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Home My WebLink About5662-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. ~)~ ...... Date ............ THIS CERTIFIES that the building located at ...]l~,m. ~ ........... Street Map No.. x,~ ........ Block No..~. ...... Lot No.. '~t ....... 8~t~tl~O~ ............ conforms substantially to the Application for Building Permit heretofore filed in this office dated ........ D~ ..... ¶3"', 19. ~. pursuant to which Building Permit No..~. dated ....... ~®a. · .~.3 ....... , 19. ~., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is Pr.$~t~ .~..f4~7 .d¥~.~g ........................................ The certificate is issued to .. ~ .~1~ ....... 0~®~ ............................. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval UNDERWRITERS CERTIFICATE No... 11~ ...................................... HOUSE NUMBER...~ ..... Street ................................................. Building Inspector TOWN OF SOUTHOLD ~ BUILDING DEPARTMENT TOWN CLERK'S OFFICE ~ SOUTHOLD, N. Y. BUILDING PERMIT N? (THIS PERMIT MUST BE KEPT ON THE PREMISE UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 5662 Z Building Inspector. S-9 SCHD SUFFOLK COUNTY DEPARTMENT OF HEALTH Date J~t Bldg. Permit No. TO WHOM IT MAY CONCERN: at The sewage disposal facilities for a structure (Give deed location) located have been inspected by this department and found to be satisfactory. FORM NO. 6 TOWN OF SOUTHOLD Building Deparb,ent 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. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use 3. Copy of certificate of occupancy $1.00 $5.00 Date .. JLLLy. ~.13.,..198.L ........ New Building ............. Old or Pre-existing Building ...~( ........ Vacant Land ............. Location of Property ....1.q4..0..~.o.~. 9.~.i.s' . .~.o.a.d.~..S.o.q~..l~.o.l.d. ~. ~.e?...~.o.:.~. ................... House No. Street Ham/et Owner or Owners of Property . ¥.r?.~.~..~.a:t..z.i.~.a. ........................................... County Tax Map No. 1000 Section ... 7.8. ......... Block .... 3. .......... Lot .... .1.6 ..... .~ .... F~led Ma No ' Lot No Subdivision ................................. ' p ................... Permit No ........... Date of Permit .......... Applicant .~.=..a~..k..~.a..~..i. qa. .......... ~[~.. Health Dept. Approval ........................ Labor Dept. Approval ........... ~. .... ~. ~.. U nderwriters Approval ........................ Planning Board Approval ......... .~.~\[ .~?~' ~eque~t for Temporarg Certificate ..................... Final Certificate .... .X ............. Fee Submitted $...~ · 99 ...................... Applicant . .I. ................ ... '~olph I{/. Bruer, Attorney for Frank Patz~na Rev. 10-10-78 Examined ...... J~e,~er~be.r......J. 5.~.., 19...2.l. ,%oplication No ......~.6~.2 ................. Approved .............. ~! ................. !!....., 19...!!... PemitNo ...... 5~62...Z ................. r~ ~c/~,~ p~ ~ Disapproved a/c ...~.-,.,,,.~-,~.~.,.~-.,,-,.~.=.~,.~.~.=.~.~..~..-.~..-..~.~.~.==.?.~.~.= ~ C~"/ ~ (Building Inspector) ~ APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building Inspector. b. Plat 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 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 pprt 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, a~nd other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for/e'~'~val or aleutian, as herein described. The applicant agrees to campy With all applicable laws, ordi nonces, bui. lding~,,.ed~, housi~,~d,~.~.i...~i and regulations. · ' ................. i[~,~ignature o~' a. ppli'~cln~t, or hal e, if a corporation) .... ...... ,'"' ................................ (Address of applicant) State whether applica~}t is owner, lessee, agent, orchitect~engineer, general contractor, electrician, plumber or builder.< Name °f °wner °f premises ~ .........................'............... If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Location of lend on whicypr~sed work will bandana. /v~p No.: ........... /. ....................... ,J,.ot No .......... .~ .~?~...,...~ ,~ Street and m ...~..~ ~ ...... :.~.~ ........ ~ ............ */ ........ ~,: ................ ~.~.....~..Z.~,...~.~.~ State existi~ use and ~cu~y of premises and intended use and ~cu~ncy of pr~osed c~structi~: ~. ~i~iting US~ and ~cupancV. ........................ ~~...~ ~. ......................................... .......... ................................. ................................ 3. Nature of work (check which applicable): New Building ~ Addition Alteration Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................ 4. Estimated Cost .............. .O.....O...0.........~... ..................... 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 ............. ~ ....................................... I ..................... j ................................................. 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 ............................ N.umber of Stories ................................ 8. Dimensions of entire new construction: Front ............ .~.....~.. ............... Rear ............ ~..~. ....... Depth ..~ ............ Height .................... Number of Stories ......... ~ ........................................................................................ ./.Z...3.. 9. Size of lot: Front ...... ............Rear ...... ................... Depth .~.~...~... ................... 10. Date of Purchase ........................................................ Name oAForrr~er Owner ........................................................ 11. Zone or use district in which premises are situated .;.~. ...... ~ ...................................................................... 12. Does proposed construction vio~l~-~a~onin_~law, ordinance or regu~.,~L.....~..(~.....~ .................................... 13. Name of Owner of premises~-.....~ ....... Address ..~.....~ ................ Phone No ..................... Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor ................... ~.~ ............................. Address ............................................ Phone No ..................... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-beck dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or comer lot. STATE OF NEWk, X..~(.~.,~S' ' ~ COUN OF .......................................... ~..~ ................. being duly sworn, deposes ond says thor he is the applicant (Name of individual signin~pplication) ,,~ ~ above named. He ms the ............... ~.~.~ ........ ~.~.. .............................................................................................. (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to ~ke and file this applicat~n; that all statements contained in this application are true to the best of his knowledge and belief; and that the ~r~ will be performed in the manner set fo~h Jn the applicati~ fi~ therewith~ Swom to ~fo~.me this ~ ~ / / . f , / / / ...................... . .......................... .............. ~ ELIZABETH A~N NEVILLE~