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Home My WebLink About5865-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No..Z~.~.Q'. ..... Date ............. OOt ..... ]$ .... , 19. THIS CERTIFIES that the building located at . .*'.lle~® .P~ke, .p~IT..Rd[ ..... Street Map No. I~C, .pl~aga~lock No ........... Lot No. ~[t6~?. .... Matt,.trick.. N..][· .... conforms substantially to the Application for Building Permit heretofore filed in this office dated .......... gay ..... 1.1.., 19.72. pursuant to which Building Permit No. dated .......... l~a.y...'~ .... , 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 ...~';~va. te. one · f&m~.ly- d~sl!.Img- ..................................... The certificate is issued to .. John. &. l)eroSh~, l~ler ....... 0~e~ ............... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval ... ~.;...[i: ............................ UNDERWRITERS CERTIFICATE No ...... ~,1~.~ ............................... , ........ HOUSE N UM BER..'1~,0~...P.o~l~lGrcJ~.O&llO~. Pal.(. HO~O. P:l, kO).. (..l~To. RD · ) ....... .. Building Inspector FOF,,~ 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? 5865 Z Permission is hereby granted to: ..... · to~m~a" '~' · ~ o~'e'bb,r · 'i(v:X.1.'er ....................... .......... I~'~ ................................................ to ...~t.:~..~z~..a4a.~t,~ea...e~ ..exie~ .~g.. 4~e~. ~.;F. ag ............................................................. at premises located at ...~r~r~..lt...~..~....~l~.~lat...lt3:eg;Saa3t;. .......................................................... .................................... lm, V~...B~ad...~ ltome..t~:Uc~e...~£f ..W.em.t. pl~l~a.. 3d ......... ~laSz, lL~l~l~:· pursuant to application dated ........................~IIL~r ......... ~ .......... , 19.~:..., and approved by the Building Inspector. FORM NO. 6 TOWN OF SOUTHOLD Building Department 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 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 disposal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, industrial buildings, /V~ultiple 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 Date ..... . .~...~.~..../!~..~....~.. .................... / - / New Building .................... Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property ..... ,'~/....~..~..~..~,/.~.,~..~/.~......./~..7.......~..~..~...~.../..?~..~...c.,~. .............................................. ~ner Or ~ners Of Prope~..~.~....~...~ ..................................................... Su~ivision ......................... ~ ................................. Lot No ............. Bilk No .............House No ............. Permit No.~.~.~ ..... Date Of Permit ..... /.~Applican ~...~ ........................... Health ~pt. Approval ............................................ Labor ~Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ .................................... Construction on above described building and perm/~'~,~eets all applicable codes and regulations. Applicant ........ ....~:~Z~...~.. :.. ~~ .................................................. Sworn to before me this ~/ g-~c~/ ..... ii ........ aa~ OT ....................................... ~. (stamp or seal) ~ ~ Nota~ Public~.~~ Coun~ TERRI LEE ELAI( J~OTARY pUBLIC. State ot New Yot~( No. 52,6168295 FORM NO. 6 TOWN OF SOUTHOLD Building Department 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 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 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 Date .., ~,~,,,,/~1~., ,/,/~,.~,., ,;~,, ............ New Building .................... Old or Pre-existing Building..... ....... /................ Vacant Land ............................ Location Of Property ...................... ,/~.'..~..~..T...~.~.~,~/~.....~. ................ ../~..t~..~...~../...~'..~....~../.~. ....................... Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No..~.,~..~....~. ..... Date Of Permit .. . ..,~Z....App ica t .~ ........................ Health Dept. Approval ............................................ Labor Dep.t~Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ .................................... Construction on above described building and per,nit meets all applicable codes and regulations. Applicant /~..~.....~...~.~ Sworn to before me this (~ ,/'/-~'// ...... t.( ....... da~ ...~.~X~a.,...~. ~ ~ , %oq~ (stamp or seal) Nota~ Public~.~~Coun~ TERRI LEE ELA~( PUBUC, State of New ¥orX No. 52-6168295 ~alified in Sultolk TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined Approved ............... c..~. ...................... , 19 ........ Pemit No. Disapproved a/c ....................................................................... APPLICATION FOR BUILDING PERMIT INSTRUCTIONS ~ a. This applicetion must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, wit~'~ 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. ¢. 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 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, Suffo[l~ 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) nHome Pike" Pt Pleasant k~att, (Address of apphcant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ..................................................... ~l-v' ~ ~P' ........ ........................................................................... r ........................ -q ~ ..... Name of owner of premises ..... ~.l~,t..~..~.~..M~....}~c~l.l.e.r___., ........................................................ ~Q.~..~ .................. If applicant is a corporate, signature of duly authorized officer. ~ ~ ~ ~ ..................... ................. 7' ~. Loc~fion of l~nd on which ~ropo~d work will be done. ~p No.: .~.t....~Z~a~No...4..~. ................................ s~reet ~nd Numar .....~[.~o~...~e~...~..~..~..$~a~.% ....... M~%~B~.~k ........................................... ~unicip~lj~ 2. state exi~ng use ~n~ occupant? of premiss ~nd intended use ~nd occupancy of proposal construction: ~. Existing use ~nd occupancV ~¥I~.~ ................................................................................................................ b. Intended use ~nd occupancy ............... sa~oI~...~,.~a....~~ a .......................................................................... ,. ....................... Addition ..................... Alteration ............... 3. Nature of work (check which applicable): New Building · · x_xx Repair ......................... Removal ......................... Demolition ........................ Other Work .................................... (Description) 4. Estimated Cost ....................... .~. ~ ,~.(~0.. da. ...... Fee ...... .1. ~'. ~ .Q.Q ............................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units .4~a-~ ........ 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 ........................................ 8. Dimensions of entire new construction: Front ........... .~.c) ......... Rear .......... .1..~) ............. Depth ...~.2-,~.1 .................. Height ................................................. Number of Stories ..... Q~ ............................................................................. 9. Size of lot: Front ...................................... Rear .......................................... Depth .................................................. Height .................................................... Number of Stories ...................................................................................... 10. Date of Purchase ..................................... Name of Former Owner ............................................................................ 11. Zone or use district in which premises are situated .............. .~!..A.!~...~,~ .................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ........... ~o ............................................ 13. Will lot be reoj'aded -~a(~ ............................. Will excess fill be removed from premises: [ ] Yes ix] No 14. Name of Owner of premises ...,[o~...&..Z)n~4~f,~,3~..[Li,.n.3,e,z~. ................~[a.t,~,~.~,La~,k. ........................................... (Address) (Phone No.) Name of Architect ..................................................................................................................................................... (Address) (Phone No.) Name of Contractor ..............~.~ ............................................................................................................................ (Address) (Phone No.) PLOT DIAGRAM ~ erinterior or 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 wbeth- corner lot. STATE OF NEW YORK, COUNTY OF ....... ,~.~'4)..~. ........................... ) ........................................... ~;O~z[cl.__~(.. ';O[.~.~[n ................................ being duly sworn, deposes and says that he is the applicant above named. {Name of ,~ndividualstgntng contract} He is the ........................................................... ~)~n'.Tt~.ln.....,~.j:.'l~ ............................................................................................................... ( Contractor,,agent, corporate of. Ftcer, 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 cji.his knowled§e and beliet; and that the work will be performed in the ~nnar ~t forth in the application fi ed therew th Note~ put,TH T. ~OKEN ~ , ~.,o. o~0~4~~ ~,-,ew York ........................... ~..} ....... day of ........................ ~.~i~ ~'~27~.?/k Cou,~_ Notary Public ...... ~~...~.:..~~ ~-~ ............ ' ........................................................................... ~ // {Si~mre of applic~t)