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HomeMy WebLinkAbout6708-zFORM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Of[ice $outhold, N. Y. Certificnle Of Occupnncy No..Z~t~38 ..... Date ............ l~ep~;..1.'~ ......., 19 ~. THIS CERTIFIES that the building located at Cle&l'~$ew. Ave ............ Street Map Nc~?Ta ........ Block No ........... Lot No..~... Sontho~Lcl .N,~.~ ............. conforms substantially to the Application for Building Permit heretofore filed in this office dated ............. July...~, 19.?~ pursuant to which Building Permit No. dated ............ Ju.~r .... ~., 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 . Pr.$vate .omc..£am~y. d~ll~l ....................................... The certificate is issued to ... I~enJ~n. ~ .F~or. ence..V.ol~kl ...... ~.r.~[ ....... (owner, lessee or tenant) of the afor.esaid building. Suffolk County Department of Health Approval .. I~,R. ............................. UNDERWRITERS CERTIFICATE No ..... ~.~g ................................ HOUSE NUMBER ..l~O ....... Street ...Cl~&lW~... Ave ..................... Building Inspector FO]~iV~ NO. 2 TOWN OF SOUTHOLD~ BUILDING DEPARTMEN~T TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING prERMIT (THIS PERMIT MUST BE KEPT ON THE PJ~EMI~ES COMPLETION OF THE WORK AUTHORIZED) UNTIL FULL N? 6708 Z Permission is hereby granted to: ' ..,~I~..'V.o~Insk~t.....A/.C....~1..-..~oli~k~t · .H. ~.~ .~...~.~.r..i..~.~. ............................................... to ...~lll..~..add.l.~leu..c~...ex£a~g...~w.e. lltug..: ............................................................ at premises located at ....:..,T~.~...~ ....... J~,]~,...~.~.O ................... ; ........................................................... ............................... g.~:.~.~.e.~..A...~. ............... ~..u.~ ~. i~.~ ................................................... : ..... ~ ~ , ]9...~.~., approved by pursuant to application dated .......................... T..~.~.~...~t .......... , and the Building Inspector. Fee $....~..~,~10 ......... TOWN OF $OUTHOLD Building Department Town Clerks Office ~uthold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and sgbmitted in duplicate to the Building Inspector with the following; for new buildings or new u~se: 1. FinoJ survey of property with accurate location of all bui dings, 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 Rbsidences and similar buildings and installations, o 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 ail property lines, streets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, d~ccupancy 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 occupancv $5.00 2. Certificate of occupancy on pre-existing dwelling b~: land use $5.00 /~/ 3~ Copy of certificate of ~ccupanc¥ $1.00 ..//,~J 'Date New Building ................. ~ JDld or Pre-existing/J3uilding ...... ...~..~.:, ......... .Vacant Land .......... ~ ................ Location Of Property ~/~,.~(~J~...:~....,~, ~..~ ' ~'. /..)/_ ~- //~ /~' ~ ...... ~...~..~... ................ Owner Or ~ners~ .~ ,/.4~Of Property...~'"~~:"'"~~~/~ ~ ............................... Permit No. ~..~;..Z. Date Of Permit ,~Z~..Applicant ..~...~~.~ ..................... Underwriters Approval ...~ ~= :~: :'j ...................... Planning Boa~d Approval ........................................ Request For Tempora~ Ce~ificate ........................................ Final ;Certificate Fee Submitted $ ~ ......................... Construction on above described building and 9ermit~ meets all applicable c~es and regulations. ./. Applicant ............ k ....... ........ I.e. o, ............. o, Approved TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. 19.7.~..... Pemit No....~.....Z..~....,~,,~ Disapproved a/c ..................................................... Date ................. , 19 ..? INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building nspector, w t~ 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Pict plan showing location of lot and of buildings on premises, relationship to ad oining premises or publ c streets or areas, anid giVicn, g a detailed description of layout of property must be drawn on diagram which is part of this application. ~., 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 part for any purpose whatever until a Certificate of Occupancy shall have bee 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, Suffoik~ 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. State whether app~xa.nt,. ~v,,ner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder~ ........ .......................................... ....... .............. ......... " ................................ O owner of premises ...~.~1~..~......~....~.~/~ ...... U~ ................................ If aafolical~t is a corpolsaCe, sigr)at/[/re ~:1~¥ au~o. rized officer. ~. ............. (Name~f~d titl~'of corp6rata officer) ~' 1. Location of land on whic~g~j~r,gposed w, ork will be/e~ne. Map No.: ..~..~;..~. L,.ot No....~w..../~.. ......................... Street and Number ....... ~,~.~/~,~.....~ ....... ~l~. ...... .~./.~...'....~//.~.. ........................... / MunicipaliW 2. State existing use and occupancy of premises anc~ intended use and occurmncy of proposed construction: a. Existing Use and occupancy ......... ,..~ ~. ............ ~ .............................................. b. Intended use and occupancy ........ ~ .......... ~ ....... : ................................................ 3. Nature of work (check which applicable): New Building ....................... Addition ...... ~ ....... Alteration ............... Repair ......................... Removal ......................... Demolition ........................ Other Work .................................... ~e (Description) 4. Estimated Cost 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 occupancy, specify nature and extent of each type of use ..................................... 7. Dimensions of existing structures, if any: Front .....~.~..~...-.. Rear ..............~m?....... Depth ........ ~..,.,~.. ................. Height ..................................................... Number of Stories ./.. / / Dimensions of same structure with alterations or additions: Front ...... ~..,~. .......... Rear ............... ~'s~.. ................. Depth ............. ~..,~...~. .................... Height ......................................... Number of Stories ........................................ .......... ~ ......... Depth ........ .~.... .................. 8. Dimensions of entire new construction: Front ...... .,,.~.. ........... Rear Height ................................................. Number of Stories / / / 9. Size of lot: Front .......... /..(Z..([.. ................. Rear .......................................... Depth ........ ~.~..~. ............................... Height .................................................... Number of Stories ...................................................................................... 10. Date of Purchase ...... Z.~.~...~.. ............... 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: .~ ............................................... 13. Will lot be recjraded ~ ..... .~ ....... :. Will excess fill be_,l~e,~noved fr, e~n p,r~mise,,~: [ ] Y.J~ ,el ~ 14. Name of Owner of premises ...,~i~tt~....~...~...~......~:~_~.~Z'~.~'.....~,~...~...:.~.-..~--.-7~ X./ ~I" I/V/~. I ~, . /.I III I /.,,T" ' ~ (/A ,,~ _ ~ · 4 .I... ~ (Ac~lt-dJ~ . ~,.~. (P_hc~re No.) Name of Architect .....~t.~./~'--~.~Z~.-,,...,~,~./~....~.~.....'....~L~...'....~...?,, ~ --~ ( d~res~ . , (Phone) Name of Contractor~/~g.~~:l~., ......... ~~ ....... ~';/.~.... ......... ~'~- - ~ - · ' (Address)' / (Phone Ng~ 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. I STATE OF NEWY~R~[ ~ ~ ) ......... ............................................................................................ .............................................................. ~ (Co~t~ctor, ~, cor~te officer, ~.~ o~ said owner o~ owners, and is duly authorized to ~rform or have ~rformed ~he said work and to make and file this application; that all ~tatements contained in ~s application are true to the ~st of ~ knowled~ and belief; and that the work will s~t ~or~ in ~he application filed ~herew;th. ~U~ITH 7.