HomeMy WebLinkAbout6751-zFORM NO. 4
TOWN OF SOUTHOLD
BUll,DING DEPA_RTII~2~IT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
NoZ~6.9~ ....... Date ........... Dec ....... 1.1~ ..... , 19.73
THIS CERTIFIES that the building located at . lhntth..}load ............... Street
Map No..Indian. Ne~l~l~lo ........... Lot No... at ..... Pecolllc...N. ,y.. ........
conforms substantially to the Application for Building Permit heretofore fried in this office
dated ......... July.. 21~..., 19..73 pursuant to which Building Permit No..
dated .......... .~I..u....~y .... ~.1~.., 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 ... l~,$vate .orte..f. amtd.~, d~elli~[ .....................................
The certificate is issued to . .I!ar~.ey. I)aazl ....... .0.~.zller ............................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ... NFlt o ............................
UNDERWRITERS CERTIFICATE No. pending ....................................
HOUSE NUMBER ...l ~.~1 ...... Street .. Smith. JJri.v~ ..........................
' ' Buildi~ Inspedltor
!
FOIIM NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMEHT
TOWN CLERK'S OFFICE
SOUTHOLD, H. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
6751 Z
Permission is hereby granted to:
at premises located at .~I~.~..~.~.....[~II~I~..~II~..]P~I~I; .................................................................
.............................. ~..~d.....~.e.~..ea,t.e. ...... ~,X., ....................................................................
pursuant to application dated ............................... .~.....~..~. ....... ..~......, 19..~..3.., and approved by the
Building Inspector.
Fee $~. ~.~..~. ............
Budding Inspecto~
FO~M NO. 6
TOWN OF $OUTHOLD
Building Depa~tment
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 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 end 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
3. Copy of certificate of occupancy $1.00
$5.00
I~te Dec 11~ 1973
addn X
New Building .................... Old or Pre-existing Building ............................ Vacant land ............................
Location Of Property ...,S,.,~,~.~,~,...,~,.,o..a;~..,..?,.,e,,c,.,o,~.~,c, ....................................................................................
Owner Or Owners Of Property .,,,,~,~t,~,y.~.~,,,,,,D,,e,,{t~. .........................................................................................
Subdivision .............. .I...~..~.~.a..~....~..e..C...~.....~..e:.Z'...~. ........... Lot No...~..1. ..... Block No ............. House No.....1..~..~..0
Permit No. ~.~..~..1~ ........ Date Of Permit ~/.~,~/.~...~....Applicant ..~F~f~...~..~.~.['.~.~. .........................
Health Dept. Approval ...... ~..~,~ ............................ Labor Dept. Approval ............. ~...~.~.*. ..........................
Underwriters Approval ...... ~..e...~..d....~L~...~ ....................... Planning Board Approval ....... ~..'..~...*. .......................
Request For Temporary Certificate ........................................ Final Certificate ....... 3[3; ..............................
Fee Submitted $~....%.Og.. ...........................
Sm Rd
Construction on above described building and permit meets al,~ applicable codes and regulations.
Applicant ..... ~4-.~.~,/-L~.~ ............ ,.~,.,~ ,~.,.,, .....................................
Sworn to before me this
........... 1].LI'. day of ........... D. etg ........ ~.~.~ ......... (stamp or seal) ~7~
Notary Public ....................................County
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFIGE
Examined 19..
Approved 19..7j Permit No ...... ~ ........
App'icotion ................
~ ui ding Inspector) /
APPLICATION FOR BUILDIN~ PERMIT
Date ....L~. ~./.~..~....... ~.... ~. ....... ,~..../.., 10.. ~...~......~b
INSTRUCTIONS
a. This application must be completely fille~ in by typewriter o~ in ink and submitted in triplicate to the Building
Inspector, with 3 setg 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 givihg a detailed description of layout ofproperty must be drawn on the diagram which is port of this application.
c. The work covered by this application may not be commek2ced 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 o 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, os 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 appli~ont,,~' - - ~ff2z__,nefne, .f o corp~';;ti;n) ....
(Address of af)pl~ ...... ~ ...........
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 offi~e~"
Builder's License No .....................................................
Plumber's License No .................................................
Electrician's License No .............................................
Other Trade's License No ...............................................
Location of land on which proposed work will be done. Map No.: .......... .~..~ .~..Z. ................ Lot No...2.../. ...............
Street and Number ..././~.~./.~./~...J./..~...~.~......../~.../(..~..,~.. ........... ~....~.~.~'~..~1~).~ ............ '.~...~....~..g..~.l..~-, ...............
Municipality
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 .~..~...-~...L...~.//~/~' ~/
3. Nature of work (check which applicable): New Building .................. Addition ......~ . Alteration .................
Repair .................. Removal ..................Demolition .................... Other Work ....................................................
,~t6~ (Description)
4. Estimated Cost · Fee .. .~J..~/.. ~
(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 ...... ..~.~. .................... Depth ..,~...O.. ............
Height ...... ~ ............... Number of Stories !
Dimensions of same structure with alterations or additions: Front ............ .~...~.: ................. Rear ..~'.~
Depth ....... 3.,~......~. ............. Height .......... ,~...0, ............ Number of Stories ........ / ......................
8. Dimensions of entire new construction: Front .................. /~)~. ........ '( .... ..... Rear .......... ./..O...~..~..~[ ...... Depth ...... ~..~ .............
.... J....~. .......... Number of Stories / .
Height r
9. Size o7 lot: Front ..................~..~. ................................ Rear. / ~O ' Depth .¢~..~...~..~..~....~.....(...~.~.../.
10. Date of Purchase ..,..~..~.,.~.~.~ ...... /.~'.~,.~. .................... Name of Former Owner .,~..~...~.~../.~.?.../4'.~.~T~.. ........................
11. Zone or use district in which premises are situated ~J/~-~./~../~'-~/J/..7'/1~.~:..
]2. Does proposed construction violate any zoning law, ordinance or regulation: ..4~...~. .........
13. Will lot be regraded ...... ~..~.. ............... Will excess fill be removed from premises: (/Yes ( ) No
14. Name of Owner of prem ses ~...~....~..~.~'~..~. ~...~...~ A44r~o, .~.~.~-O4//~: .....................
............................................................... Phone No. 7.~.?
Name of Architect .............................................................. Address ................................ Phone No .......................
Name of Contractor ~../.~.~' ~/4/'~.~]r/,/~/ Address ~'~'7~X/~///Z~- .~..~'~'/'-
..................................................................................... Phone No. 7...~. ................
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
whether interior or corner lot.
STATE OF NEW YORK,
COUNTY OF ................................
................................................................................................. being duly sworn, deposes and says that he is the applicam
(Name of individual signing controcO
above named.
He is the ................................................................................................................................................................................
(Contractor, agent, corporate officer, otc.)
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 contained in this application are true to the best of his knowledge end belief; and
thor the work will be performed in the manner set forth in the application filed therewith.
Swam to before me this
(S'g oture ~'f a~pl(cant) '