HomeMy WebLinkAbout5957-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificnte Of Occupnncy
No..Z..~.2..2~. .... Date ............. J..1~8.....~.~ ..... , 19.73.
THIS CERTIFIES that the building located at .. ~t, lane .............. Street
Map No...1~; ....... Block No.~;~ ........ Lot No. 1~..Gl'~l).or~..!/:~,. ..........
conforms substantially to the Application for Building Permit heretofore filed in this office
dated .......... ,I~...16.., 19.~1. pursuant to which Building Permit No. ~f.Z..
dated ............. J~ .20.., 19.72, 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~:[,V&t,~. O~ .fm~Ll.y. t~ll~ .....................................
The certificate is issued to . .Rs~t~hel'. l[~a~ .... .~el' ............................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval .~. ?.R.~ ...............................
UNDERWRITERS CERTIFICATE No... ~ ......................................
HOUSE NUMBER.. ~0 ....... Street..~1~.~.~. ~.gt~.~. ...................................
Building Inspector
FOEM NO. ~
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N~ Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 5957 Z
Permission is hereby granted to:
g.,..~rlowz~k,~....A/lC..~,st, hoz...leunan .......
................... ~t,~]~o~ .......................................
to ..Jluck~.~ .. a~t .a~LdJ.~l.m~..nn.. v~ta t- ~ ..du~:Lllmj ..............................................................
ot premises located ot .............. J~Jl~t~...~.a,l~ .....................................................................................
........................................................... 4t~I~'~ ....... #e~'~ ..............................................................
pu~suont to opplicotion doted ........................~.~L~$......~ ............ , ]9.~..., ~nd opproved by the
Building Inspector.
Fee $...1.~.~ .........
Bu,ld~ng Inspector
· O~M NO. 6
TOWN OF SOUTHOLD
Building Deportme.t
Town Clerk~ Office
Southold, N. t'. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application must be filled in typewriter OF[ 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 oil 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 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 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
.... .........
New Building .................... Old or Pre-existing Building ...... '..~'. ................ Vacant Land ............................
Owner Or Owners Of Property ...... ~ ....... ...~.....~.. ~ .................................................
Sul:~ivision ..... ~ ............. Lot No......."~,..... Block No......-~....... House No .............
Permit No..~..~..~...~....~ate Of Permi ~pplicont ..............
Health Dept. Approval ............................................ Labor Dept. Approval ................................................
Underwriters Approval ........... ~ .............................. Planning Board Approval ...'T ....................................
Request For Temporary Certificate ......... ~ .......................... Final Certificate .....~..:...'~..........'~. .................
Fee Submitted $ ....~b~.¢....~...-~.....'. ...........
Construction on above described building and.~o,erp~it meets all aj3glica)qle codes and regulations.
Sworn to before me thif~
........ ~.. day of .'~~....~..f..7
FORe-NO. 1 ·
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
Examined ...~...~.......~.., ]9..~..? $OUTHOLO, N. ~.
Disapproved O/C~~ ...........
APPLICATION FOR BUILDING PERMIT
Date
1 NSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, withl~
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, and
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 an h t I
y purpose w a ever unti 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,
ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections.
(Signature of applicant, or name, if a corporation)
Name of owner of premises ..~..~ ........................................................
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 Numbe~...~.~...--. ...................... ~'"~'"'"'~'"'~'~'~i~i~ii~ ..........
2. State existing use and occupancy of premises and int~ded use and occupancy of proposed construction:
a. Existing use and occupancy .~..~..._ ................................... ~ ............................................
b. Intended use and occupancy Ll~.~..~~....~...~.....'~..~ ........................
10.
11.
12.
13.
14.
Nature of work (check which applicable): New Buildin, g ....................... Addition .....~ ...... Alteration' ...... ' .......
Repair ......................... Removal ......................... Demolition ........................ Other Work ....................................
(Description)
Estimated Cost ....i~..~....~ ........................ Fee .............. ~.?...~..-~.. ........................................................................
(to be paid on filing this application}
If dwelling, number of dwelling units .................Number of dwelling units on each floor .........................................
If garage, number of cars ............................................................................................................................................
If business, commercial or mixed occupancy, specify nature and extent of each type of use .....................................
Dimensions of existing structures, if any: Front ...... ....-~... ........ Rear ....... ...2~... .............. Depth ~'~
Height .................... b..~.. ................................. Number of Stories .............................................................................
Dimensions of same structure with alterations or additions: Front ..... ,~.....~.. ........... Rear ......~.......~.. ...........................
Depth .......... ...-~'....~. ........................... Height.........................................J ~'' ~ Number of Stories ...~ .........................
Dimensions of entire new construction: Front ............ ~ ............ Rear -- Depth .................................
Height ................................................. Number of Stories .........................................................................................
Size of lot: Front / ~ ¢ Rear .......... ./..~ ....................... Depth
Height ....................... ~ ......................... Number of Stories ............. ~ ....................................................................
Date of Purchase ~..~.~'0 \-,~-~ ·
................................. Name of Former Owner ...a.=.-..~ .................................................................
Zone or use district in which premises are situated ...L.~'.~ ...............................................................
Does proposed construction violate any zoning law, ordinance or regulation: ..... ~......-~. ......................................
Will lot be regraded ...... ~....~. ................ Will excess fill be removed from premises: [ ] Yes ~d, No
Name of Owner of premises ..... ~.....~...~ ~,.'Z..~. ~
· ~lz~_~/~l ,~, (Address) O~'~'~'~ ........ i~;~'~ ~' ~l'~i ................
Name of Architect .....................................................................................................................................................
_ ~ (Address) (Phone No.)
Name of Contractor ~~ ~ 'Y)',~,,--
..................... ................ ............... ...............
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.
STATE OF NEW YORK, )
COUNTY OF ...................................................... )
He is the ............................................................................................................................................................................................ '~
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly au~l~j~dl.,t~c~fl~orm or have performed the said work and to make and file this application; that all
statements contained in this applic~(~nrya~eub~[~es~et~l~ i~%t~frkhis knowledge and belief; and that the work wiil be ~rformed in the ~nner
set forth in the application filed th~.~344~b3 Suffolk Coun~
~ Commission E~s March 30, ~9~~'~ ' ~
................ .......... of .............................
........ .....................................