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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: 07/30/07
No: Z-32496
THIS CERTIFIES that the building ACCESSORY
Location of Property: 45295 MAIN RD
(HOUSE NO.)
County Tax Map No. 473889 Section 75
(STREET)
Block 2
SOUTHOLD
(HAMLET)
Lot 5
Subdivision
Filed Map No.
Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated
MAY 1, 2006 pursuant to which
Building Permit No. 31957-Z
dated
MAY 2, 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 NON-HABITABLE ACCESSORY GARAGE WITH STORAGE ABOVE AS APPLIED FOR.
The certificate is issued to TOMASZ & BARBARA MEJSAK
(OWNER)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
N/A
ELECTRICAL CERTIFICATE NO.
3017767
06/11/07
PLUMBERS CERTIFICATION DATED
N/A
Rev. 1/81
.
Form No.6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
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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 bllilding or new use:
I. Filial survey of property with accurate location of all buildings, property lines, streets, and unusual natural or
topographic fcatures.
2. Final Approval from Health Dept. of water supply and sewerage-disposal (8-9 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 2/1 0 of I % 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:
I. 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. ~- ees
I. Certificate of Occupancy - New dwelling $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00,
Swinuning 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 CeIiificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
New Constmction: -.---LL--_ Old or Pre-existing Building:
Location of Property -22'...21:{> hd.,f'v, Rei.,
House No. Street
Owner or Owners of Property: ~1-'WtZ--f2- ~fd
Suffolk County Tax Map No 1000, Section [) 7<)" Block
Date. 1- 2C~CJ7
(check one)
..-SOu.-Ik4t
MY:
Hamlet
~rP02-
Lot
tJCJ ,-
Subdi vision
Filed Map.
~
Applicant: 1&0--1a...f2-
LO~~
Permit No. 31.fS..7
Date of Permit.
Health Dept. Approval: ____
Underwriters Approval:
Planning Board Approval: __._____
Request for:
Temporary Certificate
Final Certificate:
( check one)
Fee Submitted:
$
t..o ~":l '\' C)\..
R.t (.:1).& C\)
-------------.-
~<U'z ~
Applicant Sign Ire
J 5 ~ 7-- ,5
lID~~lID
I BY THIS CERTIFICATE OF COMPLIANCE THE 3 I
~ NEW YORK BOARD OF FIRE UNDERWRITERS ~
~ BUREAU OF ELECTRICITY ~
~ 40 FULTON STREET - NEW YORK, NY 1 0038 ~
~ CERTIFIES THAT ~
~ ~
~ Upon the application of upon premises owned by ~
~ ~
~ LAGUN ELECTRIC TOMASZ MEJSAK ~
~ 724 PULASKI ST. 45295 MAIN RD. ~
~ RIVERHEAD, NY 11901 SOUTHOLD, NY 11971 I
~ Located at 45295 MAIN RD. SOUTHOLD, NY 11971 ~
~ ~
~ Application Number: 3017767 Certificate Number: 3017767 ~
I Section: Block: Lot: Building perm~ IC'fS7 BDC: ns11 I
~ Described as a occupancy, wherein the premises electrical system consisting of ~
~ electrical devices and wiring, described below, located in/on the premises at: ~
~ First Floor, Second Floor, garage only, Detached Garage, Outside, ~
~ A visual inspection of the premises electrical system, limited to electrical devices and wiring to the extent detailed ~
~ herein, was conducted in accordance with the requirements of the applicable code and/or standard ~
~ promulgated by the State of New York, Department of State Code Enforcement and Administration, or other ~
~ authority having jurisdiction, and found to be in compliance therewith on the 11th Day of June, 2007. ~
~ Name OTY Rate Ratin. Circuit ~ ~
~ Alarm and Emergency Equipment ~
~ Sensor 1 0 Smoke ~
~~ringandD"iCes ~
@! Outlet 14 0 Fixture ~
~ Fixture 7 0 Incandescent ~
~ Fixture 7 0 Flourescent ~
~ Outlet 14 0 General Purpose ~
~ Receptacle 5 0 General Purpose ~
~ Switch 8 0 General Purpose ~
~ Receptacle 2 0 20a ~
~ Receptacle 3 0 GFCI ~
~ Service ~
~ I Phase 3 W Service Rating 100 Amperes ~
~ Service Disconnect: 100 cb ~
~ Meters: I ~
~ seal ~
~ ~
~ cl 1 I
This certificate may not be altered in any way and is validated only by the presence of a raised seal at the location indicated. I
~
'~~-
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.
31957 Z
Date MAY
2, 2006
permission is hereby granted to:
TOMASZ & BARBARA MEJSAK
45295 MAIN RD
SOUTHOLD,NY 11971
for :
DEMOLITION OF TWO ACCESSORY BUILDINGS AND CONSTRUCTION OF A NEW
ACCESSORY GARAGE IN THE REQUIRED REAR YARD AS APPLIED FOR.
at premises located at
45295 MAIN RD
SOUTHOLD
County Tax Map No. 473889 Section 075
Block 0002
Lot No. 005
pursuant to application dated MAY 1, 2006 and approved by the
Building Inspector to expire on NOVEMBER 2, 20
Fee $
406.40
-.
ORIGINAL
Rev. 5/8/02
3'CJ57
N/F JEROME 84.70'
N 55'39'30"E",
'"
..
3.5'
Z poURED CONCRETE N (/)
..
ur N fOUNOATION &: wAlLS " N
<q CXl
0 (GARAGE) .j>.
<D (J)
0 300' e;;
N
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~
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r ~ ~RTH DRIVEWAY 'U
--- t-'I
2: )> I.-- ~
"- U1 "
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~ WOOD 24,2' ;u
:I: r STEPS l'
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-< 2-STORY t::r:1
RESIDENCE '" Z
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n c:::
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<2 PORCH
S'/':~O 30,0'
<01- 22.0'
<5'
'-1
N
'-" 0
0 ({) <D
'-1 m m,
<D
56'1200 W 83.50
S ROAD
MAIN
GUARANTEES INDICATED HERE ON SHALL RUN
ONL Y TO THE PERSON FOR WHOM THE SURVEY
IS PREPARED, AND ON HIS BEHALF TO THE
nnECOMPANy,GO~RNMEN~LAGENCy'
LENDING INSTITUTION, IF LISTED HEREON, AND
TO THE ASSIGNEES OF THE LENDING INSTITUTION.
GUARANTEES ARE NOT TRANSFERABLE TO
AOOmONAL INSTITUTIONS OR SUBSEQUENT OWNERS,
UNAUTHORIZEDAL TERA nON OR ADDITION TO THIS
SURVEY IS A VIOLA TION OF SECTION 7209 OF
THE NEW YORK STATE EDUCATION LAW.
COPIES OF THIS SURVEY MAP NOT BEARING
THE LAND SURVEYORS EMBOSSED SEAL SHALL
NOT BE CONSIDERED TO BE A VALID TRUE
COPY.
SCALE 1 "= 30'
AREA = 14,377.72 SF
OR
0.33 ACRES
SURVEY OF
DESCRIBED PROPERTY
SITUATE
PECON/C, TOWN OF SOUTHOLD
SUFFOLK COUNTY, N, Y.
IUL 18
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TM# 1000-075-02-005
SURVEYED FOR: TOMASZ MEJSAK
BARBARA MEJSAK
SURVEYED BY
STANLEY J. ISAI<SEN, JR.
P.O. BO 294
NEW SU FOLK. N.Y.
631-7 4-5 5
2 17 JULY 06 RELOCATE FOUNDATION (GARAGE)
1 JO JUNE 06 LOCATE FOUNDATION (GARAGE).
GUARANTEED TO:
TOMASZ MEJSAK
BARBARA MEJSAK
DECISION 2000 REAL ESTATE SERVICES, INC.
N/F JEROME
~
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N
"E'"
55'39'30 .
f-,<-
~1
.7'
203'
~
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'1 J: WOOD
J: )> STEPS
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24.2'
2 - STORY
RESIDENCE 01
N
PORCH
30.0'
no'
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tv
'-" 0
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'-J "'. co
CD
56'12 00 W 83.50
S ROAD
MAIN
'~G'M?AN rEfS INDICA TfD HERE ON SHALL RUN
ONi..}' TO TH: PERSON FOR WHOM THE SURvn
,'$ FREPAREO, ANO ON HIS BEHALF TO THE
TifLE COMP~,NY, GovERNMENTAL AGENCY,
L[,\'~INC: IN$ TlrV nON, IF LISTED HEREON, AND
'0 r.'i[ ASS'GNE[S OF THE L[NDING INsrm.mON
LTARANTFE::: ARE NOT TRANSFERABLE TO
Are r:~~WAL INS T/ TU nONS OR SUBSEQUENT OWNERS.
UNAUTHORIZED ALTERATION OR ADamON TO THIS
SURVEY IS A VIOLA TlON OF SECTION 7209 OF
THE NEW YORK STATE EOUCAT/ON LAW
COPIES OF :'HIS SUR\lfY MAP NOT BEARING
THE LAND SURV[YORS EMBOSSED SEAL SHALL
NOT BE CON510m[Q TO BE A VALID TRUE
COPY.
SURVEY OF
DESCRIBED PROPERTY
SITUATE
PECON/C, TOWN OF SOUTHOLD
SUFFOLK COUNTY, N.Y.
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SURVEYED: 30 JULY 2004
SCALE 1"~ 30'
AREA ~ '4,37772 5 F
OR
0.33 ACRES
3195'72-
TOWN OF SOUTH OLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST
[ ] FOUNDATION 2ND
[ ] FRAMING I STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] FIRE RESISTANT CONSTRUCTION
[ ] ROUGH PLBG.
[]~~ON
[~ FltIj
[ ] FIRE AFETY INSPECTION
[ ] FIRE RESISTANT PENETRATION
REMARKS:
INSPECTOR
31q~1-r
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] I~ATION
[ ] FRAMING/STRAPPING [~NAL
[ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
()~jl. - -
REM",KS. I:,,-;X" ~ 8'1 1'''-''4 ai4A
JJd.[L J~~ ,
(f) MN/'lJ)"ls ';;.I/r)t.~('" ?JU4~ I
DATE
INSPECTOR
3h(7
TOWN OF SOUT
Q65.1~02
INSPE TION
ILDING DEPT.
-->
[ ] FOUNDATION 1 ST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] I~LATION
[ ] FRAMING I STRAPPING [ !(FINAL
[ ] FIREPLACE & CHIMNEY [] FIRE SAFETY INSPECTION
[ ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
REMAK~~~ .~R.tt(
DATE
INSPECTOR
-
-
--- -------"'- -~.._~
31~S7~
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST
[ ] FOUNDATION 2ND
[ ] FRAMING I STRAPPING
[ ] FIREPLACE & CHIMNEY
[ ] RRE RESISTANT CONSTRUC'nON
REMARKS:
[ ] ROUGH PLBG.
j){INSULATION
[ ] FINAL
[ ] FIRE SAFETY INSPECTION
[ ] RRE RESISTANT PENETRAnoN
~ t-_ ~<L,
~ 6/c -4- ~/
INSPECTOR ~,~
DATE IJJ 'J.'J- - 0 ~
J19J7-c
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDA~ION 1 ST [
[ ] FO ATION 2ND [
[ FRAMING I STRAPPING [
[ ] FIREPLACE & CHIMNEY [
REMARKS: .~
] ROUGH PLBG.
] INSULATION
] FINAL
] FIRE SAFETY INSPECTION
01
INSPECTOR
DATE 1PlfJ~
I
3/c;S"7-c
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[ ] FOUNDATION 1 ST [] ROUGH PLBG.
[ ] FOUNDATION 2ND [] INSULATION
[ ] FRAMIN~RAP!I~ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS:
cJJ:"~ ~C:,
~-
~
DATE
crll/ () ,
INSPECTOR
~
3tqo-?i:
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
INSPECTION
[~OUNDATION 1ST
[ ] FOUNDATION 2ND [
[ ] FRAMING I STRAPPING [
[ ] FIREPLACE & CHIMNEY [
REMAR~;<
] ROUGH PLBG.
] INSULATION
] FINAL
] FIRE SAFETY INSPECTION
f L f/I^~~'
DATE 1(/3 ( O~
INSPECTOR
3 11S"7~
TOWN OF SOUTHOLD BUILDING DEPT.
765.1802
SPECTION
[ FOUNDATION 1 ST [] ROUGH PLBG.
[ ] FOUNDATION 2ND [] INSULATION
[ ] FRAMING I STRAPPING [ ] FINAL
[ ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
REMARKS: /~dd ~
(D ~~~~ ,"--
~~ Tb ~7 3'~
DATE
&tJ-&/rJ~
/ /
INSPECTOR
I
~SPECTIONREPORTT DATE COMMENTS
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777
FOUNDATION (1ST)
FOUNDATION (2ND)
-
19' h lot
/ /
11/'.1' I
/ (
rJ-tf.
?,
,
ROUGH FRAMING &
PLUMBING
I
INSULATION PER N. Y.
STATE ENERGY CODE
~ \ ~
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L.,.-. 1..-.:1 '-. h~ ....1. d1 0: ~- - · .. , 4 0Jf-->>L
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FINAL
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A ADDmONAL COMMENTS
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N/F JEROME ,,^D"'S~
G< '"f" ."e
.F 10 ~. 84.70'
"- 55'39' 30"E--'-
f-/- Ul
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e/V .7' OJ
203' -l>>
(J)
1 IN
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,- ~ --;;; DRIVEWA~ _ 'U
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RESIDENCE en Z
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PORCH
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S 56'1200 W 83.50
MAIN ROAD
'':;V.Al?/OIJTEE5: INDICA TED HERE ON SHALL RUN
ONi.. y TO m: PERSON FOR I-W-fOM THE SURVEY
,'5 FR[PAREO, AND ON HIS BEHALF TO Tl-IE
TiTLE COMP~,NY. GOVERNMENTAL AGENCY,
LE\2IN( INS TI TU nON, IF LISTED HEREON, AND
r: T.'-i[ ASS'CHEfS or THE L[NDING INSTlTUnON
~TAR/.NT[[~: ARE NOT TRANSFERABLE TO
;,tC r;~llvAi.. iNST;n..:nONS OR SUBSEOUENT OWNERS.
SURVEYED: 30 JULY 2004
SCALE 1"~ 30'
M?[A. = 14.J7772 .~ r
l),r;;
o 33 ACRES
UNAUTHORIZED ALrrRATION OR ADomON TO THIS
SU!?V[Y IS A l.1OLA nON OF SEcnON 7209 or
THE NEW YCORK STATE fOUCATlON LAW
COPIES OF 'HIS SUFi''/fY MAP NOT BfARING
THE LAND SURV[YORS EMBOSSED SEAL SHALL
NOT BE CO~ISIO[R[O TO BE A VALID TRUE
CCPy
SURVEY OF
DESCRIBED PROPERTY
SIWA TE
PECON/C, TOWN OF SOUTHOLD
SUFFOLK COUNTY, N.Y.
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
www.northfork.net/Southold/ PERMIT NO.
~/c:r~7 L;
BUILDING PERMIT APPLICATION CHECKLIST
Do you have or need the following, before applying?
Board of Health
------.. 4 sets of Building Plans
Planning Board approval
.----., Survey
Check " c:: > 00
Septic Form
N.Y.S.D.E.C.
Trustees
Contact:
Examined
~
~r~
7
1j '- ,2rrr-
Approved
Disapproved ale
..------.,
Mail to:
Phone:
Expiration
-~~---._"
r::.-: I'.
f (: . \ ,; APPLICATION FOR BUILDING PERMIT
~, \I" .
\.' MAY \ ? 5 Date~~ IJ%'
: \.. . ; \ INSTRUCTIONS
\a. T~;;:~Pl;;::rMtlstoe-clompletelY filled in by typewriter or in ink and submitted to the Buildmg Inspector wtth 4
sets of prans, 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.
APPLICA nON 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.
,20 Cl.9
r
~
61/f/1tbf?-
(Signature of applicant or na
'16;2.cVS~V\ ~. I 6olA~'\(~. N\.{ \\'1'1\
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Name of oWner of premises -( ~",^i'\.-h;;' ~.. ~,r~ IfV\ a.:1?O~
(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. 6v:>-Nf
Plumbers License No.
Electricians License No.
Other Trade's License No.
I. Location of land On which proposed work will be done:
L.{ 0-;2.. 'i 6' ffi~, 'I'. tv-\
House Number Street
'7'Y )~c~\c\
Hamlet
County Tax Map No. 1000 Section 0 "l '5
Subdivision
Block o:l.
Filed Map No.
Lot 00 r-s-
Lot
(Name)
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
~"-~....>~ cV ~a~e-
3. Nature of work (check which applicable): New Building
Repair Removal Demolition
X Addition
Other Work
Alteration
4. Estimated Cost
-:26, OQa
(Description)
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.
7. Dimensions of existing structures, if any: Front I ct';) "
Height Number of Stories
Depth 2.0 'e 3 .
Rear
Dimensions of same structure with alterations or additions: Front Rear
Depth Height Number of Stories
8. Dimensions of entire new construction: Front 2. 'i I
Height Number of Stories
Rear
Depth '?:J:) I
9. Size oflol: Front
,q. L. 0<"\
Rear \ '1--1 \ Go,
QU'
Depth 0 :::I
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_ " _c'
L '};<{ -5;1..q '1- ~
14. Names of Owner of premises.o(~"H"'l~ Address Phone No. %"f '5"'160
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 wetland? *YES _NO _
* IF YES, SOUTH OLD 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)
&:2 SS'
COUNTYO ~.
im.::J 1Ik,~:/A being duly sworn, deposes and says that (.)he is the applicant
(Na of in lvidual 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.
Sworn to before me t~
~ ~YOf~ 20~
- ~ t/
, . ota ubli
C;;;:;c?s-2-
Signature of App .
SUSAN J. NAGY
Notary Publlo State of New Yak
No. 4896735
Qual~ied in Suffolk County
Commission Expires May 200.2