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Home My WebLink About6937-zFOBM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte O[ Occupnncy THIS CERTIFIES that the building located at . ROW. !i/8.14~t~l. RO~.. i... Street conforms substantially to the Application for Building Permit heretofore filed in this office ~.~.~._ _ dated ........ 0ot;.. t~, .... , 19.73. pursuant to which Building Permit No. dated ........ 0Ot;.. ~9~ ..... , 19.73, was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is The certificate is issued to .. (~.o.~g .e..H.~..C.o.~ .i;.l~ .................. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .. Nit ............................... UNDERWRITERS CERTIFICATE No.. IfA ........................................ HOUSE NUMBER ... 120~ ...... Street ...l~[~l.e.~l .B~..~ ........................... Building Inspeeto~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN GLERK'S OFFiGE SOUTHOLD, N. Y. N°. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 6937 Z Permission is hereby granted to: ........... ~e~..~:oz,~ .......... tOD03 ........................... to..~..z.~...~,.e.~..~..t..z...t.~z...tt,...~,..z..~......(.~.~..r.~:e.~ ................................................................ at premises located at ...... ..~.~..0..~..¥..,.......~./'.~.....]~:~I~..~.(~ .......... .(~.9;~*~.;J,~....~.~.~.e,l~...~;~O~.. Sl~) ...................................... .o.~.f,.~.t,. ......... ~.,,.~.,. ....................................................................................... pursuant to application dated .........................0...~..~. ......... .~..~. .......... , 19~...., and approved by the Building Inspector. FORM NO. 6 TOWN OF SOUTHOLD Building Deportment 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: /~'~Aq~fi)~4. 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. j~//~ ~-,.41~' 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: 1. Accurate survey of property showing all property lines, streets, buildings end 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 $5.00 3. Copy of certificate of occupancy $1.00 ...................... New Building ................ Addition ................ Old or Pre-existing Building ................ Vooant lond .............. Location Of Property ...~'..~.:...~).....~. ......... ..~...~....~. ....... ~.........~..~:. ...... .~..~ ............................. Owner Or Owners Of Property ..... ~ ' x~? .-~-'~.~..~..,...~ U' ~ Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No.~..~..~...'~..~.... Date Of Permit .Z../~.~./.~.......Apphcant ...... .~..: ....... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ .................................... Construction on above described building and, permit meets all applicable codes and regulations. Sworn to before me this .... ..~.../..... day of..~....~... ......... ..?.~. ............... (stamp or seal) ............. Notary Public TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWH CLERK'S OFFICE SOUTHOLD, N. Y. Examined ..... ~..~; .~. ........... , 19.?.~.,. Approved ..........c.~ ......... ./....~. ........... , 19.?../~... Permit No .................... , ............. Disapproved a/cc.." ................. INSTRUCTIONS Application No ....... ..~..?...Z ............. o. This application must be completely filled in by typewriter 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 port of this application. 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 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 have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Deportment 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 demc~lttion, as herein described. The applicant agrees to comply with all applicable lows, ordinances, building code, housing cede, and regulations, and to admit authorized inspectors on premises and in buildings for nec,~sary inspections. (~igl~iture of applicant, or r~me, if a corporahon) · .......... ............. ......................................... State whether applicant is owner, lessee, agent, architect, engine&r, gefferal contractor, electrician, plumber or builder. Name of owner of premises ...... ~.~..:....~ ............................................................................. 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 ............................................... Location of land on which orooosecl work will_be done. /v~ap No.: ......... ,~, ........... . ............. :z.. Lot 1~o, ........................ Street and Number ...... /,.%...¥.....~.. ........ ~./~... ......... ....... ...................... Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy .....................~ ...................................................................................... b. Intended use and occupancy ......................(.~.~....~. ........... ~.~'~.~.. ................................................................ 3. Ncrttz~-of work (check which applicable): N · Addition Alteration ....... ~...~-~ ~l "~Repair ..................Removal .................. Demolition .................... Other Work ~' (Description) 4. Estimated Cost ............ ~..(-~.~. .................................... Fee /v (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 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 ........... .J.~../. ......... Depth ..... .~.. ............... / Height ....~. ............. Number of,Stories ........................................................................................................ ~.~ .......... ~). S~t:fo~°~ur~°ar~te ..... i~i..~.'.'...~...,.../....~...~.....~C."i....NRaema~ of ;o~r~"~r~"...~...~:i!~J..- ..... 11. Zone or use district in which premises are situated ....... ~..~.......~...~..~..?'...~..~....~ ............................................. t2. Does proposed construction violate any zoning law, ordinance or regulation: ...~....D. ...................... ......./... 13. Will lot be regraded ......... ../~.....0... .......... Will excess fill be removed from premises: ( ) Yes (/~,~ No 14. Name of Owner of premises ..~..'~..:..~A¢:ktress..~.~.~.~ii.!~...~.i. ~hon~ No...~..7...~..~..~..~..~.. Name of Contractor ............................................................ Address ................................ Phon~ 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 whether interior or comer lot. ST^TE OF COUNTY O~J TM ........................................... ~ ..................................................... being duty sworn, deposes and says that he is the oppticom (Nome of individual signing above name. He is the ................................................................................................................................................................................. (Contractor, agent, co~orate officer, etc.) of said owner or owners, and is duly authorized to perform or hove performed the said work and to ~ke and file this application; that all statements contain~ in this application are true to the best of his knowledge and belief; tha~ the work will ~ performed in the manner set fo~h in the application filed therewith. Sworn ~ ~ore me this ~ ~ ~ / JUDITH ?, ~OKEN ~ ~ Comm~en Ex~ir~ ~rc~ 30, ~14. ,99