HomeMy WebLinkAbout6539-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No Z571 ~ . Date Dec 28 1973
THIS CERTIFIES that the building located at . .h.:~. :'~:....,[./{;..R.$.~.ey..6¥.e... Street
Map No.~?..B.!~z~Y. · Block No ........... Lot No.P~;. ~..o.t.. 6 ..... !!a.~. ~!.~;.u.c..k .........
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ........... .,'.!s~y ..... 3., 19.7.3. pursuant to which Building Permit No. ~.~.3 ~.%.
dated ......... I:;~. ..... ~ .... , 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
issued is .P.r. iT.a.t.e. 9.n.?. f.a.n.i~.Y..q¥.e~.~::t:n, g .......................................
The certificate is issued to . .ql~.a.r.l.e.~..3,c.h.~r.e.t.j~ ....... ¥.~. ~.~. ......................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval .... .N...~ ~ ..........................
UNDERWRITERS CERTIFICATE No..N.: 13.. ..........................
HOUSE NUMBER . 3.~5 ......... Street '.~il..e.y Av..e ................
FOIL~ NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N; Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
CQMPLETION OF THE WORK AUTHORIZED)
N? 6539 Z
Permission is hereby granted to:
at premises located at
........................................................................ .~.~..~..~.~.~L.<,. ..................................................
pursuant to application d~t~ ..................................... ~ ..... ~.~.~ 1~.., and approved by the
Building Inspector.
.....
/V
Building Inspector
TOWN OF SOUTHOLD
Building Department
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This apphcation must be filled ~n typewriter OR mk, and submitted m DUPLICATE to the Budding
Inspector with the following; for new buildings or new use:
1.Final survey of property with accurate location of all bullrings, property lines, streets,
unusual natural or topographic features.
2. Fmai approva~ of Health Dept. of water supply and sewerage disposal--(S-9 form or equal).
3. Approval of electrical installation from Board of F~re Underwriters.
4 Commercial buildings, Industrial buildmgs, Muthple Residences and simdar buildings and
installations, a certificate of Code compliance from the Architect or Engmeer responsible for
the building.
5. Submit Planning Board approval of completed site plan requirements where applicable
B. For existing buildings (prior to April 19.57), Non-conforming uses, or buildings and "pre-ex~sting"
Jand uses:
Accurate s. urvey of property showing all property hnes, streets, buddmgs and unusual natural
or topographic features.
2Sworn statement of owner or prewous owner as to use, occupancy and cond~hon 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 Lan,~ ............
Owner Or ~ners Of Prope~y .......
................................................................ ........... .............
Permit No .~.~,~ Date Of Permit ~.~:~Applicant ...... ~~..~~~
Health Dept. Approval ......... I~.....~ .................... Labor ~pt. Approval .............. l.~.....Lf~.: .......... ~ ......
Underwriters Approval ......... ~..:.]~ ...................... Planning Board Approval ...... ~.f..L~. .................
Request For Temporaw_ge~ificate ........................................ Final Certificate ......... ~~ ...............
Fee Submitted $ ....~.~ ...........................
Construction on above described building and permit/meets qll applicab~ c~s and rqgulations.
//
Sworn to before me this~
..... ......
.....
~ot~ Public .................................... County
lmOi~f NO. 1
TOWN OF SOUTHOLD
BUILDING D~ffARTMENT
TOWN C~RK'S ~FICE
~D, N. Y.
Exomined ~'/'~ ~'~
........................................ , 19 ........
3 ........ ................
Approved ................................. './.~.'., 197..~.... Pemit No.
Disapproved a/c ............................................~ ~ ...............
........................................................... .......... ...........
(Building Inspector)
Application ................... ~
No. ..........
APPLICATION FOR BUILDING PERMIT
Date ......................................... ' .~....., 19...~.~.
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, with
3 sets 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 or areas, and
giving a detailed description of layout of property must be drawn on diagram which is pert 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 pert for any purpose whatever until a Certificate of Occupancy 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 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,
ordinancaa, building code, housing code, end regulations, and to admit authorized inspectors on premises and in buildings for nece~ary inspections.
(Address of applicant)
State whether applicant is owner, lessee, agent, architect~ engineer, general 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
Li~n~
Other Trade's Licen, No ................................................... ~ ~ 7
1. L~ation of land on which propo~ work will ~done. Map No ......................... ~ ............... Lot No.....~ ...................
Str~tandNum~r ~ ~LE~. ~- , ~ ~/~
............................................ · ~).~.~.~ ........ ; .............. , .................................... .~ic..~[~i.~ ..........
2. S~te exi~ing u~ and ~upancy of premiss and intended u~ and ~cupancy of pro~ con~mction:
a. Exi~ing u~ and ~upancy ............................... ~.~ ............~.~.~..~.~ ............~.~ ...................................
b. Intan~d um ond ~u~ncy .................................................................................................... .~. .........................
3. NatUre of work (check which applicable): New Building ....................... Addition.....................~ Alteration ...............
Repair . .. ;. Removal Demolition ........................ Other Work ..............................
4. Estimated Cost /S0 0 ~ /~/~' (Description)
............................................... 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 ............................................................................................................................................
6. If business, commercial or mixed occuoancy, 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 ant re new construct on Front ........... ~.. . Rear ............... Depth ....~..~/.~ .............
Height ................................................. Number of Stories .........................................................................................
9. Size of (or: Front ............. ..'~......~.. ............... Rear 7 5~ Depth ..../...0....-~....
0u~4-
10. Date of Purchase ............... ./...~....~....~.. ......... Name of Former Owner ................. ~ .......................................................
11. Zone or usa district in which premises are situated .....................................................................................................
12. Does proposed construction violate any zoning law, ordinance or regulation: .......... ../~.....O..
13. Will lot be regraded . . .......... =...~..L./.....~.=..:.. Will excess fill be removed from premises:O [ ] Yes [ ] ~
14. Name of Owner of pram,sas .....C~........~.~..c~....~.....F~...~......-~....~.....~.. ............................ ~.~....~........~....~..f~... .................................
-- (Address) (Phone No.)
Name of Architect ............................................................
' -- Al! ldo W,5 ._ _ =(Address) L ' (Phgoe No.)
Name of .................................................... ,.? ........................................ ~ ............................................... ~. .........
(Address) (Phone No.)
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all sat-back dimensions from
property lines. Give street and block number or description according to deed, and show street names and indicate wheth-
er interior or corner lot.
STATE OF NEW YORK,
COUNTY OF ...........................................
............................ ;,'j~;~'~.~'~.~]~}~.~.;~.~.~) .................... being duly sworn, deposes and says that he is the appli~nt above na~d.
He is the .~~ .............................................................................................................................
( ~ntmctor. e~nt, commie of $~r, etc.)
of said owner or owners, and is duly authorized to ~rform orJ~r~ the ~aid work and to make and file this appli~tion; that all
statements contained in this application are true to t~ ~,~o~]~d that the work will ~ ~orm~ in the ~n~r
~t forth in the ap~ication filed t~rewlth. No. 5z-u~ ~,,~,~-~
~ Commls~fl E~i~ Mare , ~
Notary Public~~t~~ ........... ~~~~ ...........