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Home My WebLink About5694-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. ~1~ Date ~'I~.,T. .~!3. 19. THIS CERTIFIES that the building located at . X~kO. & .¢O~'. ~ .~ ..... Street Map No.. ~ ........ Block No... ~ ..... Lot No. ~... ~,. ~ ,~, ......... conforms substantially to the Application for Building Permit heretofore filed in this office dated .......... ~...6 .... , 19.~. pursuant to which Building Permit No...~. dated .......... ~ .... ~ .... , 19. ~4, 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 .. ~$~.g~ .~ .$a~Xy. ~alX~g ...................................... The certificate is issued to .. ~$.~. J~t. D.~e~ ....... ~x~e~ ..................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . .J~.. $J...]9~2 .. ~. ~,. ~.. UNDeRWRITeRS CERTIFICATE No... ~d~ ....................................... HOUSE NUMBER. ~ ........ Street .....gOTOy- C~eok- -Roa~ · .(~1.~) .............. ..... Building Inspector FORM 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) No. 5694 Z Permission is hereby granted to: ........... ~O..~c~..;,~ne ....................................... ................ .Cut~e~c~,u. ......................................... to ..~.~,~.~l..~,~.~...ar~...~.~,~r...~,.~l.fl,~, ................................................................................. premises located at ........",~..~.~l~.~le~.~k..~l~,.....~..~l~...O~.~ .......................... at ............................................... it~m,t, lm3~..~,,~,, ............................................................................... pursuar~ to application dated ......................... ~'~ ......... ~ ............... , 19..~., and approved by the Building Inspector. Fee $.. ~..(;~ ......... / F~, ~sulla~ng ~nspector / / TOWN OF SOUTHOLD Building DJparlmeM Town Cled~ 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 properly 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 fram 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 Date ............. L.~.....~.....'~.. New Building ..... ~ .......... Old or Pre-existing Building ............................ ~V~cant(~'"'""JLand ................ ~ ........ Location Of Property ..... ~...C~.~......~........~....~....~t~.......~t~.~ ......... ~.~..... Owner Or Owners Of Property ..~ .......... ~ ............................................... Subdivision ............... .~ .......... ~ .......................... Lot No.....~. Block No....~4~.... House No...~....~...~..~'- Permit No. ~.J~..?...~....~... Date Of Permit ..~_ll.l~.~..A%plican, ..... .~./~1...~....~~....~ Health Dept Approval (X . ~1~- Labor De t A raval ...~..~' ....... ~ ...................... p · pp ............................................... Underwriters Approval ........ .~....~....~...~...t....~.....(.~.. ............ Planning Board Approval ..... .~...~....~..: ...................... Request For Temporary Certificate ........................................ Final Certificate .......~ ..................... Fee Submitted $..~.....:~ .............. Construction on above described building and permit meets all applicable codes and regulations. Applicant .~.....~....~. ~.,.. ~; ................................................. Sworn to before me thj~ .......... l. dayof ..... Notary Public .................................... County (stamp or seal) S-9 SCHD SUFFOLK COUNTY DEPARTMENT OF HEALTH Date JUL 1 1 1972 Bldg. Permit No. 56%Z TO WHOM IT MAY CONCERN: The sewage disposal facilities for a structure at corner of Core~ Creek Road & Koke Drive~Southold (Give deed location) located have been inspected by this department and found to be satisfactory. Chief of General ~gineering Services JUL 1 1 1972 Disupproved a/c .......................................... " (Building Indpector) a. This application mu~t be Application No....'~....~..~....~.. ........... APPLICATION FOR BUILDING PERMIT INSTRUCTIONS comp~letely filled in by typewritei or in ink und 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~ areee, and giving a detailed description of layout of property must be drawn on the diagram whlch il part of thle appllcation~ c. The work covered by this application may not be commenced before issuance of Bulldlrlg Permit. d. Upon approval of this application, the Building Inspector will Issue a Building Permit to the applicant. Such permlt~ shall be kept on the premises available for inspection throughout the progress of the work. L e. No building shall be occupied or used in whole or in port 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 pumuant to the~ Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Lawl, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal ar demolition, II herein delcrlbed. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations. (Signature c~,appllcant, or name, If a ceqlmratlon) ............ ....... ....... ................... (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber ar builder. Name of owner of premises ..................... ~.....~.....~..~ ................................................................ If oppilcar),t is a corporatR,/~lgnature of duly authorized officer. (Nb~rne and title 'of corporate officer) 1. Locahon of land on which proposed work wd~be done. Map No.: ........................ ~ .............. Lot No.: ...~ ....... ,~ ...... 2. State existing use and occupancy of premises and intended use and occupancy of proposed coratructlon: Existing use and occupancy ................................. ' :.:.~.~..:: ............................................................................... Intended use ond occupon:' ............................ ~ ........................................................................ 3. Nature' of wink (check which applicable): New Building ~......,u~... ....... Addition .................. Alteration ............. Repair .................. Removal .................. Demolifion......~l~ ......... Other Work (Describe) .................................... · 4. Estimated Cost ~ .~ Z.) .~..~...~.. :...O~..0 .................... Fee .~.~...7~..~...'?.....~..../...~...r'~..P~"...J~. ............................... (to be paid on fi~ing 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 ................................ 8. Dimensions of entire new construction: Front ............. :~.~. ................. Rear ........ ~,~. ............. Depth ...~'.,~ ............... Height .......... ~. ........ Number of Stories ......................... ,J ........................................................................................... 9. Size of lot: Front ........ /../.~.. ............ Rear .......... ./.Z.~.~. ................. Depth ........ ~'/..~ ................. 10. Date of Purchase ........................................................ Nome of Former Owner ........................................................ 11. Zone or use district in which premises are situated ............... .~.~. ........................................... 12. Does proposed construction violate any zoning law, ordinance or regulation.;) .......~..~. ................................................ 13. Nome of Owner of premises ....~J~r~....~..,~..~...c~r......Address .,~..~.~.~..~..~....~...c..~.o..c..~. Phone No..~5..~l~...?....~'.&'..(../. Nome of Architect ............................................. ... ....... Address ............................................ Phone No ..................... Name of Contractor .~.....~!~$ B(4. fl(t//~¢ Address ~1,6"~ C~'oa ~.~ ..C~6 Phone No..Z~.~....~..O.../.~ 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 indical'e whether interior or comer Jot. STATE OF NEW Y.,~I:~ ~ ~ lee OF ..................... ~.......~.....~j~ ........ ~ ................................... being duly sworn, d~o~s and says t~t he is the aDD icant (Name of ~dividual signing application) , A - -- above named. He is the ............................................... ~~ ............... ~ ........................................................ (Contractor, ag~t, comorate officer, ~c.) of said owner or owners, end is duly authorized to pe~orm or have perfo~ed the said work a~ to ~ke and file this application; that all statements contained in this application are tree to ~e best of his knowledge and belief; and that the work will be performed in the manner ~t fo~h in the application filed ther~ith. Swam to before me this ~ .. ,. ,, . ..... ~ ...... " , .... 7' ........ ; ........... . .......... ~ ~o. 52-812~S0~ Sullol~t~}u~& Term ~pires Match 30, 19~