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Home My WebLink About5874-zFORM NO. 4 TOWN OF SOUTHOLD BLql,r)ING DEPARTMENT Town Clerk's Office $outhold, N. Y. Certificnte Of Occupnncy No. Z.~2~ ...... Date ............. Sapt ..... 5 ...., 19. THIS CERTIFIES that the building located at .. ~lthl.1.1. Road ........... Street Map No.Y,~,~eeott. l~kBlock No ........... Lot No. 1~...Southold...N oY., ............ conforms substantially to the Application for Building Permit heretofore fried in this office dated ..... ~ .....Ha),...$ ~.., 19. '?3 pursuant to which Building Permit No. ~a~ed ........... Ha)- ....l~.., 19.7~., 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 . .. Private..o,,e- .fa~i.ty. dwellia~ ..................................... The certificate is issued to E~r. &. Dol~oth~..l~)lt,v~ ............................ (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . .N ;.R.; ............................. UNDERWRITERS CERTIFICATE No .... pendSng ................................ HOUSE NUMBER ...2~0 ........ Street ... ~hlth~.],. Rt~d ........................ ·" Building In~e~to~ / ' ' ' FO~M NO. ~ TOWN OF $OUTHOLD BUILDING, DEPARTMENT TOWN CL~ERK'S OFFICE SOUTHOLD, H. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 5874 Permission at premises located at ............................................................................................................................ pursuant to application dated ~' ~ ~' 1 .~......., and approved by th~ Building Inspector. Fee $ ........................ 1~0~ NO. 6 TOWN OF $OUTHOLD Building Depar~ment 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 building~ 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 occu ~ancy on pre-existing dwelling or land use $5,00 3. Copy of certificate of occupancy $1..00 New Building .................... Old or Pre-existing Building × Vacant Land Location Of Property ............. 25.0...~lz.t~.l~,..~o,~Q..: ............................................................... : .................. Owner Or Owners Of Property .......... ~,o.,~°.t..l!.z....~,~..m..°..~.~,~ ............................................................................ Yennecott ?ark Subdivision ................................................................ Lot No ......~ ...... Block No ............. House No...2,~,,O. .... No 58742 5/15/72 Leo Kwasneski ' Permit ..................... Date Of Permit .................... Applicant .................................................................. Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters APproval .............................................. Planning Board Approval ........................................ X Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ Construction on ................... : ............ -~"~--~- ~' ' above described building aaq~perro~/meets all applicable codes and regulations. Sworn ~before me tl~ ..... day JUDITH T. BOKEN Notary Public, State of New york No. 52-0344963 Suffolk Count~_~ Camm ssJon Expires March 30, (stamp or seal) · TOWN OF SOUTHOLD -- BUILDING DEPARTMENT.~..~ .,~ TOWN CLERK'S OFFICE/ SOUTHOLD, N.Y. ~ Examined ~"1~....~/.. //~ ~'~...- .................................. 19 ........ Application No....~.~.~ ............... / Approved ....... ~1 19 ........Pemit No. Di~pproved a/c ...................................................................... [~ ........ ........................... ................................. ~M~TIO~ ~OR ~l~l~ ~[R~II Date May 1 5 72 ................................................ , 19 ............ INSTRUCTIONS a. This application must ~ com~lotelg fiH~d in bg tg~ewriter or in ink and submitted in triplicate to th~ Buildin~ Inspector, with 3 s~ts of ~l~ns, accurate plot ~an to scala. Fee accordin~ to schedul0. b. Plot plan showin~ location of lot and of buildings on ~remises, relationship to adjoinin~ ~r0mises or ~ublic stroet~ or ar~a~ and ~Nin~ a dotailod description of lagout of ~ropertg must be drawn on diagram which is part of thi~ e. Th~ work eo~ered bg this application ma~ not be commen~d before i~suance of 8u[Idin~ Permit. d. H~on a~ro~al o~ this a~lication, the Buildin~ ~nspoctor will issue a BuHdinfl P*rmit to the applicant. Such ~erm~t *hall be ke~t on the pr*mi~o~ a~ailablo for ~n~etion throughout the work. ~. ~o buildin~ shall be occupied or used in whole or in ~art for ang purpo*0 whateuor until a C0rtificat~ of Occu~aneg ~hall h~v~ been~ ~rant~d bg the Buildinfl Ins~ctor. ~PPklC~TIOffi IS Hfi~fiBY M~fi to tho 8u[Id[n~ ~epartment.for .the i~uance of a Build[n~ Permit ~ursuant to th~ Buildin~ Zon~ Ordinanc~ of th~ Town of Southold, Suffot~ GounW~ ~ew York, ~nd other applicable kaws, Ordinances or ~ulation~, for th~ construction of buildin~s~ additions or alterations~ or for removal or demolition, as heroin descHbod. Tho applicant a~rees to compl~ ~ith all a~lieabl* ordinane*~, buildin~ code, hous[nfl code,~and r~ulations, and to admit authoHzod inspectors on promises and in buildin~ for n*e0ssar~ inspections. (Signature of applicant, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. .................................................. ..C. o~ .~ r..~ .a..~.~.r. ................................................ Name of owner of premises .-.~,~me.~..~.'i.mo-~ye ....................... If applicant is a corporate, signature of duly authorized officer. ..................... i ..................... 1. Location of land on which proposed work will be done. Map No.: .~..e....~.,..,~,~.,... Lot No......~....?, .................................. Street and Number ........ ~..U..~L~,~,...~..9.~.~.. ........... .S..~.~.~.h..o..~..~.. .................................................................................... c~ ~ 0 Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ..¢[~.e.~-3.i~ ............................................................................................................... b. Intended use and occupancy ..... sa~e...~.+~h..&~..~,$.1~.o~ ........................................................................... 3. Nature of work {check which applicable): New Building ....................... Addition ..,~ ........... Alteration ............ :.: Repair ............. · ............ Removal ......................... Demolition ........................ Other Work .................................... , (Description) Fee ......... 5 .................................................................................. 4. Estimated Cost ................. ,~.,-~.Q.Q..:b ............. 1 ' (to be paid on filing this application) 5. If dwelling, number of dwelling units ..D~ ........ 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 ......1.~.../.......!.~. Rear .........~.....~. ....... J~. Depth ........... .~/....,.~O ....... Height ......................... Number of Stories .............................................. 9. Size of lot: Front ...................................... Rear .......................................... Depth .................................................. Height .................................................... Number of Stories ...................................................................................... 10. Date of Purchase ..................................... Name of Former Owner ............................................................................ · · d $ ...................... 11. Zone or use dtstnct in wh ch prem ses are s tuated ........................... ;L....~ .............................. 12. Does proposed construction violate any zoning law, ordinance or regulation: ................. p_~ ...................................... 13. Will lot be regraded .................................... Will excass fill be removed from premises: [ ] Yes [ ] No - (Address (Phone No.)' Name of Architect (Address) (Phone No.) Name of Contractor ,T~ae..~w~zz-~ea~.& .................................................................................................................... (Address) (Phone 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 wheth- er interior or corner lot. % /.3 COUNTY OF ........... .~...~..~..~..Q.~: ........................ ) Leo Kwasneski ~ing duly sworn, depots and says that he is the applicant above named. (Name of individual st~tng con~act) He is the ........................ ~.~ ...................................................................................................................................................................... ( Contnctor, a~nt, coyote of~cer, etc.) a~ aaid o~nar or ~nar~, a~d i~ duly authorizad ~ ~fform 9O~mad th~ ~aid ~ork a~ ~ maka a~d ilia ~hi~ a~¢iaation: ~ha~ all statements contained in this ,pplicat on are true to the ~*.~k~l~e~n~o~elief and that the work will ~ ~dormed in the ~nner ~t fo~h in the application filed therewith. No. 52,034d963 Suffork Coun y ...................... ~.~ .......... day of ................... ~:~ ...................... 19 ..'~ ....... ~ ~' .....................................