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Home My WebLink About4275-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office $outhold, N. Y. Certificete Of Occupancy No... Z..~.6.9.~... Date .............. De.c ~.. ~ ..... , 19.69. THIS CERTIFIES that the building located at .E/& .~ine .Tr~:e .Road ..... Street Map No..N.a.s..s:. ?.a..r.m. Block No ........... Lot No..Pt. 20. &. 21 .. Cutchogue.. conforms substantially to the Application for Building Permit heretofore filed in this office dated ......... Ea~,.... 2 ..... , 196.9. pursuant to which Building Permit No.. ~27 ~. Z dated ......... ~a]r.... 2 ......, 19 6c)., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is ...Pr.i.vate-one- .famiLy..dwe.l. ti. ng ..................................... The certificate is issued to .... Jul.i.r-tte..Lev-iness ...... 0wr~e~ .................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval ...... N.,R. ......................... ....... . :.... : : ......... Building Inspector House ~ 201~ FOR.M NO. ~ TOWN OF $OUTNOLD EUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 4275 Z Permission is hereby granted to: ............. ~...k,......~.~.....~..~..~ z.,v~,, pursuant to application dated ........................... ~ ............ ~ ........... , 19.~1~.., and approved by the Building Inspector. FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted in duplicate to the Building Inspec- tor with the following; for new buildings 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 of Health Dept. of water supply and sewerage disposal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installa- tions, a certificate of Code compliance from the Architect or Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan requirements where applicable. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of peoperty showing all property lines, streets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent informa- tion required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 t~.. Certificate of occupancy on pre-existing dwelling or land use $5.00 Copy of certificate of occupancy $1.00 Date .~...,f~C...~.../.~.,~/.~.~.¢} ........ New Building ............. Old or Pre-existing Building .... ~ ...... Vacant Land ............. Location of Property .......... ~/~'.~...~T.~'.~.~.. ~..1~..~. ................. House No. Owner or Owners of Property . .,~ ~,.~ ~ ~ ~.--~E.,-.. ~...L. ~.~i .~. ~/.,~. ~.~.,~ ........................ CountyTax Map No. 1000Section ...~!~. ....... Block ..... /. ........ Lot.../..~.. ....... Subdivision .~...'~..~..'~..... F/~..~..I.t~..5'. ......... Filed Map No ........... Lot No. ~.~..~. ~,~. ~.,. ............ Permit No ........... Date of Permit .......... Applicant . Health Dept. Approval ........................ Labor Dept. Approval ........................ Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate ....................... Fee Submitted $../..~.~/..~. ................... APPLICATI(~N FOR BUILDING PF.~RMIT Date .................... .~..ay. .... INSTRUCvrlONS a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building Inspector. b. Pl, ot plan showing location of k~t and of buildings o n premises, relati~aship to adjoining premises or public streets .~r areas, .and giving a detailed description of layout of property must be drawn on the diagram which is part of this application. c. The work covered by this application may n~t be commenced before issuance of Building Permit. d. Up(m approval ,of this application, the Building In specter will issue a Building Permit to the applicant. Such permit shall be kept ~n the premises available for inspection throughout the progress of the work. e. No building shall be occupied or used in whole o~ in pax't fiyr any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspecter. APPLICATION IS 1-1~y.I~Ry MADE to. the Building Department for the issuance of a Building Permit pursuant bo the Building Zone Ordinance of the Town of Soothe Id, Suffolk C~unty, New York, and other applicable Laws, Ordinances or Regulations, for the construction of build ings, additions or alterations, or f~r removal or demo- lition, as herein described. The applicant agrees to corn ply with all applicable laws, ordimances, building code, housing cxyde, Ired regulations. (Signature of ,applicant, or name if a corporation) ....... $o.utl~,l&... N .Y ............................ (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder ................ .~.q .ii.'c.r..a .c.~..o .~. ..................................................................... Name of owner of premises . .~..t~..~..~..t.~.e...L.e..v.J.~.e.s.s. ...................................................... If applicant is a corporate, signature of duly authorize d officer. (Name and title of corporate officer) 1. Location ~of land on which proposed w, ork will be done. Map No...N..a.s.s.a..~..F..a.r.m. ~ot Ne.P.S..20..~..2.~ Street and Number . .E~.~...Pine..~ree..l~o.~d. & .N/~..K~d~nod. ~oa, d ~...Cut, chogue ............. ~' I- ,~.o I 5- ~ Mumcipality 2. State existing use and ~ccupancy ,of premises an d intended use and occupancy of proposed construction. a. Existing use and occupancy .... ~e~;l~lg ..................................................... b. Intended use .and ~)ccupancy ........ salve .w;L~h. &dd£ti~n .................................... 3. Nature of work (check which applicable): New Building ........ Addition ....X~.... Alteration ~ ..... Repair ......... Removal ........ Demoliti.on ........ Other Work (Describe) ...................... 4. Estimated Cost ..... ~../...~T~....-~. .............. Fee . ~.,0Q .......................................... (to be paid ~n filing this application) 5. Tf dwelling, number of dwelling units . orAe ..... 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 ..................... 8. Dimensions of entire new construction: Front . .~6 ............. Rear .... 16 ........ Depth ...... 2,1,.. Height ............ Number of S~ories ..... one .................................................... 9. Size of ~o~: Front ................ Rear ............... Depth ............... 10. Date of Purchase ............................... Name of Former Owner ............................. 11. Zone ~r use district in which premises are situated...~..A.~. .~J,~; ....................................... 12. Does proposed corr~mction violate any z~ning law, ordinance or regulation? ...laO ..................... 13. Name of Ownerof premises J'., .Levllles~ ...... Address .. Cll~;chog:~e ........ Phone No ............ Name of Architect ............................. ~ddress ...................... Phone No ............ Name of Contrac~r .1~,. J~ya.~t ................ Address .. Solxtho~d ......... Phone No ............ I PLOT DIAGRAM 'dit' tl all'uildi [ wh ' r xitin Locate clearly an~ s mc y o ngs, eme e s g or proposed, and indicate all set-back dimensions from property lines. Give s .l~eet and block ~umber or descript$on acoording to deed, and sh~)w street names and indicate whether interier or co~mer Sot. ...................... -Robert. ~L ../-l~raA;t .......... being duly sworn, deposes and says that he is the appli. (Name of individt~al signing application) qant above named. He is the .......... ~.ql~.l;MaCJ~0~' ..................................................... (Oontractor, agent, c~,r~orate officer, etc.) of said owner or owners, and is duly authorized to per~qrm or have performed the said w~rk 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 perf~vned in the mann er set fort~ in the application filed therewith. Sworn to before me this ............ ~... day of ....... ]~ty. ....... 19~9. Notary Public, .................... Oounty (Signture of applicant) ~-~3°0~' 50' l;~ EOWooo ~AP OF LANO ¥~¢ SuFi~olk Co~t~ Clerk's SU~-%'L-h'EI) FO~;~, AT