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Home My WebLink About6861-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte Of Occupnncy No. Z~ ...... Date ............ l~apt ....18 ..... , 19.73 THIS CERTIFIES that the building located at Bl*&y. &~ .................. Street Map No. G.o.I ,~t~. l~lock No ........... Lot No. ~. . .~..~.e.~. !~o.~... ............ conforms substantially to the Application for Building Permit heretofore filed in this office dated ......... Sep.~...1~ .... , 19. ?~ pursuant to which Building Permit No.6.I~61Z... dated ......... .8~p.~...~..~ ..... , 197~.., 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 '. l~rSvate. ~ .fa~ly. d~ll~ ...................................... The~ertificate is issued to ...~.*..fl.* . .1~..~...J~.. ..... .(~..s.~. .... ~ .................... '" (owner, lessee or tenant) of the aforesaid building. ~ Suffolk County Department of Health Approval .liaR, .... UNDERWRITERS CERTIFICAT£ No. 1~.~ .................. :. ~ .................... HOUSE NUMBER...2~1~.0. ..... Street. 1~2~.~' &Ve Buildingi'lnspect°r / FO~.~ NO. 2 TOWN O~ $O~TSOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PP, EMiSES UNTIL FULL CQMPLETION OF THE WORK AUTHORIZED) 6861 Permission is hereby granted to: e~ o.....T~la x'..... ~/D...~a ck .. ~e ~i.t~ ........... ...... ~a.~.~ ....... ;~.~.~. ................................... to ..~.~l~..a~..~-dd,_~_~fQr...mx..sxis~..d~r~lllr~ .............................................................. at premises located at .~LD,'~...~..~. ....... ~'.*..][..~-~'~;~,,,~-.-.-]~1,~3 ............................................................... .................................. ~r..ay......A.~.~ ............... ~!a~.~. ~.~c~.... ~.&. ~.... ........................................................ pursuant to application dated ....................... ~.ep.t; ..... l~ .............. 19..7;~.., and approved by the Building Inspector.. Fee $]..~..?...0~... ............ FORM NO. $ TOWN OF SOUTHOLD Building Department Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This apphcation 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 "pre-existing" land uses' ]. Accurate survey of property showing all property lines, streets, buildings and unusual natural or topographic features. 2. Swam 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: I. 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 .................... New Building ................ Addition ~?.,4~ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ~'~.L.~...~......./~.~...~/,...'~.~...~.,...~.J,. ............................ Owner Or Owners Of Property ...~/./...~/~?.~.........~...:....(../..4'.~...~.. ........................................................... Subdivision ................................................................ Lot No ............. Block No ............. House No ........... Permit No. ~..~.(~./.....~... Date Of Permit ~.j/../~/.7.~...Applicant ~.~.~..~~ .................. Health Dept. Approval ......... ./..L..!.T...T. .................... Labor Dept. Approval ............. ./.Z..'_~.~.. .................... Underwriters Approval ........... ~ .................... Planning Board Approval ....... ..~..'./,..~..: .................... Request For Temporary_C~ertificate ........................................ Final Certificate .......................................... Fee Submitted $ ....~.....,~........ ................. Construction on above described building and permit meets all applicable codes and regulations. Applicant ...~k....'~.. ~....~..., .. ~r~. ~,¢~/~J~ ..................................... Sworn ,o before me this ......... l.~day of ....... .%~....~.7.~ .... (stamp or seal) Notary Public .................................... County TOWN OF ~OUT#OLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. APPLICATION FOR BUILDING PERMIT -'" ote ............................. INSTRUCTIONS a. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate to the Buildin~ Inspector, with 3 set~ of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this applicoti0n.~) 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 permJt~' shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in pa rt for any purpose whatever until a Certificate of Occupanc~ 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 code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. ....... ~t~,gnature o,~pl~ii'~J~nt:"*'r"~"~'me, ~a corp~;'c~ri'c~'r~i ........ (Address of applicant)/ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. 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 ............................................. Other Trade's License No ............................................... 1. Location of land on which proposed work will be done. Map No.: .......... ..~...~.../.. ................ ~.~. Lot No....~....~'. .............. Street and Number ...~,~..~..'~.~.....~.~1..~ ........... ~.....~....://..~...~....~.. ..... ~ ~ / Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: o. Exisiting use and occupancy ....... .~..~ ....... ~ ......................................................... b. Intended use and occupancy ........ [~,~....~.....~.~ v ' 3. Nature of work (check which applicable): New B~jlding .................. Addition ~:sT~--Alteration ............... Repair .................. ,R~.moval . ................. ~it~.~:...i;: ........... 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. 6ccupancy, .specify nature and extent of each type of use ............................ 7. Dimensions of existing structures, if any: Fror~t ............................ 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 ..................................................................................................................... 9. Size of lot: Front ................. ~.(,I. .............................. Rear ........... .~..~ ........... ~ .......... Depth ./...~...~.~..,~ ........... 10. Date of Purchase .......... .~....~s~...../...~..~...~. ......... Nome of Former Owner .~a~.....~...J~.~5,,~l.....~L..~' ! 1. Zone or use district in whichI ~remises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ........................................................ 13. Will lot be regraded ........ ~ .......... Will excess fill be removed from premises: ( ) Yes . 14. Name of Owner of premJse~/...~/.'.~..,~.....t.~.t~,.4~l~..... Addre~_~/~/~~ Phone Bo...~.~,(~.....~.....~ Name of Architect ......................... : .................................... Addre~.~.... Phone No Name of Contractor ...~..~.,~..~.~.~...../:-~....~....~)~.~'.~.. Address .~.... Phone No~.~'.,~;..~...~'.,C'..~ -- 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 deSCdiption according to deed, and show street names and indicate whether interior or corner lot. COUNTY OF ..... .~'i':~Z~ ~ ........ ~ ................................ //.~.~ ....... ~--~...~ ................... being duly sworn, deposes and says that he iS the applicant (Name of ir~ividual signin~ 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 and file this application; that all statements contained in this application are true to the best of his knowledge end belief; and tha~ the work will be performed in the manner set forth in the application filed therewith. Swam to before me this ~ ~.~_~~-,3~ ~ Notary Public, . ................................................... County .......... .'~........]. ............................... (Signature of ~plicant)