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Home My WebLink About6940-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office $outhold, N. Y. Certificate Of Occupancy Nc,.Z.6378 ....... Date .... .I~. r.qh.. 2~., ........... , 19...7~ THIS CERTIFIES ~at the b~ding located at 9~ ~. ~.,..~.~ Street Map No. ~ .......... Block No..~ ....... Lot No .... ~ ............................ conforms substantially to the Applica~on for B~ld~g Permit heretofore f~ed ~ ~is office dated .. ~.~Q~gr .~3~ ..... , 19 .?~. p~suant to which Build~g Pe~it No.~... dated ~.~9~ .~3.~ .... , 19~.., was issued, ~d conforms to nl~ of ~e req~ ments of the applicable provisions of the law. The occup~cy for which ~s ce~ificate ~ issued ~ . ~..q~..g~ ~ The ce~ificate is ~sued ~ .~ .T~ ......................................... of ~e Moresaid b~ding. S~olk County Department of He~th Approv~ . .. ~.~ .......................... UNDERWRITERS CERTIFICATE No ..... ~ .................................... HOUSE ~BER ~O ......... Street .. ~. ~¢~ .......................... ........................................... ~ .~,. ~. ~.~ .... / ............... Bffil~g Inspector ~0~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN GLERK'S OFFIGE SOUTHOLD, N~ Y. 6940 BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON TI~E PREMISES UNTIL FULL~', COMPLETION OF THE WORK AUTkJORIZED) ~ Permission is hereby granted to: to ~..'l.ct.. r.e,L pr :Lv.a.~e...~a,va~e .................. ' . at premises located at ...... ..~./~...~.....~.~...'~....~..~ ........................................................................................ .......................................................... . .................. Ox'-~ e~'li...--N-,.~.,~ .......................... : ............................ pursuant to opplication dated ..................... ~{I.~.....~ ................. , 19~..., ~nd ~pproved by the Building Inspector. Fee $~0~O0. ........... I~OR~I 1~'0. 6 TOWN OF SOUTHOLD , Building Deportment Town Clerks Office Sou~hold, 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 w~th 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 Remdences 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 s~te 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 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 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 Date ... ~T.~U~ .. !.;.19.7. ~ ..................... New Building ..... x ......... Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ...~]e~ze:~j:..~¢.~ee.'lr, ....................................................................................................... Owner Or Owners Of Property ..... .g..9:~r....~...~.~.Q.~. .......................................................................................... Subdivision ......... £~e .............................................. Lot No..t~0 ....... Block No. ,,]J~ .....House No,.6L0.,. Permit No...6f~zJ,0,~ ....... Date Of Permit ~/.~..~/.%.~...Applicant ..~ar~..~.ab.a~ ....................................... Health Dept. Approval ............................................ Labor Dept. Approval ............................................... Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Fined Certificate .......................................... Fee Submitted $ ..... .~QO ..................... Construction on above described building and ~per~nit meets all applicable codes and regulations. Applicant .......... ~. ......................................... Sworn to before me this ! ................ day of ............................................ (stamp or seal) / / Nota Pub,ic .................................... Coun - C K'S ~TH~D, N.Y. ~ '~ ~ ~amined ~ ~ 19~. ~Application No. ~ ~proved .............~.~ ....... :.'. ............. . 19~.>. Permit No..6...~...~.~..~..../~- ~m Di,pproved a/c~.:.....~..~.~ ...... ~.. __~ ~ ......... ...................................... ................. *"LICATI~ FOR IUILPlH~ 'E~IT ...... ......................... INTRUSIONS ~:';: · a. This a~licati~ must ~ completely fill~ in by ~ewriter o~ in ink a~ s~mi~ in triplicote to ~e Buildi~ Ink,tar, with 3 ~ of plans, ~ccurote pl~ plon ~ ~ole. Fee ecco~ing ~ ~h~ule. b. Plot plan ~ow~g I~otion of lot and of buildings on premises, relationship to adjoining premiss or public struts o~ ar~s, and givi~ a detailed description of la~uf ofpr~ must be drawn on the diog~m which is ~ff of this application.~ c. ~e work c~er~ by th~ a~licati~ ma~ n~ be comme~ed before issua~e of Buil~ng Permit. d. Up~ approval of this ~plicati~, the Buddi~ In--tar will issue a Building Permit to the applicant Such permit shall be k~t on the premis~ available for in~i~ th~h~t the work. e. No building shall be ~cupJ~ or ~ in whole or in ~rt for any pu~se whatever until a Ce~ific~ of ~cu~ncy shall have ~en granted by the Building Insp~tor. APPLICATION IS HEREBY NLADE to the Building Department for the issuance of a Buildi.ng Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other apphcable Laws, Ordinances or Regulations, for the cor~truction 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 jrt buildings for necessary inspections. (Signatue~ of applicant, or name, ~f a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. owner of premises ...... ~....~...i ...~..~ ............................................. .~ ................................... Name of 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 Trode's License No ............................................... L tn fa n M ~ ?~ oca 'o o nd o which....pro~oosed__ ~ .--~~°r~ will be done._ ap No.: ........................................ Lot No.........%. .............. Municipality State existing use and occupancy of p~~nded use and occupancy of proposed construction: a. Exisiting use and occupancy ........................ 0'J~/~t ............................................................................................. b. Intended use and occupancy ........ ~ ........ ~. .......................................................... 3. Nature of work (check which applicable): New Building ,, .............. Addition .................. AlteratiOn ................. Repair .................. Removal .................. Demolition .................... Other Work ................. : .................................... 4. Estimated Cost ..... ~..~.~ ~' ~ O , (Description) (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 ....... ,,~..~....~.. ......... Depth ..~..~/...../.. ........ Height ......~...../. ........ Number of Stories .................................. ./... .......................................................................... i... 9. Size of lot: Front ..... ~..Z./.f...~'..~,. .............................. Rear ........ .~....~...~..:..~...~ ............ Depth ...~...~...~...'...~'...?.'. ........ 10. Date of Purchase ....~/.,//~.x~../..~.,~'.. ............................. Name 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 ............................ 'Will excess fill be removed from premises: ( ) Yes (/.~'r~lo 14. Name of Owner of premises ~...~:';:~_~_~_~_~_~....~~ ...... Address ..~.~..~..~.~'.: Phone No~...~..~.~ .~ Name of Architect .................... ~/J ....................................... Address ................................ --'~"- Phor~ No ....................... Name of Contractor ............................................................ Address ......... : ..................... ~ Phone No ....................... PLOT DIAGRAM ~ · · Locate clearly and distinctly all buildings, whether exi.~ting or proposed, and indicate all set-bacl( dimensions from property lines. Give street and block number or description according to deed, and show st~ef names and indicate whether interior or corner lot. STATE OF N~ Y.~C)RI~ ~ ~.~ t S S COUNTY OF ~0 ....... )' ' ' ................................................................................................. being duly sworn, deposes and soys that he is the applicon! (Name of individual signing contracf) above~'iamed. - ,~ _..__- He sthe .0..?....~..~..i...~.. ~ ........................ (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 thor the work will be performed Jn the manner set forth in the application filed therewith. Swam to, before me this Notary Publ,~.~.~...~'~o~u~n~y~ ~...~.Z~.l~.ri~;;~.) .............................. ~ ~dhl~e, State of New YOI~ ~,.~fu~0344963 Suffolk County ~ssion Expires March 30, 19'~t~