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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
No Z-24718 Date OCTOBER 29, 1996
THIS CERTIFIES that the building. ACCESSORY
Location of Property 965 GREENWAY WEST ORIENT, N.Y.
House No. Street. Hamlet
County Tax Map No. 1000 Section 15 Block 1 Lot 27
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated APRIL 8, 1996 pursuant to which
Building Permit No. 23368-Z dated APRIL 12, 1996
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 ACCESSORY INGROUND SWIMMING POOL WITH FENCE TO CODE AS
APPLIED FOR.
The certificate is issued to NICHOLAS & GENEVIEVE BOLLETINO
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N-390035 - JUNE 28, 1996
PLUMBERS CERTIFICATION DATED N/A
Building Inspe or
Rev. 1/81
FORM NO.3
TOWN OF SOUT*OLD
BUILDING DEPARTMENT
TOWN HALL
uou/Hmoo.N.Y.
BUILDING PERMIT
(THIS PERMIT MUST 8E KEPT ON THE PREMISES UNTIL FULL
C[}K4PLEOON(JF THE WORK AUTHORIZED)
Date ............. .....�.^�`........., lP... r.���
0�� ������� �� �
w�� ����m ^� v
Permission Is hereby granted to:
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........................ ..................... ..............................�'.J ................... .. .................................................
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pumuonttoapp||oo�ondated ---. ^��------. lP..3r���—' and approved bythe
Building|
Fee
'^—^^~~^~--^^^^^' ' ^^^'' ---~^`
Building Inspector
�r
Rev. 6/30/80
Form No. 6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
A. This application must be filled in by typewriter OF, ink and submitted to the building
inspector with the following: 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)
J. 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 li lead.
5. Commercial building, industrial 'building, multiple residences and similar buildings
and installations, a certificate of Code Compliance from architect or engineer
ti responsible for the building.
6. Submit Planning Board Approval of completed site plan requirements.,
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 a 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
D. Temporary Certificate of Occupancy - Residential 815.00, Commercial $15.00
Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
New Construction. . . . . . . .. Old Or Pre-existing Building. . . . . . . . . . . . . . . . . .
Location of Property. . . 4� . . . . . 1.1. E�.�! �� . . . . . . . . . . ��/�/.. . . . . /�� . . . .
House No. Street Hamlet
Onwer or Owners of Property. ./. . . ./�US. . ����. .(,�� �� � . . . d�� T��!o . . . . . . . . . . . .
County Tax Map No 1000, Section. . ./5. . . . . . . .Block. . . . . . . . . . . . . . .Lot. . . .iz1. . . . . . . . . . . . . . .
Subdivision.//. . . .f. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filiet�d MiMap. . . . . . . . . . . .Lot. . . . . . . . . . . . . . . . .
Permit No. lyO: . . rmit.X�/f•.I� C/./.�1.Applicant�.�.���`L a,44 �d D a t e 0 f P e �+ !�"�� 01�.5.
Health Dent. Approval. . . . . . . . . . . . . . . . . . . . . . . . . .Underwriters Approval. . . . . . . . . . . . . . . . . . . . . . . . .
Planning Board Approval. . . . . . . . . . . . . . . . . . . . . . . .
Request for: Temporary Certificate. . . . . . . . . . . Final Certicate. . . . . . . . . . .
Fee Submitted: $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
@4 2 APPLICANT
336g--?_t-
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE 1
1185077 BUREAU OF ELECTRICITY
F 85 JOHN STREET, NEW YORK, NY 10038
Date JUNE 28,199E Application No.on file 11951596/96 N 390035
35
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of
NICK POLLEITINO, 965 GRMNI'lP.Y ROAD, ORIPa,TTP, N.Y.
in the ollotein location; ❑ 1st Ft. ❑ 2nd Fl. OUT .Section Block Lot
f q Basement
was examined on `IJN1F, 20►1996 and found to be in compliance with the National Electrical Code.
FIXTURE RECEPTACLES SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS INCANDESCENT 1.FLUORESCENT OTHER AMT. K.W. AMT. K.W. AMT. K.W. AMT. K.W. AMT. H.P.
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET DIMMERS
SYSTEMS
AMT. K.W. OIL H.P. GAS H.P. AMT. NO. A.W.G. AMT. AMP. AMT. AMPS. TRANS. AMT. I H.P. NO.OF FEET AMT. L WATTS
1 20
SERVICE DISCONNECT NO.OF S E R V I C E
AMT. AMP. TYPE METER 1�,4W 1 A•3W 3 0 3W 3 0 4W NO.OF CC.COND. A.W.G. NO.OF HIAEG A.W G. NO.OF NEUTRALS A•W G.
EQUIP. PER AY OF CC.COND. OF HI-LEG OF NEUTRAL
OTHER APPARATUS:
SWIEr 4ING POOL-1
TIME CLOCKSAMP.
G.L.Cs.1-1
G.F.C.1:-1
*(SVIDMMING POOL) This car'tificafe
covers compl i an-e- at tbe date of
_Lnsp,,c tj.on only. Because of unusual -
ervironnients it is advisable to
have frequent test algid or .repairs �. LL
<{< Continued on Page 2 >>>
GENERAL MANAGER
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.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
------------
THE NEW YORK BOARD OF FIRE UNDERWRITERS PAGE
1185077 BUREAU OF ELECTRICITY
F 85 JOHN STREET, NEW YORK, NY 10038
Date JUKE 28,1996 Application No.on file 11951596/96 N 39CA035
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the above application number in the premises of
go
NICK BOLLETTNO, 965 GREEMY ROAD, ORIENT, N.Y.
in thefollowinglocation; ❑ Basement ❑ lst Fl. ❑ 2nd Ft. OUT Section Block Lot
was examined on JUNNE 20,1996 and found to be in compliance with the National Electrical Code. Ka
FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS RECEPTACLES SWITCHES INCANDESCENT FLUORESCENT OTHER AMT. I K.W. AMT. K.W. AMT. K.W. AMT. K.W. AMT. H.P.
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIAL REC'PT TIME CLOCKS BELL UNIT HEATERS MULTI-OUTLET DIMMERS
SYSTEMS
AMT. K.W. OIL H.P. GAS H.P. AMT. NO. A.W.G. AMT. AMP. AMT. I AMPS. TRANS.I AMT. H.P. NO.OF FEET AMT. WATTS
SERVICE DISCONNECT NO.OF S E R V I C E
AMT. AMP. TYPE METER 1.0 4W 1,0'3W 3 B 3W 3.0'AW NO.OF CC.COND. A.W.G. NO.OF HI-LEG A•W G• NO.OF NEUTRALS A.W.G.
EQUIP. PER 0OF CC.COND. OF HIAEG OF NEUTRAL
OTHER APPARATUS:
made by a qualified person.
ROSLAK ELECTRIC LIC.#k3677-I � � LL
P.0.BOX 164
CUTCHOGUE, NY, 11935 GENERAL MANAGER
11.
a5 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.
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
70-1802
BUILDING DEFT.
INSPECTION
[ ] FOUNDATION iST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] IN CATION
[ ] FRAMING FINAL
[ ] FIREPLACE CHIMNEY
REMARKS:
DATE � INSPECTO
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Q ` ; BOAFD OF HEALTH
�D ; , FORM NO. 1 3' SETS OF PLANS . . . . . . .
O TOWN OF SOUTHOLD SURVEY . . . . . . . . . . .
-
kl� ' "�8 BUILDING DEPARTMENT Ct1EC�: . . . . . . . . . . .
TOWN HALL SEPTIC FORM - . . . . . . . . . . . . .
SOUTHOLD, N.Y. 11971
TEL.: 765-1802 FY 1
CALL �� IPOII�. -
Examined �v 19 ��, (� MAIL TO : • - - - - - - -
Approved . . . . . . .lZ ., 19 /,Wpermit NopS/. 3 34 6 . . . . . . . . . . . . . . .
. . . . . - - - . . . . . .
Disapproved a/c . ... . . . . . . . . ... . . .. . . . . . . . . . . . . . . . . ... . . .
(Building Inspector)
P ICATION FOR BUILDING PERMIT Date . . . . y : .. . . . . . . . ., 19?6
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.
t 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.
t 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.
. i
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 i pections.
f
l�ignat;%�tof applicant, or name, if a corporation)
vi TMailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
. . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name of owner of premises l:. . . :. . . . . .G .� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(as on the tax roll or latest deed)
If a li t is a corpo i signature of duly authorized officer.
. . . . . . . . . . . .
(Name and titie of orporate officer) .
/ �7. r� r
Builder's License.No. . : �•'r..'i�.�•:?
Plumber's License No. . . . . . . . . . . . . . . . . .
Electrician's License No. . 1?.�..lC -2eC..
Other Trade's License No'.
1. Location of land on which proposed work will be done., . . . . . . . d . . .W. . , , , ; , , , . . , . . . . . .
House Number Street / Hamlet —7
County Tax Map No. 1000 Section . . . . . . . . . .J . . . . . . Block . . . . . . . r. . . . . . . . . . Lot . . . .a ./ . . . . . . . . . .
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filed Map No. . . . . .. . . . . . .. . . Lot . . .—
. . . . .
(Name) . . . .
?. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy•_. . . . . . . . .../.. 11.2&V77./1. L . . . . . . . . ... . . . : . . . . . . . . . . . . . . . . . . . . . . .
b. Intended use and occupancy . . . . . . . . . . `% L . ''�,', . . .POO . . . . _
3. Nature of work (check which appIicable): New Building . . . . . . . . . . Addition . . . . . . . . . . Alteration
Repair . . . . . . . . . . . . . . Removal . . . . . . . . . . . . . . Demolition . . . . . . . . . . . . . . Other..Work.
4. Estimated Cost . . . . . . . .� . . . . . . . . . . . . . . . . Fee . . . . . . . . .
(to be paid on filing:this pplieatron)
S. If dwelling,number of dwellingunits . . . .
. . . . . . . . . . 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 . . . . . . . . . . . . . . .1. . . . . . .
. . . . . . . . . . . . . . . Rear . . . . . . Depth
8. Dimensions of entire new construction: Front . . . . . . . . . . .
Height . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . 1.
. . . . . . .
9. Size of lot: Front . . . . . . . . . . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . . . . . . . . .Depth . . . . . . . . . . . . . . . . . . . . . . .
10. Date of Purchase .
. Name of,F,prmer Owner . . . . . . . . .
11. Zone or use district in which premises are situated . /�eT 1•� y • . .
12. Does proposed construction violate any zoning law, ordinance or regulation: u
13. Will lot be regraded; . . . . . . . . . . .yw. . . . . . . . . . . . . . . . . a
. . . . Will excess fill be removed from premises: Yes o
14. Name of Owner of premises . . •30k6,fs,7,71PY. . . . . . Address . . . .OX44?--. . . . . . . Phone No.
Name of Architect . . . . . . . .. .Address
. Phone No.
Name of Contractor ., . .!!1.�14i Y�Au� • . . . . Address . . .�?7.Y1? 7?!t_.G,IC. ,phone No. �':.���
. . . . . . . .
15. Is this property within 300 feet of a tidal wetland? *YeS. i . . . . . . No.*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.
UNDERWRITERS CERTIFICATE
"IMMEDIATELY" REQUIRED
E CLDSIE UFON gPOOL TO
ONS
BEfOAE' Aa ` 0 AS N0 3f
DATE: B.P.#
FEE: BY:
NOTIFY BUILDING DEPAR
�l ; n 765-1802 9 AM TO 4 P FOR THE
FOLLOWING INSPECTIONS:
1. FOUNDATION - TWO REQUIRED
t��
, ' , FOR POURED CONCRETE
2. ROUGH - FRAMING & PLUMBING
INSULATION
f{ �'` `t FINAL - CONSTRUCTION'. MUST
.ur c lE8 +i r,
RFAA BE COMPLETE FOR C.O.
`t €t � ALL CONSTRUCTION SHALL MEET
THE REQUIREMENTS OF THE N.Y.
STATE CONSTRUCTION & ENERGY
CODES. NOT RESPONSIBLE FOR
STATE OF NEW DESIGN OR CONSTRUCTION ERRORS
COUNTY OF . . . !��.zK , , S.S
• • • • d�2/�? ✓•""��L��• • • • • 4 • . . . . . . . . being duly sworn, deposes and;says that he is the applicant
(Name of individual signing contract)
above named.
ieisthe . . . . . . . . . . . . . . . . . . . . . . . . . . . cf. .!• • ... . . . . . . . . . . . . . . . . . . .
(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
application; that all statements contained in this application are true to-the best of his knowledge and belief;and that the
vork will be performed,in the manner set forth in the application filed therewith.
)worn to before me this
. . . . . , . . . . . . .day of.
Notary Public, . . . Q. . . . . . . . . . County
. . \.CLAIRE L.GLEW
Notary Public.State of New York . . . . .X41
No.4879505 . . . . . . .
Qualified in Suffolk County �p pplicant)
Com
mission Expires December 8,19��:.
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"IMMEDIATELY UMERWRITERS CERTIFICATE
11 ICLOSE POOLTO CODE REQUIRED
UPON COMPLEF.ION m
'BEFORE"WATEW a
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765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION iST [ ] ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] IN ATION
[ ] FRAMING [ FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS•
DATE INSPECTOR
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SUFFOLK CO. HCALTH DEPT. APPROVAL
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