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Home My WebLink About6159-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No.'~N~t ...... Date ............ ~p~,~ .... 9 ....., 197'~ ' THIS CERTIFIES that the building located at . .Dogwoo6. La .............. Street Map No. I]~l~l. t~]r.l~l[ock No ........... Lot No...178 .... l~&~,t .l~rlola ........... conforms substantially to the Application for Building Permit heretofore filed in this office dated ........... 0e.t · - 1~..., 19.7~ pursuant to which Building Permit No..~.~ ~'~. dated .......... 0~.t;....1~ ..... , 19..7.2, 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 . .l~iva. te. one -fami. ly. d~e.~. 1.i~g. ...................................... The certificate is issued to ...(l~org.e..&. Ele~a-ao~....UlJ,e]~.....0~..el~l~ ................ (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .. K,R, ............................. UNDERWRITERS CERTIFICATE No ..... ~.~.R.: ........................................ HOUSE NUMBER...~70 ...... Street... ,DOg¥O.Od. L~ ............................... Building Inspector l~O~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN GLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 6159 Z Date ...................... ~L~JI~:~.....J~ ......... , 19...~ Permission is hereby granted to: to .il~L~..~..~.t ~ea..e~ .~a~&M,~ g.. ~ve~t.~ ............................................................... at premises located at ............ ,J~J.t*...~.~l~..,.JJ~J.~i;~e~,..J~il.~..~J.J....~...~;[J ........................... pursuant to application dated ................................ 0~ ......... j~...., 19,~.., and approved by the Building In~ector. Fee $.1.~*0~' .......... FOBM NO. 6 TOWN OF SOUTHOLD Buiiding Delm~tment 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 in duplicate to the BuiJding 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 dispasal--(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 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 property lines, streets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner os 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 $5.00 j Date ....... .~. .................................. LNew Building .................... ^Old or Pre-existigg ~Building ............................ ~-~Voca~t('~ Land~ ............................ ocation Of Property .... .~~..~ .................................................... :..~ ................................... Owner Or Owners Of Property .v~¢~0....~...~...~.....~.~ .................................................. Sulx:livi$ion .... G.~.~...A~,,.'~' ,.,~......~t No..,.[.~.,,~'Block No ............. House No..,.~,,.,~,.,~,. Permit No..~J...~...?....~.. Date Of Permit ~.~. ......... Applicant ......... .~.~ ..................................... Health Dept. Approval ..........,,/~,..~.,.~-,,. ..................... Labor Dept. Approval ........,~...C....~, ........................... Underwriters Approval ........... ...~...~......~... .................... Planning Board Approval ...~.../.....~... ......................... Request For Temporary Certificate ........................................ Final Certificate ..~ ......................... Fee Submitted $ ..,~.~ ................ Construction on above described building and p~mit meets all applicable codes and regulations. Apphoant .................................................. Sworn to before me this ................ day of ............................................ (stamp or seal) Notary Public .................................... County TOWN OF SOUTHOLD ,~/t BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. ........................................ , 19 ........ Pemit No .................................... Disapproved a/c ..... ~ .................................................................. APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Application No ............. ~ ................ Date ....... 'x--" ...................... , 19.~..~,, .... a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, witl~' 3 sets of plans, accurate plot plan to scale. Fee according to schedule. C~ b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, an~ 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 on the premises available for inspection throughout 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 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 ZoneI~ 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 code, 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~ .......... ........................................................................................................................................ owner of premises ..... ~"' '- ~ ...~..:..~...0.....~.~'....~.,........~....~'..,C..,'/..&/.~.~..'.~..,.......~'....,~...;,~.//~.... ............................................ Name of v If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Street and Number ...... ~..o~t...~...~.~.l~/........~=~4...~...~, ............................................................................................... 'C/ Municipali~ 2. S~ta exi~ing u~ and o~u~ncy of premiss and intended u~ and ~cupancy of propo~ con~mction: ..... ~..,...~.~.~ .~....~,.~~ -- ................................................................ a. Exi~ing u~ and ~cu~nc? b. n ended u, ~nd ~upancy ...... ~.~,.t~.~ ....... g~.~: .......... z.~.....~ ................................................ ~ I~rature of work (check which applicable): New Building ....................... Addition ....... ' ............. ;'AIter~tion.....~). ....... Repair ....................... Removal Demolition ........................ Other Work .............................. L .... ........................... (Description) BO0 .......... , ....................................... 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 ......................................... If garage, number of cars ............................................................................................................................................ 6, If business, commemial or mixed occupancy, specify nature and extent of each type of use ..................................... 7. Dimensions of existing structures, if any: Front ...... ~.?...'. ...... Rear ........ ~..¥.,..~ .......... Depth ................................... Height ......... .Y. ............................................... Number of Storms ....... ~,~ ................................................................. Dimensions of same structure with alterations or additions: Front · , Rear ' ~ ' · ...... · Stories ........................................ Depth ......~..:~...'....'.~....=7. ................... Height ........ /...Y. ........................... Number of ' o ~/~-- 8. Dimensions of entire new construction: Front .............. (. ......... Rear ...:..~....~. ............. Depth ............................... i ~t · ri · · · IM I~t~, ,~ ~:',Ar]tae OAf -~ .............. He gn .............................................. ,,um,,~ ................ - ..................................................... g. Size of lot: Front ................................................... / o o .. Rear .~...(: ..................... ' Depth ....,L.~/.. ........ ~ 2.2~ ....................... ~ Height .................................................... Number of Stories ...................................................................................... 10. Date of Purchase ..................................... Name of Former Owner .................. 11. Zone or use district in which premises are situated ................. 12. Does proposed construction violate any zoning law, ordinance or regulation: ..... A~.~..~...~- ....................................... 13. Will lot be regraded .............................. Will excess fill be removed from premises: [ ] Yes [ ] No 14. Name of Owner of premises . ~' ..~...~..%-~.~...~.,..i~...-~'.~.,~,.~.~...~--..~'.~'/'~''~'' ......................................... ..... ~ Address) (Phone No.) Name of Architect ..................................................................................................................................................... (Address) (Phone No.) Name of Contractor ...... ~/.~t.:~.~../,~..,~.....~...~..~../..a...-~---/ ........ ~.~s~./--~.-~.~- "~".a'~"~,'~"l~.'~'''''~' PLOT DIAG RAM 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 .... ~ '~ _ STATE OF NEW YORK, ) ,~ COUNTY OF ................................. ~ ............... '...'.) ........ ,,.,~,.t~.,.~,...,.....,.;;,....;:~..;....:,,,,,f..:%..,:.......-..,,~..~;[~:.....; .................... being duly sworn, deposes and says that he is the applicant above named. · , uvameolinatvtauatstgnLngcget act/ H~'is the .........~ ....................................... ~.../:: ......................................................................................................................................................... · (Contractor, agent, borporate officer, etc.) 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; and that the work will be performed in the mannei set forth in the application filed therewith. ~ TERRI LEE ELAK ................................... /.4ql~Mf p~t,~:...~ta~.aL ~ew..Y~l~.....: ....... :., 19 ............. No. 52.6168295 o ~-~' Qualified in Suffolk County Notary ,u,,dc, . ............ 6emmissie~.~x~kas. 44arch-30~.lS.'t~ ........ Count,/ ~ .......... ~ ................................................................ ; ............................. (Signature of applicant- 't LICEI~SED I.~blD