The URL can be used to link to this page

Home My WebLink About5863-zFORM NO. 4 TOWN OF SOUTHOLD] BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupanq THIS CERTIFIES that the building located at ..... ~'. .... ~..~,....'.-:. .- ........ Map No. Y,. ........ Block No..}( ........ Lot No..?:..'.. conforms substantially to the Applieation for Building Pe!'mit heretsfore filed in this office dated ...... ~'l(/~-4/../.0., 19 ~ pursuanf to which Building Permit No~ dated ............ ') .....'. )..., 19~.~., was issued, anti e6nforms to all of the require- merits of the applicable provisions of the law. The occupancy for which this certificate is issued is .~.. ,]~.,.. ~.~. ~ ~,. ~(" ........................ The certificate is issued to .~~. .~.~.~¢':~¢~".; .......................... (o~n~r, lessee or tenant) of the aforesaid building. Suffolk County Department o~ Health Approval ../~.~/¢. .......................... UNDERWRI1 kRS ( kRTII I(ATE No ............. ~ ........ . .......................... ,.,oe~,: ~,,,~... ~.~ ~ ..... ~,~.. A ........ ~... :..~ ........... ~...'. ~ ........ Braiding Inspector FOI~M NO. ~ TOWN OF SOUTHOLD 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? 5863 Z to: ~ Permissi°n is hereby g ranted~'o~A~, )~q/~' ~.~ ~Z// ~,~/~ ~ ..................................................... ~ ........................... :...,~,..: ..... ................................................. ~ ~Z - ' ~~~ at premises I~ated at .................................... ~ ..................... 7..... ................................................... ................................................................................................................................................................. Building Inspector..~L Fee $....~ ................ B~iilding Inspector I~ORM NO. 8 TOWN OF $OUTHOLD Building Delm~tment Town Clerks Office Soutkold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF ~OCCUPANCY Sworn to before me this ~...,~.,. day of., .~.~ ...... ~ ................... Nota Pub,c Co,,ty (stamp or seal) MARY O. KL .)S i NOTARY PUBLIC, STATE OF NEw YORK ff52.7306925 SUFFOLK ~OU~TY Commiss,on Expires Marc~ 30, ~ Instructions A. This application must be filled in typewriter OR ink, and, sqbmltted 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 ~uil~ings, property lines, streets, and unusual natural or topographic features. ~ ' 2. Final approval of Health Dept. of water supply and sewe~ag~ dispcsal~(S-9 form or equal). 3. Approval of electrical mstallahon from Board of F~re UnjJerWnters. 4. Commercial buildings, Industrial buddings, Multiple R~.sidences dnd similar buildings and installations, a certificate of Code compliance from the Ar~:hitect or Engineer responsible for the building 5.Submit Planning 'Board approval of completed site plan recjuirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming ~Jsesi or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, ~tre~ts, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, ~cu~ancy and condition of buildings. 3. Dote of any housing code or safety inspection of buildinj~s br 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 us~' $5.00 3. Copy of certificate of occupancy $1.00 ~ Date ................................................ New Building ..... Old or Pre-existing Building ................ i..... ...... Vacant Land ............................ Location Of Property ....~..~..~ ......... ---- -- ' ..~..../..~.......~..~.. ....... ..~...~ ................... Owner Or Owners Of Property ,. .~.~..~.~... .... ~'.. ......................................... .~... Lot No. l Subdivision ..................................................................... .. Block No ............. House No ............. Permit No..5..~,~i,~,..?...~...,. Date Of Permit' ~ /~ ?)" ...~.//...../..' ...... Applicant' .~.'~,.:'~...., .~.~'~~ ~ ~ ......................... ' L b Heolth Dept. Approval ............................................ a or IJept. ~pp~ovol ................................................ Underwriters Approvol .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final,Ce~ificate Fee Submitted $ .................................... Construction on above described budding and permit meets oil a)ph¢oble codes and regulot OhS ..... ...... i ........................................... Applicant Examined TOWN OF SOUTHOLD i BUILDING DEPARTMENT TOWN CLERK'S OFFICE Approved ........................................ , 19 ........ Permit No .......................... ... Disapproved a/c ........................................................................................... Application No ............................. (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by typewriter or in i~k 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 of property must be drawn bn the diagram which is pa.rt of this application.~,3 c. The work covered by th~s apphcat~on may not be commenced beforje IsSuance of Building Perm t. d. Upon approval of this application, the Building Inspec or w. II ~ssue~a Budding Permit to the applicant. Such permit~ shall be kept on the premises available for inspection throughout the progress 6f the work. e. No building shall be occupied or used in whole or in part for any pd[po~e whatever until a Certificate of Occuponc~ shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issudnce of a Building Permit pursuant to the~ Building Zone Ordinance of the Town of Southold, Suffolk County, New ~ork and other applicable Lows, Ordinances or Regulations for the construction of buildings, additions or alterations, or ~or Femoval or demolition as herein described. The applicant agrees to comply with all applicable laws, ordinances, buildjlng ~code and regulations. (Si~/; df applicant, or name, f a corporat on) (Addross o~ opplicant) State whether applicant is owner, lessee, agent, architect, engineer, general c6ntractor, electrician, plumber or builder. ........ .............................................. .......................... : ........................................................................ Name of owner of premises ...: ..?'... ....... -..~.......;~?.?'..~.~.:' ............................................... If applicant is a corporate, signature of du~y authorized officer. ~,~ (Name and title of corporate officer) t. Location of land on which proposed work will be done. Map No.' ..... · ................................... Lot No.: ........................ Street and Number ........ : ............... :..'~....,~ ................~. ......... .....i .......... ~..~ ...... ~/~ u ~,,7~ -~zz_;~ ~,/~ C ~," /-_~'q/V'~r Municipality ........................ 2. State existing use and occupancy of premises and intended use ancJ ockupancy of proposed construction: a. Existing use and occupancy ~4~-v' , b. Intended use and occupancy ....~ '.~.~. ................................... '.....; ................................................ Nature of work (check which applicable): New Building .................. Addition .................. Alteration .................. Repair ................. ,~3Rp, movol .................. Demolition .................. Other ~rk_._~Desc ribe) ........................................ ~ ,~ ~ t3 ~, (Jo I 0~.~'''- 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, commercial or mixed occupancy, specify nature and extent of each type of use ............................ 7. Dimensions of existing structures, if any: Front ............................ Rear ................................ Depth .................... Height ........................ Number of Stories .................................................................................................... ............. Dimensions of same structure with alterations or additions: Front ....................................Rear ............................ Depth ................................ Height ............................ Number of Stories ................................ B. Dimensions~, ~°~f ~entire new construction: Front ), ................................... Rear ............................ Depth ........................ Height ................... ~Nou~nb~r. of Stories ......'~'~t"~' ................................................................................................ 9. Size of lot: Front ............................ Rear .................................... Depth ............... 10. Date of Purchase ........................................................ N,g,~e~of Former Owner ........................................................ 1 1. Zone or use district in which premises are situated ............................................. ~ .............................................. 12. Does proposed construction vioLat~ any zoning la, w, ordinance or regulation? ...................................................... ]$. Name or uwnor or premises g ...................................... i~oaress ..................................... ~. ...... Ynone ixlo ..................... Nome of Architect '"'~', ~ ............................... ~7~fi~.~ Address ............................................ g9~.9.~ Phone NoJ'~7 ~2q'~/N° ..................... Name of Contractor ............................................ Address ............................................ Phone ..................... 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, ' )'SS COUNTY OF ..~..~...~-7...~./.-:....z~5.......~ '' ............................. [~...~...~........~..~....~..~.....~..~-ff..~.. ................ being duly sworn, deposes and says that he is the applicant (Name of individual signing application) above named. 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 statements contained in this application are true to the best of his know(edge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this ...... ~.~ ...... day of .......... ~.~.~ .................., 1 ~.3, ~/~,~_ '~~ ~ /~ ~ ~ . ~ .......... l..,~.:~ ....... q.Z ......... 7.~...~.7~-~ ................ , .............. Notary Pubiic/~.~..~.~.OT.K. kO~, County ~ ~Signoture of opplicont) ~ NOTARY PUBLIC, STATE Of NEW YORK ~52-7306925 SUFFOLK COUNTY ~mm~ss~on Expires March 30, 1~