HomeMy WebLinkAbout4795-z FORM NO. 4
TOWN OF SOUTHOLD}
BUILDING DEPARTMENT
Office of the Building InspeCtor
Town Hall
Southold, N.Y.
Certificate Of Occupancy
Date Decemb!er 23, 1987
THIS CERTIFIES that the building ADDITION & ALTERATION
Location of Property 150 Goldin Lane Southold, New York
County Tax Map No. 1000 Section 135 . . .Block ,2 .Lot 19
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Pem~it heretofore filed in this office dated
May 11, 1970 pursuant to which Building Permit No. 4795
dated June 5, 1970 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 .........
ADDITION & ALTERATION ON EXISTING ONE FAMILY DWELLING
The certificate is issued to THERESA CZECH
(ownor,~l~,aveT~Ttl~Y~XX
of the aforesaid building.
Suffolk County Department of Health Approval ..... N/A
UNDERWRITERS CERTIFICATE NO ................... ?/A
PLUMBERS CERTIFICATION DATED: N~A
...... ~" ' 'l~iiJi;~'!n;;Jc'tg; .............
Rev. 1/81
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWI, I CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISE~S UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
4795 Z
Permission is hereby granted to:
.............. ~.,...~.~(~z.v.~,.~...t.....?~ //,:.....A~.,..t~v~e t l
..................... 8 ~-~.¢] ........................................
P~ lot lt& 12 ]¢. ~o~d~n
af promisas lacatod at ............................................................................................................................
....................................... ~Z~.....~.~..~ ......... ~.~ ........ ~J.~ .......................................
pursuan,t to application dated ......................... ~ ......... .~.~ ........ ?..,., 19....~ and approved by the
Building Inspector. N0~I ~ Approved by ~ of A~eals - ~ to be elo~e~ to
street t~ cottage ~ ~/
~.00
Fee $ ........................
FORM NO. 6
TOWN OF SOUTHOLD
Building Department '
Town Hall
$outhold, N.Y. 11971
765 - 1802
APPLICATION FOR CERTIFICATE O~ OCCUPANCY
Instructions
A. This application must be filled in typewriter OR ink, and submitted m~ 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 featu res.
2.Final approval of Health Dept. of water supply and sewerag~ 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 Architecf or Engineer responsible for the building.
5.Submit Planning Board approval of completed site plan requirements where applicable.
B. For existing buildings (prior to April 1957), Non-conform!rig uses, or buildings and "pre-existing"
land uses:
I. Accurate survey of p~operty showing all property lines, ~treets, buildings and unusual natural or
topographic features.
2.Sworn statement of owner or previous owner as to use, occdpancy and condition of buildings.
3. Date of any housing code or safety inspection of building~ or premises, or other pertinent informa-
tion required to prepare a certificate.
C. Fees: Additions $25.00
1. Certificate of occupancy New Dwelling $25.00, Accessory iS10.00 Business $50.00
2. Certificate of'occupancy on pre-existing dwelling $ 50.00
3. Copy of certificate of occupancy $ 5.00, over 5 years $]0.00
4.Vacant Land CoO. $ 20.00
5.Updated C.O. $ 50.00 Date ..........................
NewCons truc tion ...... Old or Pre-existing Building .... ; ....... Vacant Land .............
Location of Property 150 Goldin Lane Southold, New York
House No. Street Hamlet
THERESA CZECH :
Owner or Owners of Property
County Tax Map No. 1000 Section 135 Block 2 Lot
Subdivision ................................. Filed Map Ne ........... Lot No ..............
Permit No. 4795 Z Date of Permit .6./.5./.7.0Applicant J.McCarvill
Health Dept. Approval NA . Labor Dept. Approval NA
Underwriters Approval NA . .Planning Board Approval NA
Request for Temporary Certificate ..................... Final,Certificate ..
25.00
Fee Submitted $ ............................. :
Construction on above described building and~p~it meets all applicable codes and reg~Jlat OhS,
Rev. 10-10-78
Locate clearly and distinctly all buildings, whether existing or p~opos~, and
property lines. Give street and block number or description 6cCording {0 deed,
whether interior or corner lot.
3. Nature of work (check which ap le): New Building ................. :. Addit . .......... Alteration ..................
Repair .................. Removal .................. I~emolition .................. Ot~her Work (Describe) ........................................
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 ...... Z ...................
If garage, number of cars ...... . ..........................
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ............................
.... /'/. ~ ' I.~ ~ .~.. ~
7. D,mens,onsofex,st,ng structures, ,f any: Front ......... ~...~ ........... Rear ........ .~.~ ................. Depth ............
Height ........... /..~.. ...... Number of Stories ........... /. ...................................................................................................
Dimensions of same structure with alterations or additions: Front., ............. .~..! ..........Rear ..... ~..~.~ .............
Depth ............ '.~....~.../. .......... Height ............ Z.J~..."~.......Number of Stories .............. /. ...............
8. Dimensions of entire new construction: Front ......... ~..~...~..'~... ............ . Rear ........... ..~.. ............. Depth ~' /
Height ........... ~.. ..... Number of Stories ........................................... : ...................... :~ .................................................
9. Size of lot: Front ........... '/'~"~'""z'"'~, / · ~-- -.Rear .......... ../.~ ................. Dep~th~ ................ ?'.....~.. .......
10. Date of Purchase ............... '.~./.....v..~./.../..~. ................ Name of For~er Owner L..~'-'~....~..~.../~..~.Z~....-~..
11. Zone or use district ..... in which prem.ses are situated ............... ec~.......'~../..~.........~..Y~TZT~....~/2.' ~ -- ~ ..... ..............................
12. Does proposed construction violate any zoning law, ordinance or regulation? ............ .~...~..~ ...............
13. Name of Owner of premises .~..,~./~/.~.~.~J~Address ..... .~..~'..~....~...~'.~;T...~.~,~Y~.~'l~hone N~?J .~..~..-..~./?e/
Name of Architect ......................................................~/'T ,~// /:_ ~ Address ........./"~ ;. ,,~i .................................. Phone No .....................
......... ..~...:../.~/...~.....C~.~/~..~.. ........ Address .C:~.~,~,.~..7. ............... Phone NoT~ .~...~. ~.~.~)
Name
of
Contractor
PLOT DIAGRAM
indicate all set-back dimensions from
and show street names and indicate
STATE OF NE~YO~C~z?~-/
COUNTY OF .~¥~/~(/~. .............
(Name of individual signing application)
above named~; He is the .............................................. .~.~.~.¢,~..,~j .......... ........................................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to perform or have perfo~rmed the said work and to make and file
this application; that all statements contained in this application are true ira 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 ,b~ef,?re me this ~.¥~
........ /..,~. ~~r .~... ...... ay of ............... t, ................ ; .....
Notary Publ,~~ELIZABETH ANN N£¥1LLE ~ .,~, ~.!~"..4~. ...... ' ;.¢~.~ County ~~ ............ . i~'~~~: ..............
NOTARY PUBLIC, ~tate of New Yor/k
No, 52,81.25850, Suffolk
Term £x~lres March 30,
FOEM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined ...................................... ~ ~.~.. ( I , 197 ........ ~)
APPLICATION FOR BUILDING Pz~.i~MIT
Date ...~~ ....... -../../...'~7,4 ............ ,19.'.~-~......
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building
Inspector.
b. Plot plan showing location of lot and of buildings on premises, relationship to ad oining premises or public streets or
areas, and giving a detailed descr ption of layout of property must be drawn on the diagram which is part of this application.
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 permit
shall be kept on the premises available for inspection throughout the progress of 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, building code, hou~g code, and regulations.
(Si§noture of applic corporation)
..... ........
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises ............... ~.../..~.....Z~/.~..~...~..~A,.~,r4~.. ............................................................................
If applicant is e corporate, signature of duly authodzed officer.
(Name and title of corporate officer)
I. Location of land on which proposed work will be done. Map No.: ..... /.~...r.....~....0..~..~.../.(d ..... Lot No.:~?.i.~...(./....~.i./..~7.....
Street and Number ........... ~.~....~.~...~.~./.~.~..~.~...~`~.Z..../~.J...~..~.~.~.~6~../~.~..~.~.~/.~. ................................................. '
/V~nicipality
2, State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occuponcy ................ . ,~,~,, ],, ~,~, ,7~, ,-., ,~,, ,~-,,~d( .~,.,. , .~,, ....................................................................
b. Intended use and occupancy .................................................................................................................................