HomeMy WebLinkAbout6826-z~mORM NO. ,I,
TOWN OF $OUTHOLD
BUTr.r~ING DEPARTMENT
Town Clerk's Office
$outhold, N. Y.
Certificate Of Occupancy
THIS CERTIFIES that the bui]ding located at . . ~ ~ ,~L~ Street
Map No ....... -~.~... Block No ......... Lot No ....... ~ ........................
conforms substantially to the Application for Building Permit heretofore filed in t.h{~ office
dated ........ ?...~-..~..(J~.. ;, ~. pursuant to which Building Permit
dated ......... ~.7.- ~.(,/~,., lQ, 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 ....~ .... ~)~E. .... {:~.~q .f. ~.¥ .... .-~ ~. ~ .}~ {_.~ ~.~ .~ ...................
The certificate is issued to . ~l/.Al.-r ~ ~ ~.. ~.. ~.~/t E-.~ .... {~' ~ P~' {' ~ '~ 'K.¥ .......
( owner, ~t )
of the aforesaid building.
Suffolk County Department of Health Approval ......... /~4...'~' '- ....................
UNDERWRITERS CERTIFICATE No ............... ~,l,..~.; ......................
HOUSE NUMBER ....... ~.-~... Street ... ~4~{~I~. 4_. t ~ ~ ..... ~5'~.}> ..........
............................................... ~ ,~..~., .~..~ ~_.~,( ..............
.... ....
FOBM NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N~ Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 6826 Z
Permission is hereby granted to:
..................... ~az...t~3. .........................................
....... Wc, o~ 1:1.f£ ..& ..~m,~a,,m ~,...]~L ......................
~ ~lhtla ~ add/t/on (deek) a~ exJ. mt..:~..~ d~el.l.,.~..It .......................
at premises located at .....~.Qg~.~.~,~'...~,...~.~..O~....e.~....~. .....................................................................
~attlt.9~. 11,~,' . ....
pursuant to application dated ............................ AI~ ......... ~...:.., 19..~.~., and approved by the
Building Inspector.
FORM NO. 6
TOWN OF SOUTHOLD
Building Delm~tment
Town CInr~ 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), No~-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 O~ Property .~...~..~...~4...~....~'~.~"'~..:,.~.l~~c'~
Subdivision ............................................................... .'Lot No ............. Block No ............. House No .............
Permit No. ~...~....~..~....Z... Date Of Permit .~/~.~/~.-~..Appllcont 9 ,....¢... 2.: .......~...~ ...........
Health Dept. Approval ................... ,~.. ...................... Labor Dept. Approval ................................................
Underwriters Approval .............................................. Planning Bo~rd Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate ..........................................
Fee Submitted $ ....... .~,........ ...............
Construction on above described building and permit meets all applicable, codes and regulations.
Sworn/ft~_~efore me,/~ ---/--, /~,//gthis Applicant ...~~-~... ~.. i.~.~.//~;./C// .....
...... .~......-~. day of ....~~....,~.-4.? (stamp or seal) ~ ~ ~
' ' ~ ,I[I~TH T EOKnN
TOWN OF SOUTHOLD
BUILDIN~ DEPARTMENT/O/~'/
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
'*proved ............... ........ :.:. ........... . .e..,..o. Z---
Disapproved a/c .............................................
.......
a. This application must be completely fill~ in by ~pewriter ot in i~k and s~miffed n trip icate to the Buildin~
In~tor, with 3 ~ of p~s, accurate plot plan to ~ale. F~ aCco~ing to ~h~ule.
b. Plot plan showing I~ation of lot and of buildings ~ premiss, relationship to adjo ning premiss or pub ic stree~
ar~s, and givi~ a detailed description of layout ofpr~e~ must be drawn on the diagram wh ch is
c. The work c~ered by this a~lication may n~ be comme~ before i~uance of Buildi~ Pe~it. "'
d. UpOn approval of this applicati~, the Building Ins~or will issue a Building Permit to the
shall be ~t on ~e premiss available for in~ti~ thr~gh~t the work.
e. No buildi~ shall be ~cupi~ or u~ in whole or in pa~ for any pu~ose whatever until a Ce~ificate of ~cupancy
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY ~DE tO the Building De~ment for the issuance of a Building Pe~it pumuant to the
Building Zone O~inance of the Town of ~thold, Suffolk County, New York, and other ~pplicable ~s, O~i~nces or
Regulations, for the construction of buildings, additi~s or alterations, or for mm~al or ~liti~, as heroin de~ribed.
~e applicant agr~s to comply with all applicable laws, ordi~nc~, building c~, h~si~ c~e, a~ r~ulati~s, and to
admit authorized in~ectom ~ premises and in ~ildings for n~es~ in~ti~.
(A~ of 6pplicaht)
State whether applicant is owner, les~e, agent, a~hitect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises ....................................................................................................................................................
If applicant is a co,orate, signature of duly a~horiz~ officer.
(Name and title of co,orate officed
Builder's License No .....................................................
Plumber's License No .................................................
Electrician's License No .............................................
Other Trade's License No ...............................................
1. Location of land on which proposed work will be done. Map No.: ....................................... Lot No. ....................
Street and Number ~~.~s~..~~..~...~~~., .....................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Exisiting use and occupancy ~
use and occupancy ........ ~...~.....~ ........ ? ..................................................
b.
Intended
Nature of work (check which applicable): New Building .................. Addition ......... Alteration ..................
Repair .................. Removal .................. Demolitic~ .................... Other Work ..................... .................................
(Description)
4. Estimated Cost ......... ~....1~,(~..~. ............. 'i .................. 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 cam ........................................ : ....................................................................................................
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 ...... /..5 ............
Height .................... Number of Stories .............. -T. ......................................................................................................
9. Size of Io~': Front ...............~.~..~...../ .......................... Rear ............. /.,~.~.....~ ............ Depth ..../.m~.....~ ...........
10. Date of Purchase ..... ;~ .~....~..F~.~.~.....I..e~.~... ........... Name of Former Owner ../'~.~l.F~.b ......
11. Zone or use district in which premises are situated .....................................................................................................
12. Does proposed construction violate any zoning law, ordinance or regulation: ........................................................
13. Will lot be regraded ...... ~C7..' ...... ,.' Wi!l excess fill,be rqmow~l from premises: ( ) Y.~ .
14. Name of Owner of premises J.~/:~..e..~...~...~yr4t~ll.~,.~.q....m..'~9~ ~...]r~...q.~.,l~.,~',~.lv~"~o.~...~2.~.a°.7..~..~.~/
Name of Architect .............................................................. Address ............................... Phone No .......................
Name of Contractor ..~.~.~:;~.s~...~..~/...-' .I..~.,~.r . .~.,.. Address . .....................
PLOT DIAGRAM
propeLr~y a[ieneC~.ec~liYv:~stdr~tianCn~Yb~locl kbUinludimn~:'r V~hre~lhees~r~it~toinngac°crorPdin%°ste:'d~, iannd/dcastheo~llstrSeetet'~nakmd~sm~°innSdifcra°tn~
whether interior or comer lot. ~/~) O d ~.~ ~ '~ ~ r~,
COUNTY OF .
........................................................ ~ ........................................ being duly sworn, deposes and soys that he is. the applicant
(Name of individual signing contract~
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 end file
this application; that all statements contained in this application are true to the best of his knowledge and belief; and
thru the work will be performed in the manner set forth in the applicatibn filed therewith.
Swam to befo~ me this
....... .-_. ,
~' J~DI~I ~. BOKEN~ . 0 (Signature of applicant)
I~Jofaly Public, Slate of New
Ne, 52-0344963 Suffolk County ~ ~
Cernrnl~ion Expires Mamh 3,0,