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Home My WebLink About6762-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Offieb Southold, N. Y. Certi[icale O[ Occupancy No. Z~I+06 ...... Date ............. August..2]~ .... , 1973. THIS CERTIFIES that the building located at . '23~' Dougla.s .Road ....... Street Map No...X~ ........ Block No...)LK ...... Lot No .... :I~. · O~ien'~ ................. conforms substantially to the Application for Building Permit heretofore filed in this office dated ........ Zu~y. ~2.~ ..... , 19. '73 pursuant to whi6h Building Permit No..-676a.Z dated ........ July.30~. ..... , 19.73., was issued, anal conforms to all of the require- merits of the applicable provisions of the law. The occUPancy for which this certificate is issued is ... P~ivat~ 'one' .far~t.ty. dwelling ..................................... The certificate is issued to .... Edward..biostr%eeh ..... , ............................. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval UNDERWRITERS CERTIFICATE No ............................................. HOUSE NUMBER .... 23~- ...... Street .... .Dout~tas:~, ttoa~l ....................... ................................................. Ori~n~ ........................ .;Building Inspect~ FO~ NO. ~ TOWN OF SOUTHOLD . BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N'. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE Pi~EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 6763 Z Permission is hereby granted to: ~.~.. ~.. ~L.~..~.~.~b~.e~ .......................... ....... ~..o.~t~;~...t~ .......................... ~ ................. ............ ~.~.e~t, ................................... i ................. ~o .b...u.~.l..~....n..e. ~...~.~..q~...(.e~:Lt ~.~)....~n..e~ s.ti~.. ~l~ Z~ ............................................. at premises located at ....~.....~J~l,~..~,~.~j ...................... '~ ........................................... ......................................................... ~:~;Le~.f, .............................................................................. ~ ......... ~u~ O pursuant to application dated ............................... ~. ....... ~ ........ .~...., 19~.,~..., and approved by t~e Building Inspector. ~' ' Buildi~'~ Inspector TOWN OP $OUTHOLD Boilding Deim~fmeaf Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and sdbmitted 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 Ibuildings, 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 UnjJerwriters. 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 ~ses, 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 as to use, o~cupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildinj~s 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 eccupanc¥ $I.00 ; Date New Building .................... Old or Pre-existing Building ........................... Vacant Land ............................ Location Of Property ,~.~).~' ~?fic~fg £x-/F~' ~fi) Owner Or ~ners Of Properly .~Q:/~Z~/~....~...~.L~.~ ....... ,~'.~:~;;~.(,.~ ................................... Subdivision ................................................................ Lot No ........... ~.. Block No ............. House No ............. ....... ......... ........ ....... Heolt~ Dept. Approv~l ............................................ Lobar Dept. ~pprowl .............................. ........... Underwriters Approval . Planning Boa~d Approval Request For Temporary Ce~ificate ........................................ Final Certificate Fee Submitted $ ~' c~ Construction on above described building and pe~H~meets all ~icabl~, c~es ,gnd regulations. App c,nt ................ ........................................ Sworn to before me this of Notary Publ, l,c ...... ;.:~;~k~./..c~',.-f,~ County JUDITH T. IBOKEN Natary Pubh¢, State of New Yor~ ~ Na, 52-0344~63 Suffolk Count~ ¢omml~*ion Exp~re~ M~r~h ~9, (stamp or seal) TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE .~. SOUTHOLD, N. Y. Examined ..~ ......... , 19....~.... Approved/~........':....~ ........ :.1. ............. , 19.?...~... Permit No..~...2(.'~-...~..... ....... INSTRUCTIONS Application No ............................. Date~ ~,2.~ ......... ............................... , (Name and title of corporate officer) Builder's License No ..................................................... Plumber's License No ................................................. a. This application must be completely filled in by typewriter o~ in ink and subm tted in tripl cate to the Building~ Inspector, with 3 sets of plans, accurate plat plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or pub c streets o~ areas, and giving a detailed description of layout ofproperty must be drown on the diagram which is part of this application. c. The work covered by this application may nat 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 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, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. g app ~cant, or name, .f a corporation) ~~ ~ . (Address of applicant) ................... State whether applicant is owner, lessee, agent, architect, engineer,'~jenerol contractor, electrician, plumber or builder. .............. ................................................... Name of owner of ,. ........................... ~.~.~F~../~.~. ........................ .~. ............................................. If applicant is a corporate, signature of duly authorized officer. Electrician's License No ............................................. Other Trode's License No ............................................... ~,~ ~ 1. Location of land on which proposed work will be done. Map No.: ........................................ Lot No ......................... Street and Number .~ .................................................................................................................. /~1~..~....~..... Municipality 2. 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 ~.. V/~/~/~ ~..~..te/~ ..~//~~_ 3. Nature of work (check which applicable): New Building .................. Addition ....~....p...~..c.~ Alteration ................. Repair .................. Removal .........: ........ Demolition .................... Other Work ..................................................... 4. Estimated Cost ~) Fee J '~ (Description) ' (to be paid on filing this application) §. 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 ....... .~'.~..../~...,~...~....r~..... Depth ..... .~...~. ........ Height ...... /.~..../. .......... Number of Stories ........ /. ...................................................................................................... Dimensions of same structure with alterations or additions: Front ....... .~..?...: ................... Rear ....~.~....: ............. Depth ...~.~./...~..~'.~...~...~...~. .... Height ......... /.~...~. .......... Number of Stories ........ ~. ..................... 8. Dimensions of entire new construction: Front ................................. ... Rear ............................ Depth ........................ Height ....~ Number of Stories ........ ~1' ........................................................................................................ 9. Size of lot: Front .............. /.~:~..~ ................................ Rear ......... ./...O~....t. ...................... Depth ..../.~....~..~ ............... 10. Date of Purchase ...... ~..~/~...y. ........ ./.~.~...~. ................. Name of Former Owner ..~..~.....Y~...~.~.......?...O:..~..~...~..~....~'...~.. ......... 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 regraded . ...... ~..~. ............. Will excess fill be removed fromm premises; ( ) Yes ( ) No 14. Name of Owner of pram sea ~.. ~...E./L/R.~......~.~.~..~.... Address/q~e~.~.*.~..~... ..... .N..~.... Phone No~./~.'...7....~..7..~..0.~.p- 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-beck dimensions from proper~ lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. I N'T$1~I o R F~o~T ' STATE OF NEW YOR~K^ .,. [cc /~' COUNTY ...... .................... · .~...~,~-~,-L....~,~.~O-~'~ .............. being duly sworn, deposes and says that he is the (Name of individual signing contract0 above named. He is the (~..k~..~,..?~..~:~, ............. ................................................................................ (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make end file this application; that all statements contained in this application are true to the best of his knowledge and belief; and thor the work will be performed in the manner set forth in the application filed therewith. Swam to before me this ........ of ........................ , C'/ Nota Pub,c, Co, nty .... ......................... (Signature of applican~'- T£RRI L~ rd. AK flOTAR¥ PUBLIC, Stat~ o! New Yo~ No. 52 Qaalified in Sutf~k County ~ .' .~l~ission Expires March 30. t9