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Home My WebLink About5752-zFORM NO, 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Cerfi[icate O[ Occupancy No..~..~].~. ...... Date ............... &p~ll.. J.~., 19. THIS CERTIFIES that the building located at . .i).$]~ .~ .............. Street Map No.. ~g ........ Block No...~. ....... Lot No...~ .... ~.~lJ;.ChOgk~.. ~?~ ~ ...... conforms substantially to the Application for Building Permit heretofore filed in this office dated .......... M$l*at~.. 20., 19. ~ pursuant to which Building Permit No.. dated ........ .M.~..~.¢.h....~.., 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 ... 2~lsilxesn. :,lse...,. tr~k. ~.la~or~ Acces.~ory..t~. ~xis~ng The certificate is issued to .. I~ .M.~,mg. & .Ce ...... ~S ....................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval ..~I.,R, ............................. UNDERWRITERS CERTIFICATE No ...... .11.~¶ ....................... , ................ HOUSE NUMBER .... ~ .... Street .......D~DO%./~.-.10.8 .... 1~.~,~1,$ ............... Building Inspector FO~ 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? 5752 a prm s oc aa .................................................................................................... pursuant to application dated ............... ~...~.~...~ ............. ,19..?...~., and approved by the Building Inspector. F. ..... FORM NO. 6 TOWN OF SOUTHOLD Building Deportment 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, anci 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. §. 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 oil 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. Owner Or Owners Of Property ................ a.-~,...,..~.., ........~.....R~ ....... ~ ...... .(~..... ............. Subdivision ............ ~ ................................................... Lot No ............. .~. ..... Block No ......... ,.. House No ............ permit No...~..Z..~.'....'..~-'Date Of Permit ... '.~../..~. ~.?.Applicant ~.~...~~~,~' ~ Health Dept. Approval ........ .~....Z..~'..: ....................... Labor Dept. Approval /(J' Underwriters Approval /d r ~, . ................ Planning Board Approval jkJ, Request For Temporary Certificate ........................................ Final Certificate ............. ~...'. ..................... Fee Submitted $ ....._~.:..~...o. .................. Construction on above described building and p~'r~it.m,eets ~pl~icl6~le codes and regulations. A hcant //'" ~'~ J'~Y~/'J~ ' Sworn to before me this (stamp or seal) FOEM NO. 6 TOWN OF SOUTHOLD Building Department Town Clerks Office Southold, hi. 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, an6 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. · ' ' · ............................................................... o: ............ kNo ............. use No ......... . , . ..... ....... Health ~pt. Approval ............ ~..:.t ........... .(..... ...... Labor ~p,. Approval .............. /.~..'..~: ....................... Unde~riters Approval .......... .~.~..~ ....................... Planning Board ~proval Request For Tempora~ Ce~ificate ........................................ Final Certificate .......... .~ ........................ Fee Submitted $ ...... .~..o..R ................. pp ............. t,4: ..,w:7... x.~ .......~..~..~: ............................................................. Sworn to before me this z~,,l~: da of ' .. 4(..~. Notary Public ~~~... County (stamp or seal) TJ~-$ 9 ' o,C. ,.?"X 8" i" NaT"rtl .-'r~ IN $"X la '/t ' FOBM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFIGE SOUTHOLD, No Y. ........................................ , 19 ........ Pemit No ..................................... Disapproved a/c ............................................................ INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted Jn 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 ofproperty must be drawn on the diagram Which Js part of this application. c. 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 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, 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 cede, and regulations. · rp 'o ) · ............................... ............................ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. /, Nome of of premises ' L)~ C~ C O,. owner ....................................................... , ........................................................................................... If applicant ils a corporate, ~gpature of,~uly authorized officer. ricer) Location of land on which~.groposed work will be done. Map No.: ........................................ Lot No ........... Street and Number ......~-......~....~...Z'........~.~/...~..~.. ~..~....~.. ~.~ ~ ............ ~"~'~'~..~.m.~ ..... /Munic pal ~ State existing use and ~cupancy of premises and intended use and ~cupancy of pr~osed c~stmcti~: a. ~sitin9 use and =cuponcy ..................................................... ~ / & .~ .... b. Intended use and ~cupancy 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration ......... "'T .... · D · · · L6Ao~IJG P~-~f~£~ Repair .................. Rem,oval .................. emoht~on .................. Other Work (Describe) ........................................ ~[' O00 ,DO 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 t~e of use ....~...o....,~.....~...: ...... 7. Dimensions of existing structures, if any: Front ............................ Rear ................................ Depth .................... Height ........................ Number of Stories ................................................................................................................. Dimensions of s~me 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 ...................................................................................................................... 9. Size of lot: Front ............................ Rear .................................... Depth ................................ 10. Date of Purchase ........................................................ Name of Former Owner ........................................................ 1 !. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation? . ~A/ O 13. Name of Owner of premises ./.~..A...~:....~..°..?...~...~.....~...~.?..'Address ....~.~..~...~...~.../~.~.~....~.:..~. Phone No.~..~.~.T...~..°...~...O Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor .................................................... Address ............................................ Phone No ..................... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-beck 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'/~'OJ~i~, ~,x l ¢ ¢ COUNTY___ ~--~ ---/~ . ~,OF ~ ............ ............ ~,~,/~t3~-~' .~,,,_.---,~,'~ff,.~.,t~,,,~'m ......... ; ......................... being duly sworn, deposes and soys 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 Jn 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. Swom to before me this ,I , W · .. II . ...~)',',',~ ...... d_ay ,of ..... ,t~',',~j~.~ ...... ~...:.., 1 ~.~.o~.. J~~ ftC,7_, ,, ~ /fl ~ ~ ,. ',~ ................ <.,~/'~.,...~.~:...~...'~... .............................. Notary Public,~..L~g-~.//~... County~,.~/'~;JJ~ (Signature of applicant) ~ EL]Z/~BETH ANN NrcVIL~E NnT~I~¥ pUBL C, State of New .... ~., 0~25850 Suffolk COU~ Term ,Expires March 30, 19~.~'