hamlet County Tax Map No. 1000 Section . . . . . S 5. . . . . . . . Block . . . . .z. . . . . . . . . . Lot . . . . . e) , .r. : . . . . . . . . Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filed Map No. . . . . . . . . . . . . . . Lot . . . . . . . . . . . . . . . (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy . . . . . . . /4. Ele.!Cu.4Tu2ff.,. . .- . . .57,nX f. :'t+.?`:^.'.;. .-�!;r••�ccr. . b. Intended use and occupancy . . . . . . 3. Nature of work (check which applicable): New Building . . . . . . . . Addition . . . . . . . . . . Alteration . . . . . . . . . . Repair . . . . . . . . . . Removal . . . . . . . . . . . . . . Demolition . . . . . . . . . . . . . . Other Work . . . . . . . . . . . . . . . 4. Estimated Cost wc� (Description) • ; rJ . . �n<�. . . . . . . . . . . . . . . . . . . . . . . Fee . . . . .� . . . . . . . . . . . . . . . . . . . . . . . . . . . (to be paid on filing this application) 5. If dwel 4,—rnrmbet 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 . . . . s. i 7. Dimensions of existing strictures,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 . . . . . 3�' . . . . . . . Rear . . . . . ;'. : . . . . . . . Depth . . .Ag. . . . . . . . . Height . . . .: . . . . . . . . Number of Stories . . . . .A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . 9. Size of lot: Front . . . . . : . . . . ,`�. . . . . . . . . . Rear . . . .`: `1. . . . . . . . . . . . . Depth . . ."' .. . . . . . . . . . . . . . . . 5. . . . . . . . . . . . . . . . Name of Former Owner � •.'. . . s 10. Date of Purchase . ": . . . . . .�. o. . . . . . . . . . . . . . . . . . . . 11. Zone or use district in which premises are situated . . . .�«%(. a.,. TL , ceC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Does proposed construction violate any zoning law, ordinance or regulation: . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. Will lot be regraded . . . . . . . =' . . . . . . . . . . . . . . . . . Will excess fill be rer)toveA from premises: Yes No 14. Name of Owner of premises rc 6--,-[a• '.Y 5 1?Address .yo.l,« . .�.((y !a.elPhone No. . . .'ri:.. . . .%1.:� -. Name of Architect . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . Phone No. . . . . . . . . . . . . . . . Name of Contractor . .h :. . ��!F F.N .5 . . . . . . . . . Address. >a.'? wS S<.ti .J: .'�1. Phone No. . .74-5. . . 3'.� 5: . 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 YO K, S.S COU OF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . being duly sworn, deposes and says that he is the applicant (Name o Adividual signing contract) above named. d 1 Heis 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. Sworn to before me this . . . . . . . . . . . . . . . :/. ' yf. . . . . ... 19�� Notary Public, . . . . 1C. . . . . . . . . . . . .. County SYMA K. ROUSE +UtsR, P'JKOC. 51.1.el Now Yed �• •�•l• .'. . ' • • ' . • . . . . . . . . . • . . . Na. W4306 - SOME c.0h, (Signature of applicant) m.,....e pw..M h 70, w I OWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHt BUILDING DEPARTMENT Do you have or need the following, before TOWN HALL Board of Health_ SOUTHOLh, NY 11971 4 sets of Building Plans__ TEL: (631) 765-1802 Planning Board approval —� FAX: (631) 765-9502 Survey _ wiviv. not-thfork.net/Southold/ PERMIT NO. Check_✓_ Septic Form N.Y.S.D.E.C.___ _ "Trustees_`______ Examined —. 20 Contact: 20_ Mail tol� ptc0ppj_t. - Disapproved a'c --__-_— tt Dy( OpOL'Tr.FM1P, airte�r� Phone: 74vS -56.1 c) Expiration____ __,20_ Building Inspector APPLICATION FOR BUILDING PERMIT q 2 5 Date .2 20 0<- INSTRUCTIONS a. This application MUST be completely filled in by typewriter or in ink and submitted to the Building Inspector with 4 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 part 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 after 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 rddition 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 3uilding 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 pplicant agrees to comply with all applicable laws,ordinances, building code, housing code,and regulations, and to admit uthorized inspectors on premises and in building for necessary inspections. /(Signature f app ant or name, if a corporation) -- (Mailing address of applicant) .rte whether applicant is owner, lessee, agent, architect, engineer. general contractor, electrician, plumber or builder pwnl3(L ne of owner of premises r ei C e N L 5 (As on the tax roll or latest deed) )plicant is a corporation, signature of duly authorized officer (Name and title of corporate officer) dens License No. — ibers License No. ricians License No. r Trade's License No. ocation of land on which proposed work will be done: q(AV ce VC-0 ,�e R-i.+ K O . -i k . Ouse Number Street Hamlet r runty Tax Map No. 1000 Section .5 5 Block Z T Lot bdivision Filed Map No. Lot (Name) L J ng use and occupancy of premises and intended use and occupancy of proposed construction: ting use and occupancy--,az s b. Intended use and occupancy__ OLS "D - rt-k.------- 3. tc- 3. Nature of work(check which applicable): New Building�i~G Addition _ Alteration__ Repair Removal __Demolition_______Other (Description) 4. Estimated Cost 3 b o 0- --------- Fee (To be paid on tiling this application) 5. If dwelling, number of dwelling unitsNumber of dwelling units on each 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: From 16' (-' Rear_ t I c, ' __Depth Height ,2 4 '' 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 (1, 1 L _---_Rear L ____Depth 44 Height � Number of Stories — 9. Size of lot: Front Lk'--1 7 . B a Rear_.3 g S y Depth 10. Date of Purchase 18 4 Name of Former Owner R U J Cc, tt�o t S 11. Zone or use district in which premises are situated _1- 12. Does proposed construction violate any zoning law, ordinance or regulation'' YES __ NOS 13. Will lot be re-graded? YES____ NO-->-- Will excess fill be removed from premises' YES_ NO x ,t,40� c�6 coaX. Co. 14. Names of Owner of premises7, A1C l&0 ti 5 Address_ �j V Phone No. Z S' c• — Name of Architect Address Phone No Name of Contractor Address Phone No. 15 a. Is this property within 100 feet of a tidal wetland or a freshwater wettand? *YES_ NO * IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAYBE 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 sun ey. STATE OF NEW YORK) SS: COUNTY `_moo _ \ (�V--1 61�ti .S being duly sworn, deposes and says that (s)he is the applicant (Name of individual signing contract) above named, (S)He is the ---- Q ,; rt --- ---------------- (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 apphcat 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 tiled therewith. Sworn to before me this 4!S. ....day of 20 OS / Notary Pu li�c Signature of plicant LINDA J COOPER NOTARY PUBLIC,state of New York NO.01CO4622563,Suffolk C,o,,u�ty/^ Term Expires December 31,`� .•-f SUFFOLK CO. HEALTH DEPT. APPROVAL H.S. NO. S6 SII= t�iSlG2TFti 2QAfl _� A�F3iC� L p r. ; ,«(1 Y gOF 2 MAP OF Pf20PEQTY ���� P02 , 1A_ psm�'., re I,c1iu^ tam fi:;, ,T I aATrjds �-w w*gmT + n9^1 THE WATER SUPPLY AND SEWAGE DISPOSAL }I !^ SYSTEMS FOR THIS RESIDENCE WILL j{ �1 .. .�. L OONFORM TO THE STANDARDS OF THE its{ a� sa,?. . SUFFOLK CO. DEPT. OF HEALTH SERVICES. AT pofw��= 1 (S) C OenAOPLICANT SUFFOLK COUNTY DEPT. OF HEALTH TOWN OFWUTHGL0. N. 4� �� 4' �Q851����� SERVICES — FOR APPROVAL OF j' O •+ ' �`— CONSTRUCTION ONLY i DATE: H. S. REF. NO.: 1 1 ' APPROVED: N/F \tj 57• 91 J. 5AWICKI, isE. 0, `4p gN T 7 , SUFFOLK CO. TAX MAP DESIGNATION: DIST. SECT. BLOCK PCL. tuC.ei \wD. ry POOL , 1000 55 2 pi. 8.1 -TA tc l A ,yam [[��•. .��.�yy�, � ' OWNERS ADDRESS: bc)l • i 2 5 1 1 r _. UTI N Y. 119i lI COLE MkN W _ _> UO , v Z -ALE ' I ° l DEED: L.30-7—/ P.S 7= (aEF. I G AR t A 80,000 F G•MONUMENT PIPE ani a:ton w.a�iunn — T O P501 L on�v is a violation of k;^of thn New York S%Me 1p •fyR.,[I'Jit. -: :t+•"'�" �" �� von 4.ivn. �r `yri' n"Wt tcad" ,: uroyoi•.inkn3 sacl ct 11+ r� LO^M r :s.�sh It nA t»=ndaand �Rr. � _.. r n. zval:'trunco7Y. f.. 3 ,@:u:en^sr krdxTwo.her,W th'.N R.T. l t e\ n, rv'.on is'wh a the cearoM fi 9ova'nmonu,i at,ncY a j. N41P AKE1' MO,--SF—PT- 18 1487 +_ mcmdtinn umd harrmn end / _...L._._ . .1',naar of the tanding irk „ r. �amass nro n tfanatore" COl J QSEYen` GiJIG�iI$k sANp SEAL (VAG+.WY) G12AVEEl 1TS7TE; OF NFI.y CONTOWQ5 fZE1=ETZ 7V "EIAN SEP. L.F'VEL. °5 � �'Y�t� r P7 B I A. �U(cV \ , `) ICK VAN YL. P. LICENSED LAND SWR41Y&S 17 C91tEENPWtT NEW YORK �;b;.—'S•; nzForr+e ros* wtnr SUFFOLK CO. HEALTH DEPT. APPROVAL H. S. NO. NO2 I ; �811it3t '�' HIICY�WE�IING om WMESTWOMMS FROM 1DATE OF Awa^; STATEMENT OF INTENT 4- THE WATER SUPPLY AND SEWAGE DISPOSAL �^ ;^T: �_, �, I SYSTEMS FOR THIS RESIDENCE WILL CONFORM TO THE STANDARDS OF THE SUFFOLK CO. DEPT. OF HEALTH SERVICES. fs) APPLICANT SUFFOLK COUNTY DEPT. OF HEALTH TOWN OF' -1"iUTI-I .iLD. N.Y. �' t,.GG.fG�1 EN EF SERVICES — FOR APPRgVAL OF ! RLE E NOTE CONSTRUCTION ONLY DATE: O H. S. REF. NO.. S I f" 00 It is the appllca s resaonsiblliiy toAPPR�VED: Imaintain adequa. .ar,i pry distance rJ�F,,�'WE15T ) c11 ' 1101 between all water supply and sewage 12. - 1 disposal facilities. SUFFOLK CO. TAX MAP DESIGNATION: 11 DIST. SECT. BLOCK PCL. YANK �{-4--r �, OWNERS ADDRESS: 39-0. L1 , , LJx 123 oTUsST HOLE 765 - 5690 r t13 _f v tc�7o O. DEED: L.307'7 R57`. (r<EF-) C�LkMAN Q O FpUNUA. >1-ALE_100_1 tt (V 1CANT'j s� _ � ' WELL `L Rt AREA B0,(= S.F TEST STAN LDMONUMENI 25 2� i l_Jt Z. 3 - ((2ON PIPE TOP50fL ... J .. . . r.,n-. N.71`�6` •-,•.�- ,:_c_ ' ` SAN i%Y : r,�..r.a,a:rs bn uaretdorel 42784 p Tr �j ry�r� LOAM °":. :a.c:, tmr on rh::n run a h1j „`71 r.. ,n ir,d,cnd a Noer "h ,f to eur-•!y L l/ !'l -n.'orasrcC.crW an hi:.Esl'.sIP[o the nn,:car.y.:7:.Gmr4Tmaniul HoncN and - •ip/ l 1 I.Grdnp in:mution listed her and to the tr"neos Of the londins hnd- tenon.Guazanteos are not nanatsrasle ' SEP 10 1986 to rer�bonal instltutio w wbe""nt , ow+mr. S C ©W. OF :.DU RSE L / G2!GONI; HEALTH SUVIMS SAND 4 C42A.V E L gyp'�p?CK �4.y 09 VA4.0.NT ) y ° A =q..�•. ( �^, .�.` r f .. - y t .. ' 5 SUFFOLK CO.HEALTH DEPT. APPROVAL H.s NO. 86�298 r .LV02T.H t , j 'T f i STATEMENT OF INTENT THE WA;SM SUPPLY AND SEWAGE DISPOSAL a 11 i tONFOIS 'FOR THIS RESIDENCE WILL - 61--R 1 iri CONFORM TQ' THE` STANDARDS OF THE ra S SUFFOLK CO. DEPT. OF HEALTH SERVICES. ISI fT L,sr1.15 SUFFOLK COUNTY DEPT. OF HEALTH Z' - - 70W,N OF5t�UTHQ.LE) N,Y C ��EL.tI?ENCL� SERVICES — FOR APPROVAL OF 0 1, ' CONSTRUCTION ONLY ' { DATE: H.S. REF. NO.:-86-50 l9$ APPROVED: {+ J. 5AWlirlCl,.Jft. t4F Wty57 SUFFOLK CO. TAX MAP DESIGNATION: r -V.•EtL �, p. . POOL ! f' I,i ` DIST: SECT. BLOCK PCL. a I N } rwwfc1 _`� 1000 .... S5 2 'rerl { G � '' ,►`" I � OWNERS ADDRESS: .f .5.761962 50 f M-% sin \ — BOX 1232 S JUTHOLL, W.Y. I f97 I �• - - i F`T HOLE 76S - 5690 �.. -�Fj•a tav✓F—SiDc DSGr - r _. I✓, - --0 r^c 1 veek �p = I DEED: L." 7"/ ' _ � �_.t rY, ,- per-�. •.�� 1, , � , .�-r , c i TEST HOLE VAMP y- � •`i i= r •: I tk,e+1ci-^d at(.ra!19a n'aC'%Lim r�1^ - , 7-,� ��•n 7!."'(a thr•Nate•Yoli'y.{n I iV.71e�� ✓" w r r emt.•`ee.� :vtr,u nmhm c nv4arW .` 2 7 D/ to Gr a va?tr � c. 42784 t "�i LOAM cuannv.-r t,r..'r.:n.•t,er-t+n•h-.^,n.••. _ pdY t;tFx W°c-•ir:v:r,r,^Nrr:ur+•.,r 4�0 t a, it G aw•u::.rrN cn Lr. MAP N-If DED SLPT.Isa1987 `:. . . ', , «•r COUQSE SEAL GIZlGri�11 !SND 1 t/rnCA.l.i T) C-I;AVEL �ofNfly y0 CT3NTOiJR5 124-lrFEr4 ;i? MEAN SEP, UV ELr. ;�.� r•JSZVEYEi7 �Ep7 8.1�6� • Q� ��}} :},,ops,< . RODERICK VAN TUYL.P, . r ;FT -7 ` r Jr A m t Y ext �r {i/� �� LICENSED LAND SUR ORS 17 A �E �5� YY Lq GREENPORT NEW YORK ,14 -Qv� iA.... ..... -�� • Wnr^.�Y•J.w�1.^.w .". ���rT���Y .�..rri!•�.r� �r.a' 'il�Frei �.•� o � 9q) p 0 ILJ � .4a ON 44 , f 1 6x&% WWFION d. !t SO S� 'oQRpVE� P• # T ENT PE o��� A�cy a FOR tigg FUS,. B�1Eo1N a PN` 765.18w1NG INCE -DNO E G . �EEo NOA�1oN GONCRE(PE�Mg1N `d ; F� OVRED 1NG & it '2 �ONM TRUCj10• JtoST sl F Otto?MCI A. F NAE MPEE�E 10N SN THE N_ 1 BE COj,151RVC�r((5 OF & Ep1ERG PEL REQUIRE RVCS10NN518EE �tE CDN �f(O,fi1 ERR DESowG� z Coo Hill `'�outeriShw.J `V�WE I I i zx 'AOA Do ARA SIUtacr I i Gr QA 'UC' WEST ELEVATIOa 1 Noer+F k�'� weST FKA^%AlC "�!o " xcly "O. 0-, �— ZI t� ry S VD whit. F2Am% O.C. {1ST ELEV�TIon� 44 C lµlRRcnrR 7.6hoA1L —�—aj , /, palc'�iss �f�''7LRFTE� �oArC� rs („CCR la" •was iM�O �Ilfll F04 N'(l/ITIO BAST �LEV !'t''rloN 1 } _- ----•---- �..r. 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