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Home My WebLink About7018-zFORM NO. 4 TOWN OF SOUTHOLD BU-[[,F)ING DEPARTM~,NT Town Clerk's Office $outhold, N. Y. Certificate Of Occupancy Ni. .Z~ Date ............ Ju~y...1~ ..... , 19~. T~'Is CERTIFIES that the bufldi~ located at Mest- ~re. {)~,~ ........ Street Map N~.l~eydon. F~or~ck No...A ....... Lot No. ~0/pt..t~.. · Southold. ~,~, ..... conforms~substantiaily to the Application for Building Permit hereto~0re filed in this 6ffice dated .......... .Dee .... L~..., 19.73. pursuant to which Building Permit No. '~Ol 8~ · dated ........ Dee" t~ ....... , 19.~3., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which t. hJ~ certheicato is issued is .P:r2~ate..ene. t'a~ ~dval~ul. ~Ath. a~d~L.t~on .............. , ........ The certificate is issued tole,. ]letlbe~,~e~, ..... 0~enel* .............. ' (owner, lessee or(tenant) of the aforesaid building. Sm'folk County Department of Health Approval .. I~.,~ e ............................. UNDERWRITERS CERTIFICATE No. Im~d~ .................................... FO~M NO. ~ TO~N O~ $OUTSOL~ BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N.. Y. BUILDING PERMIT (THIS PERMIT MUST BI: KEPT ON THE P~,EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N.o 7015 Z Permission is hereby granted, to: ~/_~ ....... ~,....~..~,,z'~,~.~., ~.~.~..~~=....,.~~o~ - ~ / ~o ......... ~a~z.r~..c.~~z.~..~ ................................................................... Building Inspector. FORM NO. 6 TOWN OF $OUTHOLD Building Department 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 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: 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 ...... .~?...~./~..~.. .................... New Building ................ Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ...~..~...~,. ............................................................ ~ ....... 0. ........./...' ......................... Owner Or Owners Of Property ~ ~..~// J.~ ~ ~..~.~:~ ~ Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No..~'-~.O..J...~....'~.. Dote Of Permit .Z..~/.~/..~..Applicant ,~..!....~...C'.../.~.~../~..~....f...O...,'~....f......./....~A~..C .... Health Dept. Approval ...._~....~.: .................... Labor Dept. Approval ................................................ Underwriters Approval ./...~..'...~., Plannin~ Board Approval Request For Temporary Certificate ........................................ Final Certificate ......... ~ ........................... Fee Submitted $ ..... ~c)r') ........................ Construction on above described building and permit meets all applicable codes and regulations. Sworn to, before me thi/s~ ........ day of. .'~ ...... .(..~.~.~..... Notary Public .................................... County (stamp or seal) // - Examined ~~ d a. This a~licati~ must be c~pletely fill~ in by ~ewriter o~ n nk and s~mi~ed n triplicate to ~e Bui~i~ In,tar, with ~ ~ of plans, accu~ pl~ plan to ~ale. F~ ~co~ing to ~h~ule. ~ b. Plot ~l~n ~win~ !~afig~ o~ lot and of buildings ~ premises, re ationship to ~joining premiss or public struts o~ ~ areas, and g:v~ a'detailed description of layout ofpr~ must ~ drown on the diagram which is ~ of this applicati~. ~ c. The ~k C~r~ by ~is a~licafion may n~ ~ c~me~ before i~uance of Buildi~ Pe~it. ~ d. Upon appeal of ~i~a~plic~i~, the Building Ink, tar will isle a ~uilding Permit to the o~licant. S~h permi~ ~ shall be ~t on the pr~i~ ~ailable for in~ti~ ~r~h~ ~ ~rk. . ~ e. No buildi~ ~11 be ~cupi~ or u~ in whole or n Pa ~ for any pa~se whatever until a Ce~ificate of ~c~n~ ~ ~11 have been gr~t~ by the Bui~di~ Insp~tor. ~ APPLI~TION IS HEREBY ~DE to the Buildi~ ~ment for the ssuance of a Bui d ng Pe~it pu~ant ~o the~ Buildi~ Z~e Ordi~e of the To~ of ~uthold, Suffolk Count, N~ York, and other ~plic~ ~, O~i~ or ~ R~ul~i~s, for the correction of buildings, ndditi~s or a~terati~s, or for ~m~al or d~liti~, .~ ~min ~ri~. The applicant agr~s to c~ply with all a~licable I~, o~i~es, building c~, h~si~ c~, a~ ~s, a~ ~ admit outhoriz~ ink,tars on premis~ and in ~ildl~ ~ n~sa~ i~tions. (Signature of applicanf, or name, if a co~omtion) State whether applicant is owner,, lessee, agent, amhitect, engineer, general contractor, electrician, plumber or builder.'~,.i Name of owner of premises ............... t~'"~llNIl~lll~ ............... ~'~ll~l~¥"~l~ll~..Jm~ ................. ~ If aPPlicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Plumber's License No..~ .~.~....~..~.~... Electrician's License No. ~.~,......e~...~..~_~'~ Other Trade's License No ............................................... ~:~,~ ~ ~ 'i 1. Location of land on which prPPosed work w be done Map No ,----. Lot No/~ '..'~..~. $-a~/~ ' -- ............................. Street and Number ...~.../...~...~.....~.~..~.....~'~.~.~...~,/.~. ................. ~a~"~..-7.. ........... :i Municipality '" 2. 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 ...................... ~lll~..~l~e......i .................................................................... · Nature of work (check which applicable): New, Building .......... : ....... ^~d~ition .................. A'fteratior~ ............. Repair .................. Removal Demolition (~.~.. ..... Other Work (Description) 4. Estimated Cost ........... ;.: ............ ......... Fee .... ~ ............................................. (to be paid on filing this application) §. 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 ............................ 8. DimensionsDepth ................................ ~ entire new construction:Height ....................... Front .................................... ~¥umber of StorieSRear ........ ............................ ~ ................ Depth ........................ Height .................... ~ Number of Stories .......... .tl ................................................................................... 9. Size of lot: Front ........................................................ Rear .......................................... Depth ................................ 10. Date of Purchase ....................................................... Name of ~9~rmer Owner ........................................................ 11. Zone or use d~stnct ~n which prem,ses are situated .......................~ ..................... ]j.~ ............................................ 12. Does proposed construction violate any zoning law, ordinance or regulation: .~...4:~......: ..................................... 13. Will lot be regraded ............. .-. .......... Will excess fill be removed from premises: ( ) Yes ('X) No 1'4. Name of Owner of premises .................................................... Address ................................ Phone No ....................... Name of Architect ...... ., ....................................................... Address ............................ ~... Phone No ....................... Name of Contractor ~ ~ ~ II~e ~e Address~~..~hone No. PLOT DIAGRAM Locate clearly and distincJ'ly all .buildings, whether existing or proposed,' and ndica~e all.set-beck dimensions from property lines. Give street and block number or description accoFding to deed, and show street names and indicate whether interior or comer lot. , ('--- lc)., -----y' ST^T£ OF NEW ~_ ~/J. ~Z )'S S COUN~ OF ..~~ ', ' ................. ~,~.s-.-~ ........ a~ ...... ~ ~ ..................... -.being duly sworn, d~oses and says t~t he is the applicant (N~me~f i~ividua signing c~trac~ ~ove name. He is the ................................................................................................................... : ............................................................. (Contractor, ag~t, c0rpomte officer,~etcJ of said owner or owners, and is duly authorized to perform or have performed the said work and to ~ke and file this application; that all statements contained in.'t~S 6Pplication.are true to the best of his knowledge and belief; and tha~ the work will ~ pe~ormed in the manner set forth in the appian filed therewith; Swam ta~re me this ~ ~ / ~/ ......... Nota~ Pubmic~~~y ....... ~ ......... ~.;.;...~.~.~.~.~ .................. ~ (Signature of applic~ JUD~ r. ~ H~e~ Public, State of New Ye~ ~8:J~-0~963 Surfak ~un~ ~ 'i