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Home My WebLink About7035-zlrO~M NO. · TOWN OF $0UTHOLD B~DI~G DEPARTMENT Town Clerk's Office $outhold, N. Y. Certificete Of Occupancy conforms substantially to the Application for Building Permit heretofore fried in this office I-/ dated ......................, :].9 .... pursuant to which Building Permit No.'Tt~........ dated ....................... I-! b~¢, 19.7.5 .... , 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 'Bo/~ 7 "( ~ ~ l~ The certificate is issued to (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .................................... UNDERWRITERS CERTIFICATE No ............................................. HOUSE NUMBER ....... .~. ?.0... 8h'eet...~..~..~..~.!~.....~..~-..~...~. .... ?.0..~...~. ...... Bui]dlng Inspector IUILOIHG FER~IT N°. .,~5 (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) ,/ at premises located at .............. .m,~-..~.~.,~..... ..... ~' : .......... pursuant to applicati°n dated ........ ./....~/~..~.. ......................... , 19./.I.'., and approved by the Building Inspector. FOlt~l NO. 6 TOWN OF SOUTNOLD 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 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 certifioate 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 os 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: l. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use $5.00 3. Copy of certificate of occupancy $].00 Dote .,.(~.. ~:~.d.f...~...Z...,~..~.~ .~.,...~.. ......... New Building ................ Addition ...... ..~,,.,... Old or Pre-existing Building ................ Vacant land .............. Owner Or Owners Of Property .~..ZZ~...~'.~. ~.. i...~4~ ,(' ~'Z~: Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No....-~'~.cq...?..~..~.~... Date Of Permit~...~..(...../~.~./.~..~.~Applicant ~...-~.~.~...~'.L..~........~.~..~,~...,~...¢.~.~X~.. ....................... Health Dept. Approval ..................... ...~..~...?.... .......... Labor Dept. Approval ...................... ..~.....~.~.. Approval ................................../L/ ~ ....... Planning Board Approval ................ ..~.....~.......: ....... Underwriters Request For Temporary Certificate ........................................ Final Certificate ~ Fee Submitted $ ~ ~ Applicant ..~./,.I.~.~.[......,~,..~..~...~...~.:..~. ......................................................... Sworn to before me this // ~_'~ ~ day of -"~.-~.~.~~ ~ (stamg or seal) ~ PuN ..... Coun~ ~ ~TARY pUBLIC, S~ate of New York SOUTHOLD, N. Y. Exomlned ....... .~. .~..~ ........... 1~.... Application No .......................... Approved .........../.d~./~,~ ............... , 19~..... permit No.~...~..~.........~.. ..... ~.O ~-~'5-~ ......................................................... .................... ........ ..... . INSTRUCTIONS o. This application must be completely filled in by typewriter o~. in ink and submitted in triplicate to the Building~~'~ Inspector, with 3 sqt~s of~plans, accurate plot plan to scale. Fee accordi.ng to schedule. · ' b. Plot plan showing lOCation Of lot and of buildings on premises, relationship to adjoining premises or public streets or ~ areas, and giving a detailed description of layout ofproperty must be drown on the diagram which is part 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 ssue a Bu ding Perm t to the applicant Such oerm t'~,' Shall be kept on the premises available for inspection throughout the work. · r ~ e. No building shall be OCcupied or used in whole or in part for any purpose whatever until a Certificate of Occuponcy~ shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the~'v 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, buildin~ code, hous~code, and reau ations and to admit authorized inspectors on premises and in buildings for neces~a~]y'1))~i~"ections, d~,~,~ ' ' .~ ................. .. ........... : ............. (~,~J re~' ~' '~c~ nt) ' .~x.~... State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or build'er. 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 Trode's License No ......... ..'. ................................... ' ~'~ LOCation of land on which prOPosed work~.~ be done. Map Nc~:~=~-T..r~...~.~:' '~"~ .............. Lot No. Street and Number ..... 'a,~'-"~'~"'"' '~"-~*~'"~~'~.-..' '~: ......... .~ ..~~ 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. NatUre d~rg~ork (check which applicable): New Building .................. Addition ....~.... ........ Alterotion ................. ]~' ~." Repair .................. RemOVal .................. Demolition .................... Other Work ...................................................... ..~. ./2/ ~ ...(Description) 4. Estimated Cost .............. .~...~...~....-T...: ............. Fee ...~......~.... ..................................................................... (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 ............................................................................................................................................. If business, com~__e~igl or mixed c~ccupancy, specify, ~nature and extent ca( e~,c:h type of use~/_~.~ 7.6' Dimensions~s~ructures, if any: Front ....~.~..~ ...... Rear ....~..4~.~ ............... Depth .~:L.~......i .... Height .../....~.....-....- ..... Number of Stories .......... ~ .............. ~ ........................................ ~i~..' ............... Dimension~of some structure with olte~on, s or additions: Front ..~'....~ ............ ~ ...... Rear ....................... Depth .....~.~.....'. .............. Height .../....c......~...,~.Number of Stories ..~:~..~.~ ............. ~m/~c./:~ ~,¢./~_~/:~'~ Front A~/4 -Rear..j~e/..~m). Depth .~...~.. 8. Dimensions ot ~ new c~struction: ..x.~e:. ~a ...................... ............. .......... Height ...-/-..~Zr.....: ...... Numbe.rof Sl:~r. iqs ...... ~../.4~;. ............................................................................... : .................. 9. Size of lot: Front ...~.....~'...~.....~.........~....~"e~6r*. ........................................ .~Oepth ................................ 10. Date of Purchase ...~).~----...~... ....... /..~.~..~..: ......... N,a4ne~of Former Owner ....,.~..~;~/J~',~.. ................ 11. Zone or use district in which premises are situated ........... (~...'.......~'~"a~.~-d.:~.,7,'--~./,el~..,~ ............................... 12. Does proposed construction violate any zoning Iow, ordinance or regulation: ...~.~)...:. ....................................... Will 13. Will lot be regraded ...... ~.~,i).:., ........ ~,~c.ess fill be removed from premises: ( ) Yes ~"No 14. No me of Owner of premises ..,~/~?,8/x~.r,/.. ~'~. ~=-~:'C,~ ...... Addree~ss~..~~' ..~-..--~.a...~. ........ ee~'one N .°~'. .7... '~T-.- ~'' '~-.'7' ~ ' / Name of Architect ...................... ~Phone No ....................... .............................................................. Address C"-~/c~--'~, Name of Contractor ............................................................ Address ................................ Phone No. ...................... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-bock 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. / STATE OF NE~./~O.I~/~// ~ c S COUNTY OF .................... ../. .......................................................................... being duly sworn, deposes and says that he is the applicant (Name of individual signing controc~ above named. He 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 contoined in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the applicat~en filed therewith. Sworn to be.~ me this -- .......... ,, NotarY Pu bi 'c'~//~--~~ *~' ~n~ "' ~;"i'~;~')' ............................. ~otory Pubic ~,' KEN · e.o. rnrnia,ie~ #~'i ~ ouffolk Count/ ~ res Mar~ 30~ APPRO,,¥ED, AS NOTED D^TE: ~¥' ? /7 NOTIFY BUILDING DEPAR'~MENT AT 765-2660 9AM TO 4PM FOR REQUIR- ED INSPECTIONS: 1. BEFORE BACKFILLING FOUNDA- TION OR'"START FRAMING 2. BEFORE COVERING PIPELINE 3. FINAL WHEN JOB COMPLETED NOT RESPONSIBLE ~FOI~ DESIGN OR CON-