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Home My WebLink About6402-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. ~20~ ...... Date ............. ~T.uB.,a... 1.8 .... , 1.9.73. THIS CERTIFIES that the building located at . W/S..~a~..A'~'~ ............ Street Map No. ~ .......... Block No....X~. ...... Lot No.. ~ ... ~ta.S~;, Ma~10~l ............ conforms substantially to the Application for Building Permit heretofore filed in this office ' 6q-ol dated l~laI' 1~ 19.~.~. pursuant to which Building Permit No. 61:t..O2L~. dated ........ pl.a.~ .... 1.~. ..... , 19.72., 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 .. Pr. ivata .one. ,family. dwe. lling & .pl~t~&tOGa~.age ................... The certificate is issued to .ViC~;,o.r.. Np.v. ak ...... .0~!e.r ............................. of the aforesaid building. Suffolk County Department of Health Approval (owner, lessee or tenant) ,fi... UNDERWRITERS CERTIFICATE No. tlOUSE NUMBER. 1'170 .Street. Bay Ave Building Inspector FOF~ NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. N°. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE P'REMISE$ UNTIL FULL COUPLET,ON Or THE WORK AUTHOR,ZE~) 6~0~ Z p~t~ ...................... : ................................ Permission is hereby gronted,t~ /~ ~ . / ,o ........... C....z...:.; .................................................... ,o ..... ~.~..:~: ....... ~:~.......~:..~=.~>....~.~.=:::.~ ................................................ *t premises Iocoted ot .......................... :,. ................................................................................... .............................................. :'": ................ ~/;'~' ....... >"~ ............ pursuant to app cat on aatea ............... ~ ............. : ............... ; ........ , ........ , pP y Building Inspector. $i~ ~ Fee ........................ Building Inspector FOR~[ NO. S TOWN OF SOUTHOLD Building Delm~tment Tower 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 triplicate to the Building Inspector with the following; for new buildings or new use: 1. Final survey of property with accurate location of all bbildings, 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 i'equirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming u~es, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, s~reets, 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 n' 3. Copy of certificate of occupancy $1.00 ~ Date .............· .~.. · · .~. · ,~. · · ... · .L. ,C.l.,~'~.. · · · New Building . / Old or Pre-existing Building Vacant Land Location Of Property .................. ...~....~..~...~..:'. ...... ~-...-~..; ....... ...~....../..-~.,.~.. ............................ (/I V Owner Or Owners Of Property ............. /..~..~...¢<...~...d.......~...,°~..~r. .................................................................... Subdivision .~..~/..~.f ............ ....~ ................... ., ............ Lot No....,,,~,, ... Bl~ock No....,~.. ...... House No.....//,.:?...0 Permit No. ~....~..~...Z.. Date Of Permit ..~.~.~.~...Applicant ..... ..~...~..:..~...~.-~.'. ............. Health Dep, Approval .'.~...:..,,~,,. ............... Labor Dep, Approval .......... i~.i'....,~,, ...................... :: Underwriters Approval ............. ~...~..~ ..................... Planning Board Approval ..... ~ .............................. Request For Temporary .~[tificate ........................................ Final Certificate ......~ .................................. Fee Submitted $ ....~......!~ .................... Construction on above described building and permit meets oil applicable codes and regulations. Sworn to before me this Applicant .............../~/¢/~',........~.....~....~ Notary Public%,'~%-~,~.~' *.:~.,~-,~,,~.~,~,,k~ County (stamp or seal) FOI~M NO, 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE $OUTHOLD, ". Y. Examined ..... , ................................ ~/~' / .?.: , 19..~:.~.' > ~¥¥ O/~-~"- ^pproYed ............................. /..~¢....., 19..~. Pemit No....~..!-./..~...~..~,,~.,~.~.~[.(i..? Disapproved a/c .~ .............. (Building Ins[~ Appl)cafion No ............................ APPLICATION FOR BUILDING PERMIT .., 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, an~ giving a detailed description of layout of property must be drawn on diagram whibh is part of this application. c. The work covered by this application may not be commenced before issuance of Building Permit. d. Upon approve of th s app cation, the Building Inspector will issue a Building Permit to the applicant. Such permit,shall be kept the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy shall have be n 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. ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. (Signature of applicant, or name, if a corporation) (Address of applicant) State whether applicant,is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ...................... ................... :.: ........................ ;: ............................................................................................. :... Name of owner of premises ....... ,~'~;,Z::r.-;:(,O.:~.....~c..C.~:'(c~.~ ............................................................................................... If applicant is a corporate, signature of duly authorized officer. {Name and title of corporate officer) Bu~'~d, er's License No Pluml~'s License No ......................................................... Electrician's License No ..................................................... '/' '2 --- //~/ Other Trade's License No ................................................... 1. Location of land on which proposed w,,ork will be done. Map No .............................................. Lot No. ...................................................... ' ................................................................................... .......... P 2. State existing use and occupancy of premises and intended use and occbpancy of proposed construction: a. Existing use and occupancy ................ ~ ................................................................................................................ ~¢/ b. Intended use and occupancy ..... Nature of work (check which applicable): New Building ....................... Addition ..................... AlterAtion.r-: .......... Repair ......................... Removal ......................... Demolition ........................ Other Work .................................... ~/~z~!.,~.~.,,~ ,~ ~ .... /'~ /Z/O fi*~_D. (Description) 4. Estimated Cost ....;).~2: ................. '.~.'.i...¢r.~,.'::: 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 ..................................... _ . 'f Dimensions of existing structures, if any; Front ...... Z,~,~.. ....... Rear .~.:: ..................... Depth ....~:~! ....................... 7. t - / ............ Height . ] ]- ....... Number of Stories .............................................. , ................... ............................. ,Cf . ./ Dimensions of same structure with alterations or additions: Front ...... 'P.'.. ................ Rear ..... ~..~ ............................. Depth )'~.{.:f Heght., {...~... ' Number. of Stores ,/,, ............................................... ~ ~ ~ { 2~z 8. Dimensions of entire new construction: Fron~..~...~t ~..{~ ........... Rear ........ ../Z ............... Depth ...~:: .......................... Height ....................... {..?..! .................. Number of Stories ............/. ............................................................................ 9. Size of lot: Front .............. .'). ..................... Rear ....... ~.~../. ........................... Depth .....~.~.Q..~,.~ ................................. 10. Date of Purchase ..................................... 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: ........ .'~.../.~ .............................................. Will lot be reoraded ......... ..~...Q ................ Will excess fill be removed from premises: [ ] Yes [ ] No 13. ~ . ,~-- /~. .. 14. Name of Owner of premises ............. ~/.J..q.:/.~,..~.. ......... ~,..~,b;.,~.~ .................................................................................... (Address) (Phone No.) Name of Architect ..................................................................................................................................................... ~/ , . (Aqtdress) ~.~ (Phone No.) Name of Contractor ..~../.G.~':C/....7~....~..{~.[.,~.-~. ............. ..~...~.G./.~..~. ........................... ~.~...~:2.?..~../.~.. .......... ................ {Address) (Phone No.) PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-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. . ....................................................................... being duly sworn, deposes and says that he is the applicant above named, / fName of ~dividprd signing c~ntract)/) He is the ............................. d~~ ................................................................................................................................. (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to ~rform 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 that the work will be performed in the manne~ set forth in the application filed therewith. IERRI LEE E~K /~ ~ ~OTARY pUBdC, Stat~ ~w York .................................. ~ay of ......... ~ ....................... ~aallf~d"rn, S~J~otX-'6uun¥ . /// . [. - ~ ' C', ~ ~mlssl0n Expzres Marcll 30, 19 7H ~ ~/ ~ Notary PubEc, ..~~ .................................... uounw ......................... ~ .............. ~ ........................... .. ................................... (S~m~e of ~)