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21856-Z
i FORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-22933 Date APRIL 5, 1994 THIS CERTIFIES that the building NEW DWELLING Location of Property 510 GRANGE ROAD SOUTHOLD, NEW YORK House No. Street Hamlet County Tax Map No. 1000 Section 75 Block 4 Lot 12 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated DECEMBER 15, 1993 pursuant to which Building Permit No. 21856-Z dated DECEMBER 28, 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 WITH ATTACHED 2 CAR GARAGE AS APPLIED FOR The certificate is issued to MARK & KAREN VAN BOURGONDIEN (owners) of the aforesaid building. SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL 92-SO-97-MARCH 25, 1994 UNDERWRITERS CERTIFICATE NO. PENDING - MARCH 24, 1994 PLUMBERS CERTIFICATION DATED MARCH 28, 1994-FRANK J. MEYER PLUMB.&HEAT. -�. *1 Building In 7octor Rev. 1/81 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) C�/j Date ..... / .y......................................... 19..(- ... N-0 21856 Z Permission Is hereby granted To: ..l.I...:JI..../.-. �N ......................./(......�... .... .. .............. .................... to ...CC�a.6..i..-......../.:�..........5:.. . ............ ........... ...... lrn,c l..� ,.............. STz. .. ............... !t::....... t./..G.!��..........h/.<//�......... . !':......1�ili ��f .d ..................... ... . .................................................................................................................................................................. .................................................................................................................................................................. ..........................................................................................................�..................................,.,,..,.,............ at premises located aT.........fl. ................ ^..................................................................................... cc- /O�i C County Tax Map No. 1000 Section ..... ...5............... Block.......CJ .......... Lot No. ..... ................ pursuant to application dared .......�Vc.......z ........................... 19. ........ and approved by the Building Inspector. �v Fee $..o/:... %�� ullding Inspector 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 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 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 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 Buildine - $100.00 3. Copy of Certificate of Occupancy - $20.00 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residentia $_21�` 0, Commercial $15.00 Date . . .. .I� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . New Construction. . . . . . . . . . . Old Or Pre/�,pfi_st�ing lding. . . . . . . . N ' I Location of Property. . . ./. . . . . . . . . . . �J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . House No. /gg/treet t Hamlet Onwer or Owners of Property. . :. .. !. . . ..?. . . . ... . "".^' aae?�. . . . . . . . . . . . . . . . . . . . . . . . County Tax Map No 1000, ection. 1.c . . . . .Block. . . ��. . . . . . . . .Lot. .� 2. . . . . . . . . . . . . . . . . , Subdivision. . . . . . . . .. F: ed . . . . .I. .L`o Permit No. . jqS��. .Date Of Permit. . . !.".L Q.. .Applicant. !. > h X`�r![l. M�. . . . . . . . . . . . . HealthDept. Approval. . . . . . . . . . . . . . . . . . . . . . . . . .Underwriters Approval. .11l. . . . . . . . . . . . . . . . . . . . . . . Planning Board Approval. . . . . . . . . . . . . . . . . . . . . . . . Request for: Temporary Certificate. . . . . . . . . . . Final Certicate. . . . . .�. . . . /. Fee Submitted: $. . . . . . . . . . . . . . . . . . . . . . . . . �! Y� APPLICAN C0 C TEL. 765-1802 Four TOWN OF SOUTHOLD , < OFFICE OF BUILDING INSPECTOR c P.O. BOX 728 v' yr TOWN HALL SOUTHOLD, N.Y. 11971 C E R T I F I C A T I O N E March 28, 1994 Date Building Permit No. 21856Z Owner 'Theodore C. Martz Jr./ Van Bourgondien (please print) Plumber hank J. Meyer Plumbing and Heating (please print) I certify that the solder used in the water supply system contains less than 2/10 of 1% lead. (plumber ' s signature) Sworn to before me this "� ,• L�/ )OHN NRAMEHt C �/� .NOT"RY PPSUr,. `',[ih "I Nen York' day of ����yi'�1 i --- N, r;io3._. Surrolr.Lo." Teem Exyrtes Feb 28.1/WM, 19 Notary Public Notary Public, Jc. i%�/U County r THE NEW YORK BOARD OF FIRE UNDERWRITERS WE ARE IN THE PROCESS OF ISSUING A CERTIFICATE OF CO MPLIANCE FOR THE ELECTRICAL INSTALLATION AS C RED IN AN APPLICATION NOTED BE APPUCATIONNO. 137( �� LOCATION G 'cq -qi> Q INSPECTOR DATE a f ISO(REV 9M) t-t)Q:t 1'-4R (.(o ME P7.I=Ts' I:.S C:iON DATE COMMENTS m�. r T FOUNDATIONI / D _ FOUNDATION ( 2nd ) _ -. �.� m 2 . — z 0 4, ROUGH FRAME h PLUMBING }� m INSULATION PER N . Y. COD STATE ENERGY CODE r 4 . —J y FINAL r ADDITIONAL COMMENTS : x C.—Cain,zz Zuc t c; 7 - O'D Gvto H\ rn O �1 a - z v - V 765-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST ( ] ROUGH PLBG. [ ] FOUNDATION 2ND [ INSULATION [ ] FRAMING ] FINAL REMARKS: c ' S L DATE IN8PECT0 M-1302 BUILDING DEPT. INSPECTION [ a4OUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION, 2ND [ ] INSULATION [ ] FRAMING [ ] FINAL REMARKS: ( �1 DATE INSPECTOR M-11102 BUILDING DEFT. INSPECTION [ ] FOUN ON 1ST ( ] ROUGH PLBG. FOUNDATION 2ND [ ] INSULATION [ ] FRAMING ( ] FINAL REMARKS: DATE ) / INSPECTO gly �� M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ J ROUGH PLBG. [ ] F DATION 2ND [ ] INSULATION [ FRAMING [ ] FINAL REMARKS: C� DATE `b INSPECTOR M-1802 BUILDING DEPT. INSPECTION [ ] FOUNDATION 1ST [ ] ROUGH PLBG. [ ] FOUNDATION 2ND [ ] INSULATION [ ] FRAMING [ FINAL REMARKS: DATE INSPECTO 1 . if - J � Y C� b � I 93 z� 1 T- F cc o m QW9H wu wv. YK If i� ui 0 : ko 1 - "- THEODORE C. MARTZ, JR. BUILDING CONTRACTOR (516) 878-8443 145 Ryerson Avenue Manorville, New York 11949 March 22, 1994 Town of Southold Building Dept. Town Hall Southold, New York 11971 RE: Permit # 21856Z Van Bourgondien- Grange Road, Southold, NY. Please add to the above plans, (1) 36" pre fabricated fireplace as shown, and (1) covered porch in front 6'x40'. Sincerely, 1 Theodore . Mar 1Iry V n lam• � �• 4 • •I r- + l� 40 f - - 2 Q�`" N/O/F CHURCH OF THE OPEN DOOR v 78.30' - ln � o a o Of o LOT B b, • �'O O LOT LOT O vv O O O N. 85'35'50" E 16.70' \ Zt N T o � O /lOJ h $O.p 5.0 AREA = 21,448 sq ft.. s k m Z eB\2; RO 7�' RPM GIJ SURVEY OF P/O LOT 9 SOUTH HARBOR HOMES" FKEDAUYN,W4 FIE NO.. 4096 AT SOUTHOLD TOWN OF SOUTHOLD SUFFOLK COUNTY, N. Y. 1000- 75- 04 - 12 Scale: 1"= 30' Prepared in accordance with the minimum Dec. 9, 1993 standards for title surveys as established Feb. 3, 1994 (foundation) by the L.1,A.L.S, and approved and adopted for such use by The New York Slate Land OC Title Association. �LAND z5 t. r�, cl SUFF FOR COUNTY L DEPARTMENT OF HEALTH SERVICES D �$ FOR APPROVAL OF CONSTRUCTION TiON ONLY 92 SO 97 The water supply one sewage d/spOsal / Y.S. L/C. NO. 49618 systems for/hn residence OR conform i F DATE AS. REF. NO. to the standards at The Sulto/k County P l V RS, P.C. Deparlmem of Health Services. l51 P. 0. PPROVEO s'p�c ////9A- MAIN SOUTHOLD, N.Y. 11971 93 - 30 5 nC,r.�_ BOARD OF HEALTH - FORM NO. 1 y!. . . . . .7 SETS O�A:75 15� TOWN OFSOUTHOLD SURVEY . : . . . _ _ _ . . . . . .OM . . . . BUILDING DEPARTMENT CIIECK . ' TOWN HALL SEPTIC FORM . . . . . . . . . . 'a_ :t�:'iY SOUTHOLD, N.Y. 11971 �� TOWN OF SUi11i (;E. _ .j TEL.: 765-1802 N0 I FY I C, CALL • . . . - • • • , . . • - . .Examined . . . �,L./ (�. . . . . , 19��C�j1� MAIL TO : . . Approved . . . . . /IV, 1 . . . . IS/� . Permit No�W.5 L J. . . Disapproved a/c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . y (Building Inspector) APPLICATION FOR BUILDING PERMIT 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 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. 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 her ' described. The applicant agrees to comply with all applicable laws, ordinances, building cod , housing a re atio s, and to admit authorized inspectors on premises and in building for necessary inspections. (Sig Lure of plicant, r me, i a/co ration) (Mailing a ress of applicant)✓ State whether applicant is owner, lessee, agent, architect, engineer=contractor, electrician, plumber or builder. Name of owner of premises K.`I � \ ���Ut °1� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Name and title of corporate officer) Builder's License No. . . . . . . . . . . . . . . . . . . . . . . . . . Plumber's License No. . . . . . . . . . . . . . . . . . . . . . . . . Electrician's License No. . . . . . . . . . . . . . . . . . . . . . . Other Trade's License No. . . . . . . . . . . . . . . . . . . . . . I. Location of land on which proposed work will be don . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3)0. . . . . . . . . . . . . . . . . . . . . . . .�� .E . . . . . . . . . . . . . . . . . . . ` . .�., . �11 . . . . . . . . . . . . . . . . . . House Number Sttrreet (I' Hamlet County Tax Map No. 1000 Section . . . . . . . .. . . . . . . . ).� . . . . . Block . . .G*T. . . . . . . . . . . . Lot . .I;— Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filed Map No. .` '9 k7. . . . . . Lot .�. .Q. . (Name) 2. State existing use and occupancy of'premises and intended use and occupancy of proposed construction: a. Existing use and occupancy . . .` . . . . . .}. . . .n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. Intended use and occupancy Ih(�, .�'T. . !`t . . :.' ': C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Nature of work (check which applicable): New Building . . . . . . . . . . Addition . . . . . . . . . . Alteration . . . . . . . . . . Repair . . . . . . . . . . Removal . . . . . . . . . . . . . . Demolition . . . . . . . . . . . . . . Other Work . . . . . . . . . . . . . . . 3S 0 (bilption) 4. Estimated Cost . . . . .�. . . .t. —O - . . . . . . . . . . . . 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 . . . . . . . . . . Z. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . .GZY . . . . . . . . . . . Nu ber of Stories . . . . . . . . . . . 8. Dimensions of entire new construction: Front . . . . . . . . . . . . . . . Rear . .� . . . . . . . . . . Depth A. . . . . . . . . . . . Height Number of Stories . . 2— . . . 9. Size of lot: Front . . . J� a 10. . . . . . . . . . . . . Rear . 1$.•3p. 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 R . . . . . . . . . . . . . . . . . . 13. Will lot be regraded . .) tpt,�,�,, Wil cess fill bex��ved from premises: Ye No 14. Name of Owner of premises't. k Bwol1 . Addres . ii?- . . . . . . Phone No.I . . '. 7 Name of Architect . . . . Address �.�.�,.�. . . . . . Phone No . . . . .p Oaf1t C Name of Contractor . . . . . . . . .'. . . . . . Address" ?!v� `E1/ Phone No' R7�. . . . 15. Is this property within 30 feet of a tidal wetland? /� ��</i`^�y 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. H STATE OF NEW Y RK, COUNTY OF . . .S .0c:. . . . . . . . . . . being duly sworn, deposes and says that he is the applicant . . . . . . . . . . . . . . . . . . . . . . . . (Name of individ.ua. .l gning contract) above named. Heis the . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed fhe 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 this . . . . ./:�_Z74_1 . . . . . . . . . . .day of.G�'LCre.Yk.�a� : . . . . ., 19 1,3 Votary Public, . . . . . . . , 4a �r�5:4= . . . . . . . . . . . Co ,�— . . . . . . . . . . . . . . UJN ;AJ.�COOPER Notary Public,State of New (S na re of applicant) No.4622663,Suffolk Cou Tenn Expires Decetnber3l,7 (r. � j0? 58 T�2 now or f orme r�Y d �3 Church Of The Open Door 78.30 - N85°3540 E - r���- EL=29 2 Z A Lot 10 cn v O A O- Lot 9 0 Area = 21448 sf. 0 DWELLING lw/PUBLIC wPT ER 1 m O Lot 8 N.85°3550 E. p 16.70� O- _ EL'26 8 \ w0 gyp\ S.0 -- oAEy wPl IG� o - RIGHT OF WAY i Z _ _ __ 4e. A yROPO'>ED \ \ I D o DRIVE wAY L71 PKOVOSED Lo t � � Z— C WAl v, EkNkE p LOCATION N (m) Ly (VACANT) 40 I - 35 � \ O I PROP/F.EG yf y\ c'ANRARY S to D Sv ST E^'L I \\ o0 2 Q :P P p cD _ y z z° y.A E O Z �- 0 F , IX rya / 2y. rn Lot 12 — 9 Z (VACANT) I O Pw,a SINGLE- FAr "iLY DW ING ONLY "SAP EXPIRES YEARS FR DATE OFAPPROV SURVEY FOR MARK VAN BOURGONDIEN a KAREN M. VAN BOURGONDIEN SQIFFOLK COUNTY DEPARTMENT OF HEALTH SERVICE' MARK OF LOTS SOUTH HARBOR HOMES" AT SOUTHOLD DATE OCT 2 , 1992 FOR APPROVAL OF CONSTRUCTION ONLY TOWN OF SOUTHOLD SCALE I " = 40' DAT REF. NO. S SUFFOLK COUNTY, NEW YORK NO. 92 -085Z NUHMUTHORIZED ALTERATION OR ADDITION TO THIS CERTIFIED T01 SURVEY W A VIOLATION OF SECTION 7209 OF THE MARK VAN BOURGONDIEN NEW YORK STATE EDUCATION LAW KAR EN M. VAN GONDIEN APPROVED - *COPIES OF THIS "VEY NOT SEARING THE LAND vEYOO'S INKED SEAL OR EMBOSSED SEAL SHALL FIRST AMEE jt{ CAN YI''JJNSURANCE NO NE E CONSIDERED TO BE A VALID TRUE COPY COMPAf{Y y MGUARANTEES INDICATED HEREON SHALL RUN ONLY TO V%v ••- n •-E�y '' HEALTH DEPARTMENT- APPR TO CONSTRUCT THE PERSON FOR WHOM THE SURVEY IS PREPARED ..`tk - AND ON HIS BEHALF TO THE TITLE COMPANY,GOVERN- C,j'Z * NEAREST WATER ORIN MI.! SOUR EP+ MIMTE�.►fIKICA[ MENTAL AGENCY AND LENDING INSTITUTION LISTED F L: R 31if CO. TRX NAP IOQSS CTION 9jLN.0CK 4'L LOT 012 NEIIEON,AND TO THE ASSIGNEE! OF THE LENSING _ ^I G- *OTHER ARE MO OW LLIINf ITHIM 100 f ET OF TM& MOICRTY INSTITUTION. GUARANTEES ARE NOT TRANSFERABLE - { OTHER THAN TNOS SH N ON. TO ADDITIONAL INSTITUTIONS OR SUBSEQUENT = v C` N THE WATER SU Y fE pfPpA Sr EM FOR THIS RESIDENCE OWNERS (,.•tea Tlt_ - 1� R DIlAMCf3 5/101FN HEREON FROM PROPERTY LINE! C WILL CONFORM ST OFT S OlK COUNTr O[► T TO Ex If TINE STRUCTURES ARE FOR A SPECIFIC .Q M HEAL iN tf1P' }�R�TJJRFjM PURPOSE AND ARE NOT TO BE USED TO ESTABLISH APPLICANT. ,J9//// PROPERTY LINES OR FOR THE ERECTION OF FENCES 'ET•'�Cry�DNt•TT AODNEW YOUNG a YOUNG � ►R EAD, NEW NDER YORKAVENUE NOTE ! 0= MONUMENT I = STAKE ALDEN W.YOUNG,PROFESSIONAL ENGINEER SUB151VISION MAP FILED IN THE OFFICE OF THE CLERK OF SUFFOLK CO. ON JULY 14,1964 AS FILE NO.4096 AND LAND SURVEYOR N YS.LICENSE NO.12845 HOWARD W.YOUNG, LAND SURVEYOR N THE LOCATION OF WELL(W),SEPTIC TANK(ST)B CES000LS(C►)SHOWN HEREON N.Y S. 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