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Home My WebLink About6862-zFORM NO. & TOWN OF SOUTHOLD BUr~.nl~G DEPARTM~.NT Town Clerk's O~iee 8outhold, N. Y. Certificate Of Occupancy co~o~ subst~ti~y to ~e Application for B~ding Pe~t h~etofore ~ ~ fhls office dat~ men~ of ~e applicable pro~io~ o~ ~e law. ~e occup~ ~or w~ ~i~ c~ ~ of ~e ~ores~d b~. S~olk Co~ty Dep~ent of He~ Approv~ ....... ~. ~ ~ERWRITERS CERTIFICA~ ~o ............... : .... , ......................... BuiMh~g T~speetor FORM NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN GLERK'S OFFIGE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 6862 Z Date .................. Se~ ....... .14 ................ , 19..~3.. Permission is hereby granted to: .... eut~h~g~e ..................................................... pursuont to application dated ....................... ~.8..?.r..~.....J..~. ............. , 19~.3...., and approved by the Building Inspector. Fee $.1..Q,,~0 ............ BUILDIHG DEPARTMENT ,~/~/~,y, ~D, H.Y. ~ ~Q~,~ .............. ~.~....., 19~. ~ ~ppli~Qti~ ~O. ~.~ ............... . APPLICATI~ FOR BU~ING PE~IT% Qte ....................... 19 ............ INSTK~IONS a. ~is applicati~ must be c~pletely fill~ in by ~ewriter oe in ink and Jn~tor, with 3 ~ of pl~s,~ ~an to ~e,F~ ~ to ~h~ ~ P~ sho~mg I~at,O~~ttdmgs~,~elo~on~ areas, ona givi~ a aetail~ d~r~ofpr~ must ~ drown on the diagram which is ~ of ~is a~licati~.~ c. ~e Work covered by this a~lication may n~ be comme~ before i~ua~e of Buildi~ Pe~it. d. U~n approval of this opplicati~, the Building Ins~tor will i~ue a Building Permit to the applicant. S~h permit shall be kept on the premises ~ailable for ins~ti~ thr~gh~t the work. e. No building shall be ~cupi~ or u~d in whole or in pa ~ for any pu~ose ~atever until a ~ific~ of ~cu~ncy shall have ~en gmnt~ by the Building In~ector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of o 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. (Signature of applicant, or name, if adlll~ration) (Address of applicant) State whether applicant is.owne.r, 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 ~ ............................................. Other Trade's License No ............................................... Location of land on which proposed work will be'done .................. '~"'d~'~" ......... Lot No.~..~..~... ........... Street and Number ...,,4~,~...~'...~.,M~',4~..~..,,,~.........~..~.....e ...................................................... / ~ ~ 0 Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ................................................................................................................................ b. I ntended use and occupancy..~,,~*--4G"Mdl~l~e~.~.,de~ll~,~ .~...... ~ ............................ Nature of work (check which applicable): New Building ..; .... Addition .................. Alteration ................. Repair .................. Removal .................. Demolition .................... Other Work ................................................ , ..... (Description) 4. Estimated Cost ......................................... ; .............................................................................................................. (to be paid on filing this application) 5. If dwelling, number of dwelling units ....... ~..~..~ ......... Number of dwelling units on each floc;r ............ ~d/ 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 ~..../..'T.~......~'.. Number of Stories ........... ~... ........................................... .......................................................... 9. Size of lot: Front .......... '~...~.....~. ................................ Rear ......... ~..~.~. ..................... 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.. Will lot be regraded ...~'..~.~ .... ( ) No ......... Will excess fill be removed fro~ p~a~se~ ( ) Yes 14. Name of Owner of premises'~' -- --~.....~...'.~Addm~.~.t.~n'~ ..... Phone No. ~'~1~......~.~9~ Name of ^rchi~ect .............................................................. -~ e~mm~--.--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. .................. '~.2~~ ........ ~'..~......~:....~..be~ ~~d~S~SayS t~t he i, the appl,can, (N~~dual ~igning cont~c~ ~ "~'- ~ ~ ~~ ""-~' above name. / .e ,, ............................. .......................................................... ' .............................................. (Contractor, agent, co~orote officer, etc.) of said owner or owners, and is duly authorized to perform or have ~ormed the said work and to ~ke and file this application; th~l]~t~e~ ~ed.~~i~_~o~e best of his knowledge and belief; and that the work will be pe~med in t~ s~o~ t~li~on'fff~with. Sworn to before ~e this ~ ~ ................... ............ .......... ~oto~ Publi% . ......................................... ......... C°unty' "'~'~Sionotur~ of apl .................. LT .i I~OF, M NO. $ TOWN: OF SOUTHOLD Building Dopo~tment 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 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 disposol--(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, o 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 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 o 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 occul:x~ncy $1.00 Dele .... New Building ................ Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Owner Or_O?ne_rs Of~?r~operty , . ........................................... Subdivision4~.-~¢~.....~...~..~./~ ..................... Lot No.~'./.~...... Block No ............. House No ............. Permit No. ~..~,~.Z. Date Of Permi~/~.~./..~.Applicant ~,~..~.. ~.~ ..... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ .......~.'.~.. .................. Construction on above described buildin~t meets all a.pl~icable codes ond regulations. Sworn to before me this y /c,/~//-~ y ................ day of ............................................ (stamp or seal) ,~c Notary Public .................................... County