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Home My WebLink About5941-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at.3.~..~..~.0.. ?.0.0.~..?.~.. ?.D....~.~. Street Map No ........ ~ .... Block No ....... .-~...Lot No. -- - conforms substantially to the Application for Building Permit heretofore filed in this office dated ........ /..~- .... '~ ~'.~. ~, 197..~-pursuant to which Building Permit No. ~...~./ dated ......... /..~.....~.q.N..E.., 197~,~ 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 ....... ~ 6.C.IL 5~ 0..~.¥. ..... ~ .~J) ~ JN ~. ............................ The certificate is issued to ...L,..0. ~.~.~......~. ~ ~ ,~ [~t~ L 't £ (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .................................... UNDERWRITERS CERTIFICATE No. "'"'-- HOUSE NUMBER.~.~..q.~. ~..Street... I~..~.0..s.! ?.,f .... .'~../~ .A. ~ ..... 2,..? ................. ................................... . ................................ Building Inspector FOBM NO. 2 TO~N OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PERMIT ('rillS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 5941 Z Date . ~ 13 , 19....~... Permission is hereby granted to: ....~a~......u...a.~..~... r.~ ............................................. .......... .l~a~....~,,Z,, ...................................... to ...~n.~a....~...~.~.~.~ !~...~,La. ~.1 .................................................................................... ot premises Iocoted ot ............ ~ffl~..M~d~.]~..~,Ol~ ........................................................................... ............................................................... itee~l~e ......... ii.Z, ............................................................. pursuant to application dated ................................. ~I;IIXI.....~.~...., 19..~.., and approved by the Building Inspector. Fee $..100010 .......... Buildi~ I~OB~ NO. tS TOWN OF SOUTHOLD Building Deparfment 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 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 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 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 oil 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 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 $5.00 3. Copy of certificate of occupancy $1.00 New Building ...~....c,.¢..?.~... Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property ................................. h-~..P ...................... ~ ............................................................... Owner Or Owners Of .............................................. p..:. ...................................................... Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No....~.....~....~..)..~Date Of Permit~<,~,x.~,l~.7.7~-.Applicant .................................................................. Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .~ .............................. Fee Submitted $ ...~..:...0~. ................... Construction on above described building~and~,~.rmit meets all applicable codes and regulations. Applicant ...[~... ~..~. ' r,~?.. ~...~ ................................................... Sworn to before me this ~ ~-~ ~ ~ .... · da of '? ..... or seo,) ........... ~ ~'~'.'~. ...... ~. .............. ..~. ..... (stomp TERRI LEE EL.AK NOTARY PUBLIC, State ot New Yo~k No. 52-616~295 Qualified in Su~l~lk County Gommission Expires March 30~ Examined Approved ,l~m NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. ig.Z.Z.. Perm,t No. Application No....../~.../....~./... .......... Disapproved a/c .............................................................................................. APPLICATION FOR BUILDING PERMIT "~ INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink und submitted in d~plicate to the Building~ Inspector. b. Plot plan showing location of lot and of buildings on premises, relationship t.o adjoining premises or public streets or areas, and giving a detailed description of layout of property must be drawn on the d~agram wi'dab 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 oval ab e for inspection throughout the progress of the work. . e. No building shall be occupied or used in whole or in port 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, ~,nd other applicable Laws, Ordinances or .~nge ual ~t; ,c~,n: o~gtrhe~ sc ~ s: ro~mC~i ,CynwC~: hb ~iI id ia;~~ c~31et i I~s ,°ro r~sn, S b u°irl dfi ,~rg r~ ~ .ay,, a~ oOurs { dh;mcan:it: ,o n~ n~S r: ;ur~ Ja~, odnl:?rjbed' (Signature cf applicant, or name, if a corporation) ...................... 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) 1. Location of land on which proposed work will be done. Map No.: ~ ..... Lot No.: ...'....~.-- Street and Number .~'..~.. ~.~--~ ~.~ .~~ 2. State existing use and occupancy of premises and int use and occupancy of proposed construction: a. Existing use and occupancy ................................................................................................................................... b. Intended use and occupom:, . ........................ 7..~ .................................................................................. .... ? 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration ............. Repair ................ ..~emoval ..................Demalition .................. Other Work (Describe) ..................................... · ~' O0 4. Est,mated Cost ........~..~..O ...................................... Fee ........... ~...¢~. ...................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ...~ ..................... Number of dwelling units on each flor ............................ If garage, number of cars ............................................................................................................................................. 6. If business, commercial or mixed ~cupancy, speci~ nature and extent of each ~pe of use ............................ 7. Dimensions of existing structures, Jf any: Front ............................ Rear ................................ Depth ................... Height ........................ Number of Stori~ ................................................................................................................ Dimensions of same structure with alterations or additions: Front ....................................Rear ............................ Depth ................................ Height ............................ ~umber of Stories ............ 8. Dimensions of entire new construction: Front ..~..~ ........................ Rear ~ .................... D~th ~. ............. Height Number of Stories ....... ~ ............................................................................................................ 9. Size of lot: Front .~.aO...~* ....... Rear .~.~...~* ............. Dept~..m..~..~ ,0. o, ~:~Z .......................................... ~ of Fo~m,~ 11. Zone or use district in which premises are situated ....... 12. D~s proposed construction violate any zoning law, ordinance or regulation? .......... ~ .......................................... o, Ow ,r o, ha,, Name of Architect ...................................................... A~ress ............................................ Phone No ..................... Name of Contractor .................................................... A~ress ...................... t ..................... P~ne 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 NEW YORK, COUNTY OF duly sworn, deposes and says that he is the applicant (Name of individu~gnmg appncat~on) above name~d. He is 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 make and file this application; that all statemepts contained in this application are true to the best of his knowledge and belief; and ti,at the work will be performed in the manner set forth in the application filed therewith. Swam to~>ef0~me this : ~ ~ ~ ........... .... Notary Publ,c, .~4(~....~..~~u,~tV'~' ~'. BOKEN ....................... i~;~'~,¥~;;;'~'~ii~;~'~ ............................. Commission