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HomeMy WebLinkAbout6147-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at Ke~ey. R~a6 ............... Street Map Ncl~elario~'. ~1o~ Block No ........... Lot No. 10. &. 1 ] ..... liOll, tl'olll.. II.e~ · ·. · conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ l~®pi; .. ~ 9., 19 .~2. pursuant to which Building Permit No. dated ......... ~9i;- · 27 .... , 1972.., was issued, and conforms to all of the require- meats of the applicable provisions of the law. The occupancy for which this certificate is issued is .Pri.~ate. on~. £amit? .J~e!.~.lng ....................................... The certificate is issued to . S~la~,r4;. &. Na~'i..~ .Woo~ ...... 4)~aer~ ............... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval ...N,R, ............................. UNDERWRITHRS CERTIFICATE No .... 1~.,t~. ......................................... HOUSH NUMBHR.. ]~+.~ ...... Street .... lkOll.~Oy. ~40~tl ................................ · ..... Building Inspector FOJOJ NO. 2 TOWN OP SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N, Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PI~EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 6147 Z Permission is hereby granted to: .. J.teax~..C...V4~i ........................................... at premises located at J~t..~O,,&..1-1...,.~,~llJrll~J~ ....................................................................... ..................................... .g~..j,,~,& r. j,t~.tl~-l.j, ........................................................................ pursuant to application dated ............................. ~t~--...$9 ....... , 19~..., and approved by the Building Inspector. Fee ~54,~ .............. FORM NO. 6 TOWN OF SOUTHOLD Building Depa~men! Town Cle~ Office Southold, N. ¥. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructionl A. This application must be filled in typewriter OR ink, and submitted in triplicate to the Building Inspector 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 dispcsal--(S-9 form or equal). 3. Approval of electrical installation fram Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installations, 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. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all praperty 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 in- formation required to prepare a certificate. C. 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 ................................ ........ New Building .....~... ........... Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property ............................:....J ...... ;...;;~. ................ ~ ........ .~:....j.~ ........................................... O~ner Or O~ners Of Praperty ............................................... . ....................................................................... /~-~ ' 'O~.l Subdivision ~,,;~ ~:~o,', ~ /,,* No. / / Block No. House No ............. Permit No......~.../.~.C...~. Date Of Permit .~'./.'.~.~:.~.~..Applicant ..',~?.~.~;..~.~.~......L,::...(..~..C...~.~.~. .......................... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ ...~..~.;.',~!.' ................. Construction on above described building gnd. permit meets oil %~coblencodes oed regulations. Appicant ~~ .~~ . Sworn to before me this · ....... day ~,,~~...?? ...... Norm ANNA W. JACOBS // O U N~ ~blic in State of New ~rk No, 52-7057150 Residin~ in Suffolk County ~mmleelen K~piree Mare~ 3~ Z~ ~ (stamp or seal) FORM NO. 1 / 0/.'~ /7 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Application No. ~' [ cf 7 Examined ......... .7. ........... , Approved 19 ~ L- Pemit No......~...~....~..../......~. Disapproved a/c~,....~ ......... APPLICATION FOR BUILDING PERMIT('-',~t \ ~ ^ Date .... ...... INSTRUCTIONS a. This application must be completely filled in by wpewriter or in ink and submitted in triplicate to the Building Inspector, wi 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, giving a detailed description of layout of property must be drawn on 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 the premises available for inspection throughout ~he 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 bee~. 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, housing cod~, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder~ If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) n n , r~l~O 0 // 1. Location of la d o wh'ch proposed work will be done. Map No.: .................... Lot No..~.....J .................................... Street and Number ....................... l ......................................................................................... .~..-!...~.. .: ..................... Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ...~...~...I .... .0...~...~.......~...?~?...~. ........ ..~...~....&l...~..... ..~...~. ............... b. Intended use and occupancy ...... .~..?....~...~....~.....~. ................................................................................................. 3. Nat{ire of ~vork (check which applicable): New Building ....................... Addition ...~ ........ Alteration ........... ~... Repair ......................... Removal ......................... Demolition ........................ Other Work .................................... (Description) 4. Estimated Cost . .~.../0'0, OO Fee ~ oO (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 ................ ./. .......................................................................................................................... 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 ....7..¥. .......................... Height ..... .-~....~....--." ........................................... Number of Stories / Dimensions of same structure with alterations or additions: Front ........ ~... Re~ .......................... Depth ................ .,~w.=..;....~ ............ Height Number of Stories ........................................ 8. Dimensions of entire new construction: Front ........ ~.~....~ .......... Rear ......... ./...~.../ ............ Depth / Height ................................................. Number of Stories ......................................................................................... 9. Size of lot: Front ...................................... Rear .......................................... Depth .................................................. Height ............. ~[ .................................... Number of Stories .......(~.. ............................................................................. 10. Date of Purchase ../..°.l...~...~ .............. Name of Former Owner ..... {.c..~...?. ....: ..... ~ ~ ..................... or use district m which rameses are s~tuated ,~....~¢~e 11. Zone .... p ' ' . .......................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ..../~.....O.. ................................................. 13. Will lot be regraded .......... .~.....o.. ........... .Will excess fill be removed from pram_ieee: [ ] Yes 14. Name of Owner of premises ........ ,,~ ~ -- ___ n ~.....~..~..o.~....~..~..;;..~.....~...~..(~Add ss) ........... ~ '-- ----'~ '~?'~'"~'"'""~'"~'?"'"~?- (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-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate wheth- er interior or corner lot. COUNTY OF ................ ~:~:7:~.?._.~....-. ............... ) ~ ...................... (Name o~indi~id, al si~i~ con~aet7 ................. being dui? sworn, depots ~nd says that he is the ~ppli~nt above n~med. He is the ................................................................................................................................................................................................................. (Contractor, a~ent, corporate o~eer, ete. J ~~~d is duly authorized to ~rform or have performed the s~id work ~nd to m~ke end file this ~Bplie~tion; that ~11 s~n~e~ ~e~plieation ~re true to t~ best of his knowled~ and belief; and that the work will be ~ormed in the ~nner ....... ............... ....... . . : ..... ......................................