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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
Nc Z-22750 Date NOVEMBER 29, 1993
THIS CERTIFIES that the building NEW DWELLING
Location of Property 45 WALNUT AVE. MATTITUCK, NEW YORK
House No. Street Hamlet
County Tax Map No. 1000 Section 142 Block 1 Lot 12
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated FEBRUARY 24, 1993 pursuant to which
Building Permit No. 21247-Z dated FEBRUARY 25, 1993
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 AS APPLIED FOR
The certificate is issued to NORTH FORK HOUSING ALLIANCE
(owners)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 89-SO-20-NOV. 18, 1993
UNDERWRITERS CERTIFICATE NO. N-272938 - APRIL 16, 1993
PLUMBERS CERTIFICATION DATED NOV. 23, 1993-MATTITUCK PLUMB. & HEATING
~7Buil!ding
Rev. 1/81
YORK X0.2
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)
F
NN9 21247 Z Date . 199...:3
Permission is hereby granted to:
I /
..1.7..............
e.
! at premises located at
....................................l7~
County Tax Map No. 1000 Section Block Z............ Lot No...... G..........
i pursuant to application dated 19.4? and approved by the
Building Inspector.
Fee X~
/ B ing nspector
Rev. 6/30/80
INSPECTORS
SCOTT L. HARRIS, Supervisor,
r Southold Town Hall
Thomas Fisher :+h ^r P.O. Box 1179, 53095 Main Road
Building Inspector
Southold, New York 11571
Crary Fish f*`1I! d.~ ~a Fax (516) 7651823
Building Inspector ' Telephone (516) 765-1800
Robert Fisher
Assistant Fire Inspector OFFICE OF BUILDING INSPECTOR
Telephone (516) 765-1802 TOWN OF SOU`XHOLD
C E R T 1 P I C A T I 0 N /
DATE:
Building Permit No.~_
(please print l
(please print
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.
(Plumbers e
Sworn to before me this
r~ie~ENfy-?L~va day of 19
Notary Public, County
Notary P e
Edith K JACKSON
No. 492079Z
OVIRW
TIesFb~f4/:,iyP~
INSPECTORS
Victor Lessard
Principal Building Inspector
Curtis Horton SCOTT L. HARRIS, Supervisor
Senior Building Inspector a"ry,,,
Southold Town Hall
Thomas Fisher P.O. Box 1179, 53095 Main Road
Building Inspector Southold, New York 11971
Gary Fish
Building Inspecto ? Fax (516) 765-1823
Vincent R. Wieczorek - Telephone (516) 765-1800
Ordinance Inspector
Robert Fisher
Assistant Fire Inspector OFFICE OF BUILDING INSPECTOR
Telephone (516) 765-1802 TOWN OF SOUTHOLD
JUNE 2, 1993
A379- BENNETT ORLOWSKI, JR.
P. 0. BOX 297
CUTCHOGUE, NY 11935
RE: NORTH FORK HOUSING ALLIANCE, 45 WALNUT ST., MATTITUCK
To Whom This May Concern:
We are unable to complete your Certificate of Occupancy
because of the following reasons:
%xx An application for Certificate of Occupancy is
not on file. (Enclosed)
XXX No Underwriters Certificate on file.
XXX The check is not on file.)$25.00
XXX No Health Department Approval on file. tv*~
No final inspection has been made.
XXX No Plumber Solder Certificate on file.
(All permits involving plumbing being
issued after April 1, 1984).
BUILDING PERMIT # 21247-Z
Please contact our office on this matter. Thank you for
cooperation.
SOUTHOLD TOWN BUILDING DEPT.
THE NEW YORK BOARD OF FIRE UNDERW7RE PAGE 1
11.2501)5 BUREAU OF ELECTRICITY
85 JOHN STREET, NEW YORK, NEW YORK 10038
Date APRIL 16,1993 Application No. onfile 80183093/93 938
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicant named on the above applier in the premises of
N. FORK ROUR1'NO ALLTANCE, #1ALNUT" AVENUfl, H&TTI,TUCYr NJ,
in thefollowing location; ? Basement T Ist Fl. ? 2nd Fl. OUT(CRAWL SPACE .SectioLot 4
was examinedon AP1111, 12 t 199 3 andfound to be in compliance with the requirements (4 this Board.
FIXTURE ECEPTACLES SWITCHES FIXTURES RANGES COOKING-1 OVENS DISH WASHERS EXHAUST FANS
OUTLETS INCANDESCENT FLUORESCENT OTHER AMT. K. W. AMT, K. W AMT K W. AMT. K. W AMT. H P.
2 1. 2
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS SPECIALREC'PT TIMECLOCKS SELL UNIT HEATERS MULTI-OUTLET DIMMERS
~4 AMT. K. W. OIL H. P GAS N. P. AMT NO A. W G. AMi AMP. AMT. AMPS. TRANS. AMT. H. P SYSTEMS AMT WATTS
9 NO. OF FEET
1. E
pp SERVICE DISCONNECT NO. OF 5 'E R V I C E
1 AMT. AMP. TYPE METER 10 2W I $ 3W 3 e' 3W 3,6 4W NO. OF CC COND A. W G NO OF At LEG 0. W' G NO. OF NEUTRALS A W G.
EQUIP. PER N OF CC. COND OF HI EG OF NEUTRAL
t 00 CB 1 R s- 1
OTHER APPARATUS:
~ HOTORSt2-F N.P.
PANBLBOARD911 1. CTR. 60
K
LAKE ELECTRIC LTC1#1.845 E
17 FOREST TRACL
RIDGE, NY, 11961 GENERAL MANAGER
I 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. w
t 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 OR 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).
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 19 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 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 - $5.00 over 5 years - $10.00
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
Date ~~~~21a~r1 3 .
New Construction... Old Or Pre-existing Building
. op Location of Property N.v. ? r. Q ./cj
House No. / Street / Hamlet
Onwer or Owners of Property.. . . . . . . . . . . .
County Tax Map No 1000, Section../ $1oZ Block....l~,)./ .......Lot..,/.
Subdivision ....................................Filed Map............ Lot......................
Permit No..c_?.o?.`/. 7...Date of Permit ................Applicant.............................
Health Dept. Approval A $ ..................Underwriters Approval..'? A
Planning Board Approval
Request for: Temporary Certificate........... Final Certicate...~..
Fee Submitted: 5
APPLICANT
,'OUIIDATION ( 1 st)
COUNDATION (2nd) _ m
y
I O
:OUCH FRAME & t
-PLUMBING
y
H
• I m
m
I1ISULATION PER N. Y.
STATE ENERGY
CODE
FI.1AL I _IZ
ADDITIONAL CO.MENTS: x
ra
x \
. H
9
' H
H~ \
D
• r
~ v
-3 I
765.1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ I ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING [ INAL
REMARKS: _
DATE ~ INSPECTOR
M-1802
BUILDING DEPT.
INSPECTION
FO DATION 1ST [ ] ROUGH PLBG.
( FOUNDATION 2ND INSULATION
[ ] FRAMING [ ] FINAL
REMARKS:
DATE INSPECTOR
M-1802
BUILDING DEPT.
INSPECTION
[Z,J FOUNDATION 1ST ( ) ROUGH PLBG.
[ ] FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING FINAL
REMARKS:
Z2
DATE ?Av'<,~ INSPECTOR
BOARD OF HEALTH......
FORM NO.1 3 SETS OF LANS
TOWN OFSOUTHOLD SURVEY f~
i ( BUILDING DEPARTMENT CI(ECR At.. JI AS.......... .
FEB z LLLJJI 4i! TOWN HALL SEPTIC FORM _
SOUTHOLD, N.Y. 11971
ar,.DEpr TEL.: 766-1802 t:OTIPY r
TOIAI I! U SOUTHOLD CALL
Examined , , 19 /":3
MAIL TO
Approved 19/C,/Permit No. 02.~0~ . . .
Disapproved a/c
(Buil g 0-10v r)
APPLICATION FOR BUILDING PERMIT J
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
slIall 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, buildin e, housing code, a d re ations to
admit authorized inspectors on premises and in building for necessary inspec : --15.
(Signature of applicant, o name, if a corpor on)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
/^e r ..........II,, .
Name of owner of premises 4 ?t4 t~rK A f/.S! , , , , , , , , , ,
(as on he tax roll or latest deed)
If app ' a is a cor o ti n ignatur of duly authorized officer.
.r.t°~...
(Name and title Of c orate officer)
Builder's License No .
Plumber's License No .
Electrician's License No . . .
Other Trade's License No .
1. Location of land on which proposed work will be done . .
5
House Number Street Hamlet
County Tax Map No. 1000 Section '!Z:..... Block l......... Lot e~.
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 .
b. Intended use and occupancy G~t1~!Ge .
3. Nature of work (check which applicable): New Building /Addition , Alteration .
Repair • • • • • • • • • • • • . • Removal . Demolition Other Work .
I , rr (Description)
4. Estimated Cost, Dv
~P .
~Q~Qr Fee kx..
, (to be paid on filing this application)
5. If dwelling, number of dwelling units l 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 7 Rear , Depth
Height oR:y4~ ..Number of Stories .....caZ.
Dimensions of same structure with alterations or additions; Front . . . . . . . . . . . Rear .
Depth ~ . Height • , Number of Stories .
ction:Front Rear............... Depth
8. Height . .sion...of. . . . .entire. new . . construction:
Number of Stories .
9. Size of lot: Front Rear Depth .
10. Date of Purchase . Name of Former Owner
11. Zone or use proposed mises are situated
12. Will . Does lot be district in
construction which viol date any zoning law, ordinance or regulation:
13 raded Will excess fill be removed from premises: Yes No
14. Name of Owner of Name of Architect . premises
, • . • • • . • • • Address Phone No............:.. .
Address Phone No.................
Name of Contractoprm3ses
Address . Phone No. ,
15. Is this property Pyes,tY Souwithin thold T00 feet of a tidal wetland? *yes........ No.,..
Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly all !buildings, whether existing or proposed, and, indicate alI 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.
i ,
~I
i
i
~I .
STATE OF NEW Y
S
couNT~~ . . 5
nn~ ~ilQf*1..
• • • • . • • • • • • • • . • • $ • • . being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
above named.
He is the .......................1, C~?u,Ve:~-Q^f......................
(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 contai4d 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 mre- this
..:I... / .day f. tC~ t °aly 19 Y~
otary Public, County
c
ROBERT I., TT,JR, Signature o pplicant)
NOTARY PUB , State of N.Y.
No. 47250 , Suffolk Cou
Tenn Expir4s May 31,19
P
WELL pWEL GG WELL d CESSPOOL
OVER 150
CP \ (DWELLING' / >
Iz- LLIN \ ~ 7z
(DWE G) 0-r c
NI pR1A TDOR0 P~ -11 VI - ( f2
P
SURVEY OF Besse 7
Y Z \ IDWELL QV~NGEfl j5C
PROPERTY " 1>• 27' E29',.t- I > I
AT MA TTITUCK m WELL o
zg, TOWN OF SOUTHOLD we11I 9"PV n" m 1 -1-1 SUFFOLK COUNTY, N. Y. s m A
O
+P) ea
1000 - 142 - 01 - 12 03' N~ NS _
Scale 1" = 20'
Feb, 19, 1988 aA 0
Mar. 2, 1969(revise) it a
.P N 2 , E ~ 'e
y w ~ 1
a 3 3 WELL E., j
IOVEA > ~ ~ 3 ~5 •~4 2~.2 x
WELL C O \ 1't4 2i2 ~ 9231 34' ° p c P
CERTIFIED TO, > e533 00" W ~ ~
NORTH FORK HOUSING ALLIANCE, INC. Q S77 2_ ~ O 3 Z "PC W cA ) PECONIC ABSTRACT INC. „ W I- S 7 27100 c° E ( R 0W
77.21,00 8 5 M- ALNUT n WSON
•Z 7320~~- z~ FREDDIEO'~
U n NIpIF SDN
TEST A. LAW
DATA ~a MA (VAC"ANT)
DARN BROWN LOAN B /
/p; BROWN BIN.Y LOAN ,.5• ~~yE~~t~~/~pp SINGL~,E FAMILY DWELLN4 ONLY {{~~WWy
BROWN LOANY SAN. B• Ga•'atG~ UM YEARS FROM PA~'•
TJ
PALE eaowx S1 IFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
NE.IUN r. rho /.oaohms of or/l and cesspash; shown M, rsspaols shown hereon an, s o61 led from others.
toAasE sAN. FOR APPROVAL OF CONSTRUCTION ONLY AREA a 5,96984-ft. obanvolbns and or from data ata oblalnW from of
•"Tf`8 0 8 IN HS REf/~I~
J'(`/ yy The wooer supply and sewage d/onfor his ,wage d/sposal ce wlll conform
=Ods for fibe surveys as shed far s use T eparstand resldeneewell conform the rds of The Su/folk County Suffolk County ervfces.
x.11 1fo ROVED by P P earfinenl od / Health Servl.es. 4 r
i~S/"> - ,Y AI~ IIAssI-A.L.S. and Ner,vadstilldpted D ~~aa ty 4 "~L -
f? O ' ''d 6 p
~ : N. LIC. NO. 49618 Appeared ht aeem lance with Baa•1N010of 11ecLm
P C UrRVE5'0 P.C. damminfleni dated
(516) Q5 lp P. O. 0
MAIN RO `/-/11 w.a,.. ' < <n a..~~
SOUTHOLD, N.Y. 11971 aarnauravAmmosnuse
f 88 - 144
\ P
WELL lDWELLIN!
cP , TOWELLING) WELL a 30SSPOOI
D
(DWELLING) \ 7z 7z
c
N/O/F A f00RIEK C
i VIGTORI
SURVEY OF " , 99.25' 2 y 3
PROPERTY _
° 27' 00° E ~~e Z \ (DWELOVER 150.
AT MATTITUCK N 77 ,--30
TO TOWN OF SOUTHOLD c m WELL
m A
SUFFOLK COUNTY, N. Y. "EST
1000 - 142 - 01 - 12 "e O
Scale 1". 20'
Feb, 19, 1988
Mar. 2, 1969(revise)
Mar. 22, 1993 (found.) O ~y 4 Ze a o O
z a m ~ ~3 1J
W tG
WEL L50'~ 3 3 IaVER Q
11.1 2
WaU O O I11, ,aS4~y R2 ' .
92 34' LU 92.94' ° C P
CERTIFIED TOP pp" W > 'y
NORTH FORK HOUSING ALLIANCE, INC. 27'_, 3 ,1 ar ~c PECONIC ABSTRACT INC. Q 9533, 5-a
11 o Z F 27 p,r W eaW ) 0
00 W --S 7f U (R-0.W
s 77° aT A VEN E
ON WALNUT O Z 132 p0 - Ws
` FREDDIE O• LA
U TEST DA rA O/ A.
TOLE LAWSON \ ;`DL
DARK BROWN LOAM B• 8 (VgGgNT)
BROWN SANDY LOAM /,D•
BROWN LOAMY SAND
~e
PALE BROWN Mso1uM TO ~VFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES V "1y1143 r-V
COARSE SAND FOR APPROVAL OF CONSTRUCTION ONLY The lacalens of weds end ceespoak shown A
AREA 5,050salf. observatlaas and or from data obtained from cuspoak shown Mr.on ors em aalm,.d la,n aMers.
1• TE HS REF. NO.
The wafers hry and sewage disposal sewage d/syasa!
~EOf NEW ~o a PROVED standard faar 1111. surveys'.. seehi d systems for hl)s residence wNl conform e the standards of The Suffolk County once wg! co aunty Ye vIces.k County
S~ 0~ i MEr c by the L.AA.L.S. and approved and ado led De artment of Health Services. ep - _ _ _ for such use by The New YarN Selo. Lund p S.rlces.
> >o 77Ne Assoclullon.
r i`r en-a 'k N LIC. NO. 49616
P E O , P.C.
!5161 =.5p@ 0J P. 0. ,1D L Sv
MAIN R
SOUTHOLD, N.Y. 11971 'd~ fez I.,. ~nn„Te . ssRrWrcArnv AODSa' aeeRms
88 - 144
fpWEL LING)
WOVER6150SSPOOL
cR IDWELLIN61 D Dr.~
L
(DWEELING) \ C N10 ~ICiORIA TOORRZIK ~ C
SURVEY OF 69.26 , 3 ~ Z \ IDWELL~NG 150.
PROPERTY d-r~ 3' m WEB, OVER
AT MA TTITUCK " 77 27 DD 1 za.l `'30 -
TOWN OF SOUTHOLD
` m csr m ~
SUFFOLK COUNTY, N. >Z SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES C HOLE q91 O
1000 - 142 - 01- 12 APPROVAL OF CONSTRICTED WORKS
Scale 1"= 20r H.S. REF. NO R -tQe) _ up AN ~A
Feb, 19, 1988 The sewage disposal and wAtar supply Facilities it thla Inceti0o hasty bw _
Mar. 2, 1969(revise) saNalactodly inspected by Iris Department and are in 1 O
Mar 22.1993 (found) Dr gemptancawMNKy
0 c~ aa•MrIN pons. (a z May 5, 1999 (final) p Q • . PF. 3 _ 'a-
16Y.-.L~O..L7J W 1 -3~ O \ CJ'
DIVFA'EL isau us OFFICEOFI'IASTEWATEN MAkIGEMENT 3 L O
WELL O 11N 2i.E p-.E F
9294 92.94'
w Z
27, CERTIFIED TO, O 0" W , plr~ NORTH FORK HOUSING ALLIANCE, INC. 77° - Z run , W
PECONIC ABSTRACT INC. Q 6533'__S~ - i\OO co pxo 27, pp' °sa BR/DGEHAMPTON NATIONAL BANK os cp S 7721' 00" W zA-'~ S 77~ VENUE (R.OW)
m A s~
O Z 132.00 "eVVALN~ DOg O.LAWSO"
V~ N/01F W TEST Q W A. LA S0"
H DATA OLE U- MA NT)
DARK BROWN LOAM y'- ' (SAGA
',Ip; BROWN SANDY LOAM 1.5•
BROWN LOAMY SAND S'
• . ~PALE BROWN <.I IFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
MEDIUY TO The locafions of weas end cesepoah, shown COARSE SAND FOR APPROVAL OF CONSTRUCTION ONLY AREA a 6,00914.lg. oasWrwlbns and or data oalahWd iron d eesapaoh shown hueon me r.^..' R:h 2 ale
n• 89 SO 20 dote oDlahed /ram oMers. Frfyt
E HS REF. NO. p` hlP
A~ Pre accordance with the minimum The water supply and sewage d/sposo, pared in systems !or his residence anti/ conlorr, d sewage disposal ~ ' "r ""~i r 'donee wfff Counly vices.
G standards for fifle surveys as a kbllshed to the standards of The Suflo/k Count The Suffoik County i Services.
b' MEItOf 'ROVED by the LJJ.L.S. and ayproved and adopted Department of Health Services. io r• + - for such use by The New York State Land 3
t 9m Sa - _ - T11/. Assodeflon. s
LIC. NO. 49618
P ~SU13 , P.C.
!5161
P. O. AfAIN ROAD
L nssc~rnw Amsn.~os7drsan~~y~ SOUT OLD, N.Y. 11971
B8 - 144