HomeMy WebLinkAbout7549-zFOEM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No...~. ~ ~& Date ..~...,~_~ ..c~-' 19..~.~
conforms substantially to the Application for Building Permit heretofore filed in this office
...... ~.. ~.~ . .., 19 ~ pursuant to which Building Permit No .........
dated
dated
....................... , 19. , was issued, and conforms to all o~ the require-
ments of the applicable provisions of the law. The occupancy for which this ce~ificate is
............ ..........
(owner, lessee or ~enam)
of the aforesaid building.
Suffolk County Depar~men~ of Health Approval
UNDERWRITERS CERTIFICATE No...
cl,~ ~
BUtLDi~ mT
(THIS PERMIT MUST BE .KEPT ON, THE'*I~EMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED~)
N? 7549 Z
Permission is hereby granted to:
~;r...~_.....~...c....~.o...ke. ~...~ .............
......... ~l~m~ .................................................
to ..~}.~.~..~L~n~.~U,.~L.o~...~,e.~..~'l~m.:~e~.e~e..~..~.}A~M ............... i ...............
at prembes located at ...~/~..~2L~I~i~.~I~I{ ...................................................................................
................................................... ~la, t,.tJ, iAlStI; ........ ~I~3[~ ....................................................................
pursuant to applicatio~ dated ............................... ~ep4)-....~....., 19:.l~., and oppmyed by the
Building Irapector.
u Idlng Inspector (
FORM NO. 6
TOWN OF SOUTHOLD
Bu;Iding Department
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
instructlens
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 cfll 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 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: I. Certificate of accupancy $5.00
2. Certificate of occupancy on pre-existing dwelling or land use $5.00
3. Copy of certificate of occupancy $1.00
Date Z2/5/?L~
New Building ................ Addition ....X. ........... Old or Pre-existing Building ................ Vacant Land ..............
Location Of Property .~.~.~b...~`~`~e~.~.~`~`1~.e~`qD~.~9..~`~.~.~.~.~.~`.~.~..q~..~.~.*~ ..............................
Owner Or Owners Of Property ....... .R.P..}.~..r-.~....~..'.....R..9.~t.~.h..]-. ..........................................................................
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No. ~.~.c~.~ ........ Date Of Permit ....9.../.~.~/..?..~..Applicant !.~.o...b.~.~...~.t,..B..o?fe..h.~ ............................
Health Dept. Approval ............................................ Labor Dept. Approval ................................................
Underwriters Approval .............................................. Planning Board Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate ..........................................
!k~ no
Fee Submitted $ ......... ~.~.:.>/. .................
Sworn to before me this
..... · ~.~...~. day of. ~,~r~,.~..~......../.i .~..:~ (stomp or seal)
Application No..?.....~.....~...~.. ............... ~
(Building ~ector)
Date ........ ~.;..~. ............. , 19 .
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, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this application.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Building ~nspector 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-. I
shall have been granted by the Building Inspector.
B .A,P,.PLIC~ATIO~N.IS HEREB. Y.MA~DE to ~tl~e B.uil,di,ng~ D_ep,a, rt~ent for the issuance of a Building Perm t pursuant to the
uumng Lone urainance at the /own or 3outhola, :~ul'rolk ~ounty, 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, ordinangesT~uilding code, housing code, regulations, and to
admit authorizedinspectorsonpremisesandinbuildingsfor ne~ssar~.~._~,Jnspections.,~__~ ~ and
................... (~ ,~, ,~ ~,~- __~
/ (Address of applicant)
State whether op~cont is owner, le~ze, agent, architect, engineer, general contractor, electrician, plumber or builder.
..... ....................... .........................................................................................................
Name of owner of premises ..~.~r::.~ ......... i.~'.'~.~,./~.~f),(.~] .......................................................................................
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No .....................................................
Plumber's License No .................................................
Electrician's License No .............................................
Other Trade's License No ............................................... /hc,,x .
Location of land on whb:Jo proJ)osed work will be donaCx Map No.: ....................................Lot No......~.. .................
Street and Number ..~..I..~../.~..~.~.....~
-- '~' ......... "'"'"'"'"'"""~"'"'"'Municipality""'"'"'"'"'"'"'"'
State existing use and occupancy of,~ises and intended use ({nd occupancy of proposed construction:
o Exisiting use and occupancy ...~....~z:.?. L~..~
b. Intended use and occupancy
3. Nature of work (check which applicable): New Building'. ................. Addition ..../~ ......... Alteration ................
Repair ............. ~. Remova ...... Demo t or. ................. Other Work .................................................
~-'~' ~, ,-~ (Description) '
,.~ '~: ,~^,~~;/K"~ ~'~ ...Z
4. Estimated Cost ..~M.~...~.~ ..................................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 pature 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 ................................
8. Dimensions of entire new construction: Front ................... , ................ Rear ............................ Depth ........................
Height .................... Number of Stories .............................................................................. '..; ....................................
9. Size of lot: Front ...~.~ ........................................ Rear ..~ ..................... ;: ............ Depth ................................
10. Date of Purchase ..... Z~ ............................~ame of Former Owner~ ....... ::'.:.:~ ......................................
11. Zone or use d~str,ct ,n wh,ch premises are s,tuated
.......................... ~ ............ ~....,,.... ...... . ;:"'"'~': .............................
12. Does proposed construction violate any zoning law, ordinance or regulation: .~.j~f.......Zv.':....?..: ...........................
13. Will lot be regraded ............................ Will excess fill be removed from premises: ( )'Yes '".~. ( ) No
PHone No .......................
14. Name of Owner of premises .................................................... Addre~ ................................ " ' ' '
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 from
property lines. Give street and block number or description according to deed, and show street names and indicate
whether interior or corner lot.
S-FA-F F,-~(Df'xN EW.. YORK,
cou~T,y DF-~..~:~...~'
........... ..':-~...~.R~,t.¢...~.:.~. ...... ~%.'~.V~¢.¢.-, ..................................... being duly sworn, deposes and says that he is the appHcam
~(Name of individual signing contract)
above named. '
He is the ~%
................ T' .......................... ~'d;'~'f ;; ~f;;;' ;~;;~',"~'&';~';g~;' ;~'f[~;Z ';';~'.'~ ...............................................................
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 a~e to the best of his knowledge and belief; and
that the work will be performe~ in the manner set forth in the appli~ation~led therewith.
Sworn to before me this
~d~-~-, - ~~~ ~9 ~ ~ ' ~/ /
........................ aay o~.~...~.~
Nota~ P,b]~,,,:~.~..~~ ...... Cou,~ ..................... .J.~'. .................. L..:Z:g.~ .....................................
- ~ ~ ~ ~ J (Signature of applicant)
-' ~( ~.~~ v