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Home My WebLink About5690-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte Of Occupnncy No...~..9~. ..... Date .............. .~.0~',. ~ ......, 19.72. THIS CERTIFIES that the building located at .. 1~.$. bl~lll. Road .......... Street Map No... ~ ....... Block No...:XI~ ...... Lot No. ~.. 8otttholL~... N.![, .......... conforms substantially to the Application for Building Permit heretofore fried in this office dated .......... ~la~ ....~..., 19.~.2. pursuant to which Building Permit No.. ~fig0z dated .......... .~.~...~. ..... , 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 . .Pray. ate..two, family..dweJ_~mg. ,. with. doctor, s. off. ice ............ The certificate is issued to . .Win,. I~, .Don~an. 1~ ..... O~rner ......................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . ~.:R.: .............................. UNDERWRITERS CERTIEICATE No .... P~gldl~l~g ...................................... HOUSE NUMBER.. ~620~ ..... Street ......[qe.5,Xt. Rogd ................................ TOWN OF SOUTHOLD BUILDING DEP~ARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N, Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE Vv'ORK AUTHORIZED) 5690 Z Permission is hereby granted to: ~.... ~aee~ ..,~/e..-~ ,..~tt~ ......... .......... :~e~,..~ .......... ................. ! ................. ................. ,~v,q~e~o,g,...~.~ ...................... ~ ................. to ..... ~:~i~..e~..~ .. ~...e~2~,~,~q~ ..d~e:IZ2~i~ ......................................................... at premises located at .........~,~J~..~E~,~.~d..: ........ .........~ ...... : ............... , ....................................... ................................................ ~e~.-..~,~;~ ............................................................................. pursuan~ to application' dated ............................. ~ ......... .~.-...i,...-, Building Inspector. 19....~, and approved by the ! Building Inspector . '~r' irOR~ NO. 4 TOWN OF ~OUTHOLD Building Delm~tmen~ Town (:~erks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCGUPANCY 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 dispcsal--(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 $5.00 3. Copy of certificate of occupancy $1.00 zo/3z/? BuildingAd d ::[ 1;:[ on New Building .................... Old or Pre-existing ............................ Vacont Lond ............................ Location Of Property .~./..~....~.~[.~.~,~.....~..°...~.~.~.....~..°..~'.~b.~.~..~....]~.'.~.t ............................................................... Owner Or Owners Of Property ..... .~...~........~..~.~..]..~..~........~..O...D..~...~..D ............................................................... Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No. 5690 Z Date Of Permit ~..~..~.....~.Z...~pplicant D~ · William H. Donlan Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate .............. ; ......................... Final Certificate..........................................~w° ~az~.].7 ];n4elZing Fee Submitted $ .....-~... ............................ Construction on above described building and~pe, rmit meets all applicable codes and regulations. Applicant ......~.,..~... ~...~.~.~ ..~..~ .? ............... Sworn to before me this ~/- ~ Notary Public ..~...;...~ounty · "'~'" JUDITH T. BOKEN (stamp or seal) FOltM 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 clwetling or land use 3. Copy of certificate of occupancy $1.00 $5.00 Dote ........................... ~e~ Building .................... Old o~ Pre-existing Building ............................ ~ocont Lo~d ............................ Location Of Property ~/~ ~ner Or ~ners Of Prope~y ....................................................................................................................... Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No. ~90 Z Date Of Permit ~'~11 St ?~l, pplicant BI% wi:l.'li~ H. Dorll~l Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Two Pa, all}, D~llln~ ~equest For Temporo~ Certificate ........................................ Fina~ Certificote .......................................... Fee Submitted $ ....,~...:.",,.. ..................... Construction on above described building a~nd/~permit meets all applicable codes and regulations. Sworn to be~ore me this ..... (stamp or seal) BUILDING DEPARTMENT ~ ~WN CLERK'S OFFICE -- ~ ~ ~.,.T~,D ~, ~ ~ E omr ed ...~.....~.~..~ ............... , 19 ........ ~ .... ~pr~ ........................................ , 19 ........ ~em~t No..~.~..L .................... Di~pproved a/c ........ ~ ................................................. ~ .................. ~....~ ....................................... ~ ........... ~-~ ................... ~..~. (Building Inspector) .~y_~-'-~ ...,"z-~e.a.~ ,~' ,-/-~ ~ ~"'~~/'-- ~ ~ ~ APPLI~TION FOR BUILDING PE~T ~ ....... ...................... INSTRUCTIONS a. This application must be completely filled in by typewriter o.r in ink 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 ofpraperty must be drawn on the diagram which is part of this application. c. The work covered by this application may not be commenced before issuance of Builcling Permit. cl. Upon approval of this application, the Building Inspector will issue a Building Permit to,he appricont. Such permit shall be kept on the premises available for inspection throughout the progress of 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, Suffolk County, New York, and other applicable Laws, Ordnances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein descr bed The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, (Signature of app ideflt, o~6me, ifa corporation) .......... O' ........... 6T,:i~i~';' ~:~' ~,~,~ii~-i .......... ~ .............. State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ......................... ............................................................................................................................. Name of owner of premises ....~../~..:.., ,~.;: ......~...': ....... ~ ~.~. ,X?. ................................................................................... If applicant is a corporate, signature of duly authorized officer. ~ (Name and title of corporate officer) 1. Location of land on whicl~proposed work will be done Map No.: ........... .....~... Lot No .i~,. . Street and Number .~.~. ~.~1..~....~..~ ~.0..~..~..- Municipality 2. State existing use and occupancy of premises and intended us9 and .occupancy of p[oposed construction: E stn and =cu an 5' b .ll a. g use p cy ....................... ;[I .............................. ...~ ...... ~ ..................... ..~. ................................... b. Intended use and occupancy .(~. ~ I~1C~ 3. Naeure of~work (check which applicable): New Building ......... ~ ........ Addition ............. Alteration ',r'": ............ Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................ 4. Estimated Cost ............................................ S I ~ ~.~ ~)(30 ............. 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 o~ each type of use ..~ ./~...~'.../..~'.....~.. ...... 7. Dimensions of existing structures, if anyl Front ....... ~....~. .............. Rear .....~.....~.. ................... Depth ....~...~.. ......... Height ..d~.~.it. ............. Number of Stories ..... . .~... ................................... , .............................................. :. ................. Dimensions of same structure with alterations or adclitions: Front ..... ..~...~.. ................... Rear Depth ......... .~..~... ............. Height , .~...7 ................... Number of Stories ...~... ........................ 8.Hei¢~ht"..~.~...'' Number°fSt°rie I-.'~.Dimensions°-f?ntirenewconstructi°n:sFron~''i'-~''''''~'''''':'~'''~''~'~ ..... Re~r'"~'""~" ................ Dapth...-~-.-..~..~. ....... ~ 'g'''" ....... ~..~.'..~...~. ~!ar '".'.~'i', ~ .................. ;~'-~'"'~.~..'~.'?~'i~':~'~-~;~ ............................ 11. Zone or use district in which premises are situatad ..... ~....~.~./....~'....~..~...-~. .................... ...~ .............................................. 12. Does proposed construction violate any zoning law, ordinance or regulation? ........ ..'~...~'...: ........................................... 13. Name of Owner of premises~...:...~..*....~..:...~....O~..~.~....~'.....Address ~..~../...~'....~...~.:....~....~.....~'...ff~...!~.. Phone No.~....~...-~.' Name of Architect ...................................................... Address ............................................ Phone No .................. Name of Contractor ..... ............................................... Address ............................................ Phone No. PLOT DIAGRAM Locate clearly and distinctly oil 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 comer lot. STATE OF NEW YORK, COUNTY OF .~.g~J[~. ............. .f'~'"' .................................. .~,~]..~aZg,..~.....:?~.~,.~ ..................... being duly sworn, deposes and says that he is the applicon! (Nome of individual signing '6j~p"lJ~'fron) above named. He is the ....................................... c.o~t.:~c~.oac ......................................................................................... (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 knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Swam to before me this I ............... ,'...t....: ....... t: ............................. Notary Public, ./,~-,~~Coun~ o:~ ~l~:~o~k (Signa r~ at ap icont) ._ B£?B ANN N~/ILL£ NOTARy PUBLIC, State of New York NO, 52-8125850, Suff0Jk Cou~ty~ Term Expires March 30. lg.'/~