HomeMy WebLinkAbout5612-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No. ~..~l[ Date ........
THIS CERTIFIES that the building located at Dlt~,tly Roa~ Street
Map No.t~t~O~; ]~aOl.][~lock No. IlleO ~[ .Lot No. -32
conforms substantially to the Application for Building Permit heretofore filed in this offme
dated lion' . ~, , 19 ~ pursuant to which Building Permit No.
dated . · ~O~ .. ~ .., 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 I~'~;~'0~ i~tlltl].~' ~O]k].~ .......................
The certificate is issued to . l~l~.il~ l[~tl~&l~a -
(owner, lessee or tenant)
of the aforesaid building.
· 1~b..~.7....~9'2~. b~ it.
Suffolk County Department of Health Approval
UNDERWRITERS CERTIFICATE No 11[.~]3~9~
ItOUSE NUMBhR ~1~} Street . ']D~,iI. ItiF
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PEIUVUT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 5612 Z
t
Permission is hereby granted o: j~ ~. ?-- .~ ... ~, ~ .~ _ ~
............ M..:.~,.,....I.... ...... ~'.0.~.~:1.:....~.~. ........
.... ..... .............
a, prem,s,, ,~o,ed~, ...;/~........a.~ ............ ~~~..,~ .......................
.......................... ~'~'1 ...... ~ ........... ~'~~ ...................................
pursuon~' to QppliCQtiOn doted ........................... ~....~. · ............. , 'l~)..~.~..,, and QpproYed by the
Building Inspector,
~.,.lg .............
TOW~ OF $OUTHOL~
Building Department
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
instructions
A. This application must be filled in typewriter OR ink, and submitted m tnphcate to the Building
Inspector w~th the following; for new buildings or new use.
1. Final survey of property with accurate Iocahon of all buddings, property hnes, streets, aha
unusual natural or topographic features.
2. Final approval of Health Dept of water supply and sewerage disposal (S-9 form or equal)
3. Approval of electrical installation from Board of Fire Underwriters
4. Commercial buildings, Industrial buildings, Multiple Residences and simdar buildings and
~nstallations, a certificate of Code comphance from the Architect or Engineer responsible for
the building.
5. Submit Planmng Board approval of completed s~te plan requirements where applicable
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-exist~ng"
land uses:
1. Accurate survey of property showing all property hnes, streets, buddings and unusual natural
or topographic features.
2. Sworn statement of owner or previous owner as to use, occupancy and condihon of buildings.
3. Date of any housing code or safety inspection of buildings or premises, or other pertinent in-
formation required to prepare a certificate
New Building ........~ .......... Old or Pre-existing Building ........................... Vacant Land ..........................
Location Of Property .... ~..J~...D~.~...~O~...~3.0..O...~.l;.~...~e~.~;...Of...DIg~I,?.qO~..,~,~,~.~ ......................
Owner Or Owners Of Property .... .k~'.,,...~.~,~..~,;J,.~..,~.g,.~'.~,3,..9,~l~.Q~ ...............................................................
Subdivision ..~.~.~.t;...~3,0.~I,~...~.C~.,...~,. ............ Lot IXIo..,~.$. ...... Block No ............. House No ...........
Permit No...~..~.~'...J.~....'..~... Date Of Permit .................... Applicant ..... ?.~..S.?.....C..o...~..s.~.~.u....c.~..o..~.....C....(~....~..~. ........
Health Dept. Approval .... .~'...~.~...'.~..?..~.. ..................... Labor Dept. Approval ........ .~./...A. ...............................
Underwriters Approval .... ..N.....~..3.~.?..?. ......................... Planning Board Approval ........ .H./.:.~. ........................
Request For Temporary Certificate ........................................ Final Certificate ............ ~ .........................
Fee Submitted $ ....................................
Construction on above described building and permit meets all applicable codes and regulations.
Applicant .........................................................................................................
Sworn to before me this
................ day of ............................................ (stamp or seal)
Notary Public .................................... County
S-9
SCHD
SUFFOLK COUNTY DEPARTMENT OF HEALTH
Date I Z I'?- ~ I ") J
Bldg. Permit No.
TO WHOM IT MAY CONCERN:
at
The sewage disposal facilities for a structure located
!
(Give deed location)
have been inspected by this department and found to be satisfactory.
b°t ~1
D ISy
F ObO
REVISIONS
APR 21,1972-.
NOTE
I=MONUMENT
SUODIVISION MAP FILED IN THE OFFICE
OF THE OI.K~K OF SUFFO~.K COUN~'Y
ON ~PH. 9~1970 AS MAP N0.~440.
YOUNG & YOUNG
400 OSTRANDER AVENUE, RIVERHEAO, NEW YORK
ALDEN W. YOUNG HOWARD W. YOUNG
i SURVEY FOR:
PHILIP HARALA/~BOU
!LOT N0.$2
"~UNSE T KNOLL S;'SECTION 2
AT MATTITUCK I GUARANTEED TO:
:TOWN o~ SOL/THOL-D J
SUFFOLK CO,...N Y I B Y~,~( ~ ~.~
$cAbE' 1,~ 4 O' ~ oATz'NOV. ~, 1971 NO. 71- 692
...................... , Application No .................................
~oproved 't ~ ~' O"~'/.Z- Z-- /,/, ~'"~/C. o
........................................ , 19 ........ Pemit No ..................................... '~
D,s_approved a/c .~..'7..~...~.-.~ )2OxJ ~7;3g
r- , ~ (3 I ~.o.,.! ..,w.,.'"tj',t'~t~::'""'.':~'-:'"; ................................. 'T
~_. ~ m'~ -~ "~ __ "OLS...v' (Building :~l~pectorl . ~
, _---rr.'l -,~' -rz__ _' , . APPLICATION FOR BUILDING PERMIT
--?~ ~-~ ~ ~'-~'~ · ~ 0~< Dote ............ ~ ....... ~ ............ ~2.1.
TOWN OF SOUTHOLD~-/:~"~
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE~/
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 adjoining premises or public streets or
areas, and giving a detailed description of layout ofproperty 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, ordi nonces, building code, housing code, and regulations.
....... ....
(Signature of applicant, or name, if a corporation)
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Nome of owner of premises ............................... ..~....~..&.J'2..~. ~ .~..(~...~. ...........
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer) ~
1. Location of land on which ~ will bedone.c~.aP No.~~...~..... Lot No.....~......~... ...........
Street and Number ................ ~lD-.e~ ................ ~~ .................................. "..
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Exisitlng use and occupancy .~....(~..¢~' '
b. Intended use and occupancy ......... ~'"~""~'1: ................................................
3. Nature of work (check which applicable): New Building .i..' .............. Addition .................. Alteration ..................
Repair .................. Removal .................. DemolitJor .................. Other Work (Describe) ........................................
4. Estimated Cost ............. -'~...~../...~..O...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 ............~ ................................................... i ..............................................................
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ............................
7. Dimensions of existing structures, Jf any: Front ............................ Rear ................................ Depth ....................
Height ........................ Number of Stories .................................................................................................................
Dimensions of some structure with alterations or additions: Front .................................... Rear ............................
Depth ................................ Height ............................ Number of Stories ................................
8. Dimensions of entire new construction: Front ....................... Rear ....~.....G. Depth
Height .................... Number of Stories ...~;L~,--~. ....................................................
9. Size of lot: Front ............................ Rear .................................... Depth ................................
10. Date of Purchase ...................................................... i. Nam~of F~rmer Owner ......................................................
11. Zone or use district in which premises are situated ..~....~ .............................................................................
12. Does proposed construction violate any. zoning law, ordinance or regulation? ......... .~.....'~.~.~ ....................................
13. Name of Owner of premises ............ 4~L..`.~..........-..~..~..~Address~'~..*.~.~-.~~...~.....~.....~.-~ Phone No .....................
Name of Architect .....~ ................................................ Address ................... ., ........................ Phone No .....................
Name of Contractor/...~.~..~..:L~..(~ .~....~...~.~...~..~.D.....~-4~ddress ............................................ Phone No .....................
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.
STATE OF NL~A~YO~.~.,~'_ icc ~]~)'~
COUNTY Of ~ ........ ~'~
............................. .V/. ................................................................ being duly sworn, deposes and soys thor he is the applicant
(Nome of individual sigping~applicatio,n)
above named. He is the ....... ~....~.....~.~.q........~....~....~.. .........................
(ConYractor, agent, corporate officer, etc.i ...............
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 contained in this application are true to the best of his knowledge and belief; ond
thor the work will be performed irt the manner set forth in the application~Jled therewith
Sworn to before me this -- [ -- ~'_ ~) ' ~ .
.................. · .~...~9y of ........ ~. -....~../. .......
./I._ ,/I__. ...........
Notary Public~.L.4~/-~ ....... County ~E~JI~ -(S~gnat~re of applicanT' ........................
ELJZ.~BETH ANN NEV~L~
~IOTARY PUBLIC. State of New York
No. 52-$125850, Suffolk Countlh
~Term Expires March 30,
]1 F-1 :ZI Fq
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