The URL can be used to link to this page

Home My WebLink About6857-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at . Cox .]~e~k. Road ........... Street Map No. ~ ....... Block No.. ~ ...... Lot No. ~. .... ?I.~.~..~.~.~u.e..~...N..~.~., ....... conforms substantially to the Application ~or Building Permit heretofore Efled in this office dated ........... ~gP~...~ ], 19~. pursuant to which Building Permit No. 6~.. dated ........ ~$ ...~ , 19.~3 , was issued, ~d conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which th~ certificate is issued is ~ 9~ .~. ~l~.~g ..................................... The certificate is issued to ~- ~d~.. ~ ....... ~ ................. (owner, lessee or ten~t) of the aforesaid buil~ng. Suffolk Cowry Dep~tment of Heal~ Approval N. ~ ~ ..................... ...... ............. HOUSE ~MBER . ~ 2~q ..... Street ..~. ~f$~..~ ......................... Building InspeCtor l~OE!~ NO. ~ TO~VN OF SOUTHOLD BUILDING DEPARTMENT TOWN GLERK'S OFFIGE SOUTHOLD, N. Y. BUILDING PER~IT (THIS PERMIT MUST BE KEPT ON THE P~,EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 6857 Z Permission is herebygrant~:~.~. '7'"/~ J..Z b/~ .~/-~ ~J__ ~//~ pursuant to application doted [ ! ~'~>7- 1~....'~...,, ond approved by the Building Inspector. ~ /5' o~ Fee $ ........................ Building Inspector FORM NO. 6 TOWN, OF SOUTHOLD Building Delm~ement Town CJel~s Office bi'hold, 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 buildings and "pro-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 end 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 occup~ 2. Certificate of occupancy ~t~---pro-existing dwelling or land use $5.00 3. Copy of certificate of occupancy $1.00 Oote ...... New Building ................ Addition . ............... Old or Pro-exls~g ~uilding ...~.. .........Vacant Land .............. Location Of Property ..... ~...o~...~..~,&.....~.~.~.~,...,/~'/r.~.l.'T~,,~.~.~,.~.'.~,....~)..:.~., ................................... Owner Or Owners Of property ..... /~.,%...--../.~.~/~.,~/........~...~..~.~.~(gJ ............................................................ Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No.~.~...~L.. Date Of Permit .?Z((lZ,~...Applicant .~(~,.~.~.~.&....~..~'~l~..~..~a ....... Health Dept. Approval ....... ~ ............................ Labor Dept. Approval .............--"'-. .................................. ~.. ~..~. '2,.)., 5 Planni ........................................ Underwriters Approval .......... 7 ........................... ng Board Approval Request For Tempome~, Certificate ....... ~ ......................... Final Certificate ......~..... .............................. Fee Submitted $ .~:....'~.. ......................... Construction on above described building and permit m. eets all applicable codes and regulations. Applicant ............ ~~~ ............... ? ............... (stamp or seQI) ,~ ~'~ '~'/~ Sworn to ,before me this ..~..~.A. day of ......... ,.L~ ..~ .... Notary P lc .................................... ~ M. OOLEMAN /~~.~_~ Notary Public, S~te of New York No. 52-5, 58570 Qualified in Suffolk. County Commission Expires March 30,1974 4/~E4 : 1.9093 4CRE5 F~I G.H T 55Z92' Examined ...................................... , 19 ........ Approved ................................... :.., 19../.../... Permit No. Disapproved a/c .............~:::.':...~ ~ ............................................................. .......................................................... ~ ..................... ~,;: ............... (Building Inspector) TOWN OF SOUTH(X,D TO~N ~,~.l~i('~ OFFIGE SOIJTHO~D, N. Y. Application No ...................... APPLICATION FOR BUILDING PERMIT ~ Date ...~....~..~.l~J.[~.~-~.....I.l.)....., 19...~.~.... INSTRU~IONS ~ a. This a~licati~ m~t ~ completely fill~ in by ~ewriter ~ in i~ and s~mi~ in triplicate t~ ~ Building Ins~tor, with 3 ~ of pl~s, ~cumte pl~ plan ~ ~le. F~ ~o~ing to ~h~ule. b. Plot plan ~i~ I~ation of lot and of buildi~s ~ premiss, relati~ip to ~joining premiss or public str~ o~ ar~s, and givJ~ a de~d~ d~ripti~ of I~ of~ mu~ be dm~ on ~e diagram Which is ~ of this applicati~. c. ~e wo~ c~er~ by ~is a~lication may n~ ~ comme~ before i~uance of Buildi~ Permit. d. U~n approval of ~is a~licati~, ~e Buildi~ I~tor will issue a Building Permit to the a~licant. ~ch permit shall ~ ~t ~ ~e premi~ ~ailable ~r in~ti~ th~h~ the work. e. No buildi~ ~all be ~cupi~ or u~ in ~ole or in pa ~ for any pu~ whatever until a Ce~ificate of ~¢~n~ ~11 have ~n gmnt~ ~ the Building Ink,tar. APPLICATION IS HEREBY ~DE to the Buildi~ ~nt for ~e i~ance of a Buildi~ Pe~lt pu~ant to ~e~ ~uild~n~ Zon~ O~inance of ~he T~ of ~t~ld, Suffolk Count, New York, and other applic~le ~, O~i~nc~ or ~egul~s, mr the constr~h~ of buildJ~s, ~iti~s or a[~mti~s, or for m~l or ~llti~, ~ heroin ~ri~. ~e applicant agrees to comply with all a~licable I~, oMi~, buildi~ c~, h~si~ c~, a~ ~l~l~s, a~ ~ admit authoriz~ in~ecto~ ~ premi~ a~ in ~ildlngs ~r ~ i~ti~s. (~ of ~lica~t) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. .......................................................... ................................................................................ Name of owner of premises ..... .~..].,~'-R.,...../.~..~t~.........~..~.~/m~.t~ ................................................................................. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ........................................ ..~..:.~:. Plumber's License No ................................................. Electrician's License No ............... a~...~':...~....~...-. ........ Other Trade's License No ................................... ~...~... I. Location of land on which proposqcl_ work will be done. Mop No.:.. ....................................... Lot No ......................... Street andNumber....~.g ...... ..~.J .... ~.~.,~t.~).~ ~/,~.'Z'..~..~.~..~.~J~. ~, ..... ~.. ........................... ' ' *9St- J~u'~i'~il~lit~ .... 2. State existing use and occupancy of premises and intended use and occupancy of propaeed construction: a. Exisiting use and occupancy ............... .~.~._F.~ .... ~..'~./. ~ ......... b. Intended use and occupancy .... ~ ~..~....~.. ~.O...O....~...~. . . 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration ....~ ....... '.~ Repair .................. Ren"joval .................. Demolition .................... Other Work ................................................ . .... . (Description) 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 ~Xtent of each t~e of use ............................ ' of Jf Front ' "~J-I ~ Rear J..~....~...~...~..' ~' existing structures, any: ..J..~....~.....~...--~.. .... .......... Depth .................... 7. Dimensions Height .....~...~'..T..: ....... Number of Stories .......... /......~...~ .......................................................................... Dimensions of same structure with alterations or additions: Front ..../.~.~...x'......~.....~T,..~ ........ Rear ../..(O.r....~....~....~..! .... -(' . Depth ................................ Height ....~.~.~....~..~ ........ Number of Stories ......... t~ ..................... 8. Dimensions of entire new construction: Front .................................... Rear ............................ Depth ........................ Height .................... Number of Stories ..................................................................................................................... 9. Size of lot: Front ........... .. ..................... , ...................... Rear .......................................... Depth ..= ........................... 10. Date of Purchase ....................~.g.¢~.,.~.,..(.~.~[ .............. Name of Former Owner ..~.l~P.J~e~:~......~.~.~'.~.,~ ....... 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 ....... J~..~. ............. Will excess fill be removed from premises: ( ) Yes ( ) No 14. Name of Owner of premises~L~.:..'T'.L~?]l;>..~....'~.L~.~.l..-...~ ..... AddreZ~°~.i~,~.l'2.~.5~/~'~.'Z~A,~o Phone No. ~.~.~.-../~.~.~.1. 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-back dimensions from ~ .property lines. Give street and block number or description according to deed, and show street names and indicate ~ether inter or or corner at I// // "/ ///,// / // / f // / J/ // // // / / / /// I"/// //,.('/.,' ×//., P~r(o STATE OF NEY'Z. "ZORK_ J ¢ ¢ COUNTY OF ..~..l~.....~..~. ............ ~.~ ................................................................................................. being duly sworn, d~o~s and saYs t~t he is the applicam (Name of i~ividual signing controc~ above name. He is the .................................. ~.~.~.~.~ ......................................................................................................................... (~ntmctor, ag~t, co,orate officer, etc.) of said ~ner or ~ners, and is duly authorized to perform or have performed the said work and to ~ke and file this application; that all statements contained in this application are tree to the best of his knowledge and belief; and that the work will be ~rformed in the manner ~t fo~h in the application filed therewith. Sworn to before me this ........ .................. . .... ~oto~ Public, . ......... /...~ ..................................... C~n~ ............ ~...~.~..~...x.x.w..w..:..:.....~ ................. / ] / g , .. ~ ~. :- (Signa~re of applicant) ~ e~ ~n~fl 30,1974 THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF ELECTRICITY 85 JOHN STREET, NEW YORK, NEW YORK 10038 THIS CE~IFIES THAT only t~ el~t~al ~uipment ~ ~scH~ bel~ a~ int~Bc~ by t~ ~pl~ant ~ on t~ a~ appl~at~ numar in t~ p~mises of i~ t~e ~oll~ing l~ation; ~ B~ement ~ 1st FI. ~ 2nd FI. ~ction Bilk ~t w~ e~ami~d on ~T~ ~ ~ ~ ~ ~ ~ ~ and~ound to be in compliance with the requirements o~ this B~. W. ~ o Ruland~ Mattltuck, L.I. COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT RE ALTERED IN ANY MANNER. "MIL L E F~ S RIGH o~ OF' WA y" ~5Z92' $$6.90' SURVEY FOR THEDA SHULHA AT MA'rTITUCK TOWN OF SOUTHOL.D SUFFOLK COUNTY~ N.Y. SCALE I APRIL 24 ~ RIVERHEAD, N, Y..