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Town of Southold 2/5/2018
4vez'sk'o,I, P.O. Box 1179
53095 Main Rd
6- 61 Southold, New York 11971
CERTIFICATE OF OCCUPANCY
No: 39494 Date: 2/5/2018
THIS CERTIFIES that the building SHED
Location of Property: 365 Pequash Ave, Cutchogue
SCTM#: 473889 Sec/Block/Lot: 103.-7-29
Subdivision: Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore filed in this office dated
11/21/2017 pursuant to which Building Permit No. 42204 dated 12/1/2017
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:
ACCESSSORY SHED AS APPLIED FOR
The certificate is issued to Robins, Kenneth&Janice
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL
ELECTRICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DATED
A t riz d Signature
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, NY
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES
WITH ONE SET OF APPROVED PLANS AND SPECIFICATIONS
UNTIL FULL COMPLETION OF THE WORK AUTHORIZED)
Permit#: 42204 Date: 12/1/2017
Permission is hereby granted to:
Robins, Kenneth
365 Pequash Ave
Cutchogue, NY 11935
To: to construct an accessory shed as applied for.
At premises located at:
365 Pequash Ave, Cutchogue
SCTM # 473889
Sec/Block/Lot# 103.-7-29
Pursuant to application dated 11/21/2017 and approved by the Building Inspector.
To expire on 6/2/2019.
Fees:
ACCESSORY $180.00
CO -ACCESSORY BUILDING $50.00
Total: $230.00
Building Ins ector
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 2/10 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$50.00,Additions to dwelling$50.00,Alterations to dwelling$50.00,
Swimming pool$50.00,Accessory building$50.00,Additions to accessory building$50.00, 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. ( 7
New Construction: V Old or Pre-existing Building: (check one)
Location of Property: 5LA�L S k
House o. StreetAbliv
Hamlet
Owner or Owners of Property: i T
Suffolk County Tax Map No 1000, Section Block Lot
Subdivision Filed Map. Lot:
Permit No. Date of Permit. Applicant:
Health Dept. Approval: Underwriters Approval:
Planning Board Approval:
Request for: Temporary Certificate Final Certificate: (check )
Fee Submitted: $
pplican ignature
N
SOUT�o�
TOWN OF SOUTHOLD BUILDING DEPT.
765-1802
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLEIG.
[ ] FOUNDATION 2ND [ ] I ULATION
[ ] FRAMING / STRAPPING [ FINAL
( ] FIREPLACE & CHIMNEY [ ] FIRE SAFETY INSPECTION
( ] FIRE RESISTANT CONSTRUCTION [ ] FIRE RESISTANT PENETRATION
( ] ELECTRICAL (ROUGH) [ ] ELECTRICAL (FINAL)
fl
REMARKS: � l� �0- v
DATE ANSPECTOR '
ti
FIELD INSPECTION REPORT DATE COMMENTS
FOUNDATION(1ST) d
------------------------------------
C
FOUNDATION (2ND)
z
0
ROUGH FRAMING& O� y
PLUMBING
� 1
4
'0
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INSULATION PER N.Y. H
STATE ENERGY CODE C
i A�
FINAL
ADDITIONAL COMMENTS
-» 30 -oo r 4111 # 2-728 g
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TOWN OF SOUTHOLD BUILDING PERMIT APPLICATION CHECKLIST
BUILDING DEPARTMENT Do you have or need the following,before applying?
TOWN HALL Board of Health
SOUTHOLD, NY 11971 4 sets of Building Plans
TEL: (631) 765-1802 Planning Board approval
FAX: (631) 765-9502 Survey
Southold town ny.gov PERMIT NO. Check
Septic Form
N.Y.S.D.E.C.
Trustees
C.O.Application
Flood Permit
Examined ,20 Single&Separate
Truss Identification Form
Storm-Water Assessment Form
C tact:
Approved —,20 Mail to:
Disapproved a/c
t Phone: — x
�J
Expiration
r
�', But pe for
NOV 21 �1?
APPLICATION FOR BUILDING PERMIT
F Date , 20
TOv`+'INOFSU1lTI,HOLD 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
addition six months. Thereafter, a new permit shall be required.
APPLIC TION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone rdinance 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 inspe tors on premises and in building for necessary inspection
(Signature of app icant or name,if a corporation
Aalal,45A k ro ✓ -
(M ing address of applicant) / ( 4 r
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder
Name of owner of premises V
(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. 5 17 — d
Plumbers License No.
Electricians License No.
Other Trade's License No.
1. Locationof land A which propose work will be done:
A,--7
House Number Street V Hamlet
County Tax Map No. 1000 Section Block 1 Lot 01\e3
Subdivision Filed Map No. Lot
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
3. Nature of work(check which applicable): New Building Addition Alteration
Repair Removal Demolition Other Work
(Description)
4. Estimated Cost Fee
(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
Et i
8. Dimensions of entire new construction: Front - � Rear �U Depth rJ
Height 116 ' F I I Number of Stories
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? 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 Address Phone No.
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, 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.
18. Are there any covenants and restrictions with.respect to this property? * YES NO
* IF YES, PROVIDE A COPY.
STATE OF NEW YORK)
SS:
COUNTY 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.
sworn to before me ft�s`
day of NZA"W 6-120
CONNIEM BUNCH
� �Yv Notary Public,State of New York /
No M Rl 16185050
Notary f ublic ouaNfied in Suffolk County ignature of Applicald
Commission Expires April 14, •_
Scott A. Mussell ��°SU ���
SUPERVISOR o MANAGEMENT
SOUTHOLD TOWN HALL-P.O.Box 1179 d
53095 Main Road-SOUTHOLD,NEW YORK 11971 ti�fO �� Town of So u th o l d
CHAPTER 236 - STORMWATER MANAGEMENT WORK SHEET
( TO BE COMPLETED BY THE APPLICANT )-
DOES
PPLICANT )DOES THIS PROJECT INVOLVE ANY OF THE FOLLOWING:
Yes No (CHECK ALL THAT APPLY)
❑6& Clearing, grubbing, grading or stripping of land which affects more
than 5,000 square feet of ground surface.
❑ B. Excavation or filling involving more than 200 cubic yards of material
within any parcel or any contiguous area.
❑ C. Site preparation on slopes which exceed 10 feet vertical rise to
❑(:J/ 100 feet of horizontal distance.
D. Site preparation within 100 feet of wetlands, beach, bluff or coastal
erosion hazard area.
❑[�E. Site preparation within the one-hundred-year f loodplain as depicted
on FIRM Map of any watercourse.
❑ F. Installation of new or resurfaced impervious surfaces of 1,000 square
feet or more, unless prior approval of a Stormwater Management
Control Plan was received by the Town and the proposal includes
in-kind replacement of impervious surfaces.
If you answered NO to all of the questions above, STOP! Complete the Applicant section below with your Name,
------ Signature,Contact-Information, Date-&-Count}--Tax-Map-Numbers Chapter236-does-not-appbL-W your-project_ —__—
If you answered YES to one or more of the above, please submit Two copies of a Stormwater Management Control Plan
and a completed Check List Form to the Building Department with your Building Permit Application.
APPLICANT. (Propert Owner,Design fesstonal,Agent.Contractor,Other) S.C.T.M. n 1000 Date:
Ii'i a lI 1�'
NAME.
Section Block Lot
1i _P i'I'Mi IN"I l,.
Contact Information: '/
Reviewed By.
Date:
Property Address / Loca on of- Construct to i Work — — — — —
❑ Approved for proce»ing Building Permit
Stormwater Management Control Plan Not Required
J ❑ Stormwater Management Control Plan a Required.
(Forward to Engineertn, Depai(meit for Review.)
FOR SMC P - rOS MAY 2014
Dzl
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TOW,c. cl i
/ SURVEY OF PROPS -
SITUATED AT I
4- CUTCHOGUE
TOWN OF SOUTHOLD
\ , SUFFOLK COUNTY, NEW YORK
i S.C. TAX No. 1000-103-07-29
SCALE 1"=20'
a
'S'
JUNE 5, 2000
ar y9J Sy• P
Ore f
/ AREA = 16,295.15 sq. it.
/e -_2O ho�. qy y 0.374 ac.
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O1. F KEN ROBINS
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EDUCATION lAw.
•• • \ / JS4' �� COPIES OF THIS SURVEY MAP NOT BEARING
THE LAND SURVEYOR'S INKED SEAL OR
TO BE A VALID TRUE COP/.
Q
�•\ ,p EMBOSSED SEAL SHALL NOT BE CONSIDERED
A� �j,�\, °• \ VJ �� / // � CENOFlCATIONS NNOATED HEREON SHALL RUN
(� `('•• ° / IS To THE PERSON FOR WHOM THE SURVEY
'2 DL / / YY R PRE OMPA .G IE N6 BEHALF TO THE
�G• D O / TITLE COMPANY, IDN USMEMIE AGENCY AND
• \` Cr / .,N/ TOTHTENDING ITISTRUIIDN F T EO HEREON.AND
'J / TO THE ASSIGNEES OF THE LENDING INSER
4� 7VfN7N.[LIOFIGTI0N5 ME N01 TPoW3ERABLE
FJ
THE EXISTENCE OF RIGHTS OF WAY
i 19• AND/OR EASEMENTS OF RECDRD, IF
�O r4y ' 00 ANY, NOT SHOWN ARE NOT GUARANTEED.
�� • •• \ PREPARED IN KCORDANCE WITH THE MINIMUM
STANDARDS FOR TLEAND APPROVED AND
ADOPTEDSHEJoseph A. Ingegno
FOR THE LIALS AND E NEW YO AND ATE LAN
cH.sucH USE Br THE NEW YORK STATE LAND
m" Land Surveyor
• \ �i N
Tdi-Survey--SMbdiVnian, - Site A—x - C-tauctan Layout
PHONE (631)727-2090 Fox (631)7227-1727
? •�, 4 ' OFFICES LOCATED AT UAILMG ADDRESS
\'�• .4 6 Q�e NYS Lc No 49668 1.780 ROPNOKE AVENUE P.O.Ba. 1931
RIVERHEARD New York 11901 Riverhead. New York 11907-D965
20-366
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phone.(631)298-7116
REAR ELEVATION FRONT ELEVATION
SCALE: 1/4••I'-0" SCALE: 114".1'-O"
tc :
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RAFTER TIE DOWN
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