HomeMy WebLinkAbout6867-zFORM NO. 4
TOWN OF $OUTHOI.D
BUILDING DEPARTI~fENT
Town Clerk's Office
$outhold, N. Y.
Certificate Of Occupancy
No. 2;61+19 ...... Date ........... Apr~7~. · · £3 .... , 19.7~.
THIS CERTIFIES that the building located at .[,la~atook~. l~d ............. Street
Map No.. ~cx ........ Block No.. x~ ...... Lot No, ..xxx... [ta~:~:L~uck...E.Y. .......
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ....... ,Sept .. ~ ? .. , 19.7.3 pursuant to which Building Pemit No.
dated ..... 3ep.~;.. 2 7 .... , 19.7.3., 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 pr. iva~;e, garage ............
The certificate is issued to . Lra. ~thill.
of the aforesaid building.
· · · (~mer. ............................
(owner, lessee or tenant)
Suffolk County Department of Health Approval }; ,t{ ..........................
UNDERWRITERS CERTIFICATE No.penc!l~g .....................................
HOUSE NUMBER ............ Street ..........................................
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? 6867 Z
Permission is hereby granted to:
m~..~'~. ......... A/.~...~;r.~...~w-...l;.b.;t.~.. ..........
.......... ~'~.....~.~ ..................................................
.................. ~.~?. ~.....~. :.~.... ........................
~a .~.. ~.w....~..~?..a..t...e....~.a_.r..a. ~..e. ...............................................................................................
premises located at ...................... ~;.,,,r.~,,o,,o,~,a:..~.o,~,.(]: ....................................................................
...................................................................... N&t~i~ek ....... N.~Y., ....................................................
pursuant, to applicati,on d~ted ..................... .~..e..~..~.. ......... .t..~ ........... , 19..~.~..., and approved by the
Building Inspector,
Fee $.i:.0..:...0~... ............
FORI~ NO. 6
TOWN OF $OUTHOLD
Building Department
Town Clerks Office
$outhold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANGY
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 Commercml buildings, Industrial buildings, Multiple Residences and similar buildings and
installahons, a certificate of Code compliance from the Architect or Engineer responsible for
the building.
5. Submit Planning Board approval of completed s~te plan requirements where applicable.
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-ex~sting"
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 inspechon 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 $5.00
3. Copy of certificate of occupancy $1.00
D te
..... ...................
New Building ...... ...~. ..... Addition ................ Old or Pre-existing Building ................ Vacant Land ..............
Location Of Property .....~....~...~...~'.......~.../~...~...~...~....~..~';'...~....~..~/.,. ........... ...~.~..T..r~...'~....u...c.../~ ...........................
Owner Or Owners Of Property .... ~,./,~..,~.. ..... .~/...,/-~..~/,~..~..../..~....~.. .........................................................................
Subdivision ................................................................ Lot No ............. Block No ............. House No ...........
Permit No.I~,~.~,2 ,.~,. .... Date Of Permit ..~..:.,/,~..,7.,~....Applicant /~.,~,,..~,./~/.....,.~,~... ,~.,,~.~'..,z~.. ...........................
Health Dept. Approval ............................................ Labor Dept. Approval ................................................
Underwriters Approval .............................................. Planning Board Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate /~ ......................................
Fee Subm,tted $ ...,~./..~.,0. .......................
Construction on above described building a~,.permUr ~meets all app, Jj~able coj:~ and regulations.
Sworn to before me this
(stamp or seal)
{,.~ ~' T " .
II
, .... f:: ~ " ''~, ~ '7 ~,, ,, ~p)o~]~ F~OO~ i~R Tu~Y/~C, ~T ~flR~FOa~ ~0
!
proved
........................................ , 19.. Permit No ...................
Disapproved a/c ............................................................................................. y~j~. ~/.7/,~/? ~
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
App ~ ............... U... ..........
Dote .... , .
........................................... 19 ...~
APPLICATION FOR BUILDING 'PERMIT
INSTRUCTIONS
a. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate to ~e Buildi'~
nspector, with 3 set~ of plans, accurate p at 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 of
areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this application.
c. The work covered by this applieation may not be commenced before issuance of building Permit.
d. Upon approval of this applicatlan~ the Building Inspector will issue a Building Permit to the applicant. Such permit
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 Occupancy
shall hove been granted by the Building Inspector.
APPLICATION IS HEREBY N~DE to the Building Department for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the T,o.wn.,o,f. Southo,ld.,. Suffolk .Cou.n. ty, New York, and other applicable Laws, Ordinances or
Regulations, for the construction or auna~ngs, aaa~hons 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.
......
(~lress of ~;tpplicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
............. ...........................................................................................................................................................
Name of owner of premises .Zi~.~. ...... ..~...~.....~..~./.~..L ..............................................................................
If applicant is o 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 w~ork will be done. Mop No.: ........................................Lot No .................
Street and Number ...... ~'~'.~...~..'~.. ~.6.4~.Z1~ ~...~ ,~. ~/.~ d ~,.~ ~.~...~...~.~ ~ ....
.......................................................
Municipoli~
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
o. ~xisiting use and accuponcy ...... ~. ........................ /...~. ................
b. Intended use and occupancy .~. ~... ~..
Nature of work (check which applicable): New Building Addition Alteration "~
Repair .................. Removal .................. Demolition .................... Other Work ....................................................
.~. ~ O, 0 0 ' /E) cra (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 ............................
o
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 ..... ..~...j.., .................
8. Dimensions of entire new construction: Front ..... ~...~...~. ..................... Rear ...~....~....: ................ Depth ...~....~...~ ........... :
Height ..L.~..../. ....... Number of Stories ....O.~..~... ..................................................................................................
Size of lot: Front ............. ~./~)./~.. ............................... Rear ...... L.~....~. .......................... Depth .~.~. .................
Date of Purchase ....................................................... Name of Former Owner ........................................................
Zone or use district in which premises are situated ..... : ..............................................................................................
Does proposed construction violate any zoning law, ordinance or regulation: ........................................................
Will lot be regraded ............................ Will excess fill be removed from.premises: (~ Ye~ ( ) No
Na me of Owner of prem,ses/.~.~......~.........~, blL.~.. ............... Add ress.~..~'~.~.~....u.~.~. Phone No .......................
Name of Architect .............................................................. Address~.~.~.~.~ffC~:~, ............ Phone No .......................
Name of Contractor ~'j/..d...~'..,~j/.........,~'~..~=~.....~-~'-.....~-~... .............. Address/~t6/~,l~O~...... Phone No~..'.~.....~..~.~7
PLOT DIAGRAM
Locat~ clearly and distinctly all buildings, whether exi,~ting 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
whether interior or corner lot.
10.
-' 13.
· COUNTY OF S.S
JUDITH T. BOKEN
Nota~ Public, State of New York
No. 52-0344963 Suffolk Coun/
Cornrni~iofl Expires Ma~ch 30, 19..~
................................................................................................. being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract0
above named.
H~ 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 and belief; and
thaz the work will be performed Jn the manner set forth in the application filed therewith.
Swam to befgr~me this
Notoh Pu b, ...... .......................................................
~ ' ~J (Signature of applicant)