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Home My WebLink About6546-zFORM NO. 4 TOWBI OF SOUTHOLD BUll,DING DEPARTMENT Town Clerk's Office Southold, BI. Y. Certificate Of Occupancy THIS CERTIFIES that the b~flding located at lg]fl l~rzhore~ .Ro~ ...... Street Map No. P~,..~. ~o~o ......... Lot No. ~2,g3,~. · · .~eenpor~...~,~.,. co~orms substanti~ly to the Application for Building Pemit heretofore filed ~ t~ office dat~ ....... ~ .... 7 .., 19.$3. p~suant to which B~d~g Pemit No. ~.~. dated . .~... F ..., 1~3.., was issued, ~d co,ores to ~1 of ~e req~ ments of the applicable provisio~ of the law. The occup~cy for whi~ t~ ce~ificate is issued ~ .P~l~a~e..~. ~1~ .~g. ~.t~. a~$~p~. ~..~ .............. The ce~ificate is ~sued ~ ~stm~e of .~ J.~ .~O~e~ ...... ~e.~ ................. (owner, lessee or ten~t) of ~e ~ores~d bu~ding. S~olk County Dep~tment of He~th Approval .~ ~.* ........................... UNDER~ITERS C~TIFICATE No. ~$Pg ................................... HOUSE NUMBER ...~0B~ .... Strut. ~hP~.~ .~ ......................... ''' l~'~~~g Insp~c~o~ ........ FOR]~ NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT ('THIS PERMIT MUST BE KEPT ON THE P~EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 6546 Z Dote .......................... ~. ..........~. .......... , 19..~ Permission is hereby granted to: ~ ...~.~alt. z. ................................................. ..... 1~8~ ....... ~r~,r.$..aea(~ .......................... ................. ~.e...e.~..o.~ ............. (..s..Z..~......~.:.~.:~: to ...~l~..~n...~£tl~n..~..ma~e..~lter~t£on~..~u..ax&s.ttng..cl~e~ ~ng .............. at premises located at ..~O~i~. ................. ~el~le~..~aap..~.e~oni~...B~y..~tates ............... ............................ ..~2~.....~e...R~a~ ......... ~r.e en~om.~ ...................................................... pursuant to application dated ........................... ~ ..... ~.....~. ......... , 19.~'.~.., and approved by the Building Inspector. FORM NO. 6 TOWN OF SOUTHOLD , Building Department Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions ^. 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: l. Final survey of property with accurate location of (311 buddings, 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 os to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspectmn of buildings or premises, or other pertinent in- formation required to prepare a 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 $1.00 ............... Dote _;fi, New Building ................ Addition '/ Old or Pre-existing Building Vacant Land Location Of Property '~'~t~;d~ ~il~/.~/~l-- /~/ ~',t°~'~c'w,~,,e 7- Owner Or Owners Of Properly .'.~'?..~../.~'~-'-.~.~:...~'.......~/~....--~'.'.~.~.~'~....?.~'~....~..~'.''~.~`'..~. .............................................. Subdivision ................................................................ Lot No ............. Block No ............. House No ............ Permit No ..~...?..,~...~..~,... Date Of Permit ..~"./~.~./.?.~....Applicant ..... ...'~....'~..,~...?...~,......~,. ..... .~..~.~. ........ Heelth ~pt. Approvel .... ~ ...... L~..J~ .................. ~bor ~pt. ~pr~el ..................... 1.~ ...................... Unde~rite~ Approwl ..... J..~%5~k.+ .................... Plenning B~rd ~prowl ....... '.~ ............. ~ .............. [,equest For Temporaw Ce~ificete ........................................ Fin~ Ce~ificete .......................................... su iw a ....................... Construction on ebove described building ~nd per, it ~eets ell e~c~[e-~~ul~tions. Applicant .,~, ............ ' .... ~,.,,,.--L...~ ........ ?...,~ ......................... .~ ........................... ,/ ~ 1~.~ Sworn to before me .............. ...... ...... Nota~ Public ...... Approved , 19..?..~.. TOWN Or SOUT.O,D BUILDING DEPARTMENT Town SOUTHOLD, N. Y. Application No...,,~',.:.~,,.;4;; .............. Disapproved a/c ............................................................................................ APPLICATION FOR BUILDING PERMIT ........ ............. INSTRUCTIONS a. Th~s apphcatlon must be completely filled ~n by typewriter or mmk and submitted ~n trlphcate to the Budding Inspector, ~ 3 sets of plans, accurate plot plan to scale. Fee according to schedule b. Pict Dian showing location of lot and of buddings on premises, relationship to adjoining premises or pubhc streets or areas, gwmg a detailed description of layout of property must be drawn on diagram which ~s part of this apphcat~on c. The work covered by th~s applicet~on may not be commenced before issuance of Budding Permit d. Upon approval of th~s application, the Budding Inspector wdl ~ssue a Building Permit to the apphcant. Such permit,shall be kep, the premise!, avadable for inspection throughout the work. e. No building shall be occupied or used in whole or m part for any purpose whatever untda Certlfmate of Occupancy shall have granted by l he Budding Inspector. APPLICATION IS HEREBY MADE to the Budding Department for the ~ssuance of a Building Permit pursuant to the Budding Ordinance ef the Town of Southold, SuffoIk Dountv, New York, and other applicable Laws, Ordinances or Regulations, for the constructt~ buildings, adlditlons or alterations, or for removal or demohtlon, as herein described The apphcant agrees to comply w~th all apphcable ordinances, building code, housing code, and regulatmns, and to admit authorized ~nspectors on premises and m buildings for necessary inspecti~ ........ ........ Int ~Z (S'gr aure of applicant, or name, ~f ,,~ rporatlon) State whel'her applicant is..°wner',"--..lessee'- ag~t,~ ~-,~;~,,-_ engi_,neer,~;~z..¢.,~_~.. -general contractor, electrician, plumber or buil ........................................................... /0 ................................ ........................ ...................................................... Name of owner of premises .... ~.~.:...~.......~..~.......~../. ...... .~.....~.~.~ ....................................................... If applican{ is a corporate, signature of duly authorized officer. (Name and title of corporate officer) B.ilder's L~cense No .......................................................... ~/ Plumber's License No ......................................................... ,.-r-! 0 ~ Electrician's License No ..................................................... /~,. l~. /St ~'~'~. 5' ~ I O';~her T rade's L,cense No ................................................... ~'~_~ t:: ~ ~/ ] ~ ~'~'~ '- ~' ii ~"/ 1, Location of land on which proposed work will be done. Map No~. .................... :.,~., ................... Lot No ...................... Street and Number /_~z~,~ / t/' //~ ~'¢:~'/~-- ~' ~/>'~ ~' ~~' ............................... '~2" ................................................. ?" ........./ ...... : ................................... Municipality 2. State [;xisting use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ................. .¢..~..9~.........~...~~ ........................................................... b. Intended use and occupancy .............................................................................................................................. 3; ~Xlature of work (check which applicable): New Building ....................... Additio Iteration .............. Repair ......................... Removal ......................... Demolition ........................ Other Work ................................... (Description) 4. Estirr, atedCost~*~¢' ~-~/¢~'~~'............................................... Fee...~....~..'...~. ................................................................................ (to be prod on flhng th~s apphcat~on) 5. If dwelling, number of dwelling units .................Number of dwelling units on each floor ........................................ If gar,~ge, 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 ...................................... , ' ' ne constr i n ~/o /~/o 8. DimE.nsions of ent re w uct o Front ......................... Rear ............................ Depth ............................... Height ......... ./.~.?. ................................ Number of Stories ....................................................................................... 9. Size of lot: Front ...................................... Rear .......................................... Depth ............................................... 10. Date of Purchase ..................................... Name of Former Owner .......................................................................... 11. Zone. or use district in which premises are situated ................................................................................................... 12. Doe!i proposed construction violate any zoning law, ordinance or regulation: ......................................................... 13. Will lot be regraded ............................... Will excess fill be removed from premises: [ ] Yes [ ] No 14. Narne of Owner of premises .................................................................................................................................... (Address) (Phone No.) Name of Architect ................................................................................................................................................... (Address) (Phone No.) Name of Contractor ................................................................................................................................................. (Address) (Phone No.) PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions fr, property lines. Give street and block number or description according to deed, and show street names and indicate whe er interior' or corner lot. STATE OF NEW YOI~I~ ) SS COUNTY OF .~ .~. ~,~.~ .~ .~, .............. ) ..... .......... (Name of mdzvtdual stgnmg contract) ....... being duly sworn, deposes and says that he ~s the apphcant above nam He is the .... ~..k.-.-.-.-.-.-.-A~..' X~..~. .................................................................................................................... (Contractor, agent, corporate officer, etc.} of smd owner or owners, and ~s duly authorized to perform or have performed the sa~d work and to make and hie th~s apphcation; tha statements c(mtamed m th~s apphcat~on are true to the best of h~s knowledge and behef, and that the work wdl be performed m the ma~ set forth m the apphcat~on hied therew,th y u u, .~.~-~~,~..l}~;~h ~[y ~ ................................. (Stgnature of apphcant)