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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
Date: 08/16/06
No: Z-31769
THIS CERTIFIES that the building
ROOF REPAIR
Location of Property: 58330 MAIN RD
(HOUSE NO.)
County Tax Map No. 473889 Section 66
(STREET)
Block 2
SOUTHOLD
(HAMLET)
Lot 3
Subdivision
Filed Map No.
Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated
JUNE 26, 2006 pursuant to which
Building Permit No. 32242-Z
dated
JULY 26, 2006
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 ROOF REPAIR OF AGRICULTURAL BUILDING AS APPLIED FOR.
The certificate is issued to JOSEPH F KRUKOWSKI
(OWNER)
of the aforesaid building.
N/A
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
N/A
N/A
PLUMBERS CERTIFICATION DATED
Rev. 1/81
.
Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
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:
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. Sworn statement from plumber certifying that the solder used in system contains less than 2/1 0 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 appli"ant;/_
---- eo'. r
-.-- (7 \. '
C. ~.ee~ertificate of Occupancy _ New dwelling $25.00, Additions to dwelling ;2i~O~~teratio~to dwelling $45.00,
Swimming pool $25.00, Accessory building $25.00, Additions to accessory building ~5.Q(\, Businesses $~O.OO.
2. Certificate of Occupancy on Pre-existing Building - $100.00. \
3. Copy of Certificate of Occupancy - $.25 \' \_~_.-J
4. Updated Certificate of Occupancy - $50.00 \r .
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.@---=" --
Date.
~
Location of Property: $<631l0
House No.
Owner or Owners of Property: ~'Se f ~ r.
Suffolk County Tax Map No 1000, Section o~0
New Construction:
Old or Pre-existing Building: .~
VVl a..,: 1\ {( oa r~
Street
r;,,^ (nUJc:.)<.,'
Block 000 01.
( check one)
!;oLlrh tJ fJ
Hamlet
Lot
003
Subdivision
Filed Map.
Applicant:
Lot:
Permit No.
Date of Permit.
Health Dept. Approval:
Planning Board Approval:
Underwriters Approval:
Request for:
Temporary Certificate
Final Certificate:
( check one)
Fee Submitted: $
_M~~~p~'
Appli t Signature
&-.~. 7()8\l3
Qo C1f7&,
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.
32242 Z
Date JULY
26, 2006
permission is hereby granted to:
JOSEPH F KRUKOWSKI
MAIN RD
SOUTHOLD,NY 11971
for :
REPAIR (ROOF) AGRICULTURAL BUILDING AS APPLIED FOR. REPLACES BP 28528
at premises located at
58330 MAIN RD
SOUTHOLD
County Tax Map No. 473889 Section 066
Block 0002
Lot No. 003
pursuant to application dated JUNE 26, 2006 and approved by the
Building Inspector to expire on JANUARY 26, 2008.
Fee $
150.00
ORIGINAL
Rev. 5/8/02
3 2..-2..- V- L i:::
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST [] ROUGH PLBG.
[ ] FOUNDATION 2ND [] IN ATION
[ ] FRAMING I STRAPPING [. FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS:
~
DATE
.
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST [
[ ] FOUNDATION 2ND [
[ ] FRAMING I STRAPPING [
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS: pO /d<c.L.S5"'
,10rc j& r..J~;J(e_(7;j
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DATE
INSPECTOR
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~
,
FIELD INSPECTION REPORT DATE
FOUNDATION (1ST)
FOUNDATION (2ND)
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ROUGH FRAMING &
PLUMBING
INSULATION PER N. y,
STATE ENERGY CODE
FINAL
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Tillable 3
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Total I
TOWN OF SOUTHOLD PROPERTY
STREET 583." 0
RECORD CARD
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BUILDING CONDITION
BELOW
Acre Value Per Acre
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OWNER
TOWN OF SOUTHOLD ~ROPERTY RECORD CARD
STREET 5 83. 0 VILLAGE DISTRICT SUB. LOT
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FORMER OWNER
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REMARKS
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NEW NORMAL BELOW ABOVE ,3>0' f?1
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I Per Acre Value &ll.t/i 311 HE- II I
Form Acre I Value Ie pc)
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Tillable 1 r~~n~=-_ I 250 2J.?~"'. .3/, pO
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Total I
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:xtension 2- Iq (% I Bosement , Floors
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:=-;(1', V",", ) he,),,"''-C
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Porch Attic
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Porch Rooms 1 st Floor
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lreezewoy Patio Rooms 2nd Floor
;orage Driveway
- ----- _ ---~---~
:H5, t,..'- <60
. / (. ,'c-
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322-0 ('/1&
PERMIT NO. ~~
BUILDING PERMIT APPLICA nON CHECKLIST
Do you have or need the following, before applying?
Board of Health
3 sets of Building Plans
Planning Board approval
Survey
Check
Septic Form
N.Y.S.D.E.C.
Trustees
Contact:
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
Examined
Approved
Disapproved alc
20 ').
'-
,20~
..--.-.--...-. .
'\
Phone: 7 {,J-. ;:u; ?-.f'
Expiration
'/~
I
,204-
.
C;'\ r:
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--.-..--
lJ'I) . PPLICATION FOR BUILDING PERMIT
JUN 2 8 2002 ...J
I Date ~ - ;<' Y'
l- ';,-;;:-r-'-:;-r- INSTRUCTIONS
1():~i, '-'10~l')
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 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
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 South old, 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.
,.
,I
~, \'-
0'9'/1J' /}1Cl.,i'r} ~) ) Sou ~ol "I, I?;Y
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Nameofownerofpremises ldeUJO')/,)<<,Ici' ~s~",,1 r -L P?1a.tt?//L/A../
(As 6n 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. 3/55"3 - H
Plumbers License No.
Electricians License No.
Other Trade's License No.
I. Location of land on which proposed work will be done:
S 'fJ 31<:> J11 Cl/f\/ Kd
House Number Street
Hamlet
~ ~ '".., !" ,-
'J
"<[_,;Ai-CA
County Tax Map No.1 000 Section '/7 3 9 $I <;
Subdivision
'1.,""""11:0'1
Block t t
Filed Map No.
..t,..,
I
Lot - 7- - 3....
Lot
-,
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed constructioI!:
a. Existing use and occupancy \)'!-" ., ' ',' '. '" " .
b. Intended use and occupancy
,
3. Nature of work (check which applicable): New Building
Repair \/ Removal Demolition
Addition
Other Work
Alteration
(Description)
4. Estimated Cost
Fee
5. If dwelling, number of dwelling units
If garage, number of cars
(To be paid on filing this application)
Number of dwelling units on each floor
6. Ifbusiness, commercial or mixed occupancy, specifY nature and extent of each type of use. . .' j <: ,( (
')
7. Dimensions of existing structures; if any: Front " )
Height /( Number of Stories
Rear
" ')
Depth
)i
Dimensions of same structure with alterations or additions: Front Rear
Depth ), Heighti: Number of Stories
(I)
8. Dimensions of entire new construction: Front 'J ')
Height If. Number of Stories
Rear
'j 1
) )
Depth
/'
/
9. Size oflot: Front
Rear
Depth
10. Date of Purchase
Name of Former Owner
II. Zone or use district in which premises are situated
12. Does proposed construction violate any zoning law, ordinance or regulation? YES_NO ~
13. Will lot be re-graded? YES_ NO~ Will excess fill be removed from premises? YES_ NO~
14. Names of Owner of premises
Name of Architect
Name of Contractor
Address
Address
Address /Sj; ,i, it') I 4" \'
( n" "~I' t-
IS a. Is this property within 100 feet of a tidal wetland or a freshwater wetland? *YES _ NO ~
* 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.
Phone No.
Phone No
Phone No. 117?
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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)
COUNTYOF~
-:fr:>s t!:P^ I-: /R LLkb 'IPS Ie.' being duly sworn, deposes and says that (s)he is the applicant
(Narrte of individual signing contract) "bove named,
(S)He is the t'? ~t'l e r
(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.
206 -z.--
Signature of Applicant
tary Public
LYNDA M. BOHN
NOTARY PUBLIC, State of New Yorlc
No. 01 B06020932
Qualified in Suffolk Cou~ "2
Term Expires March 8, 20 4A:r-'
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, '''IILOIII . TWO.au rl~,_________________n___
, ,'':: "v",ilEO CONCRII'I
~"' "'AMING uunllM ~
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... . ..._ . CON8TRUCnGII _
~ : :liPLETE FORC.Q. .
,. '_L CONSTRUCTIOII 1HMl....
i HE REQUIREIIEIQI OIl _ II.~
S1 A 1E CONITRUCTIOII . IfIEMY
CODES. NOT RIIPONIIIU POll
DESIGN OR ~IIWC1'lo. a a..
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