HomeMy WebLinkAbout7184-zFO~M NO. 4
TOWN OF SOUTHOLD
BUILI)ING DEPARTMENT
Town Clerk's Office
$outhold, N. Y.
Certificnte Of Occupnncy
No..Z~9.82 ..... Date .............J.~.~.... 2.8. .... , 19..~..
THIS CERTIFIES that the building located at ... C~l~lin~l. Dr.l~m ........ Street
Map No. 14att.~t.. Block No ........... Lot No..36 ..... ~4~tt~,~;~...~.:~. ? .......
conforms substantially to the Application for Building Permit heretofore filed in this office
_.__.__.~_dat~ed ........... Apr,.],- - -~6, 19. '7~ pursuant to which Building Permit No. 71~l~Z..
dated ........... Apl':[1-..~6., 19 '7~', 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 . Private. one. fa~il~. ~lwelLtn[ .vi.th. an .addi.tlo~ ..................
The certificate is issued to . J.~hn. A,. L~zio ..... ~r ...........................
of the aforesaid building.
Suffolk County Department of Health Approval
(owner, lessee or tenant)
,.B,.. .................
UNDERWRITERS CERTIFICATE No...Ii,R, ......................................
HOUSE NUMBER ..... $~00 .... Street ... Car~ .D~® ......................
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined ..............b...., 19'Z~'/' Permit~' No.?/'d~//'~"-'--Z
pro,d ..................... ': ........ ::. ....... , ....
· . .........
Application No .....................
INSTRUCTIONS
a. This application must be completely filled in by typewriter o~ 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
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 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, Suffo k County, New York, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or a terat ons, or for removal or demolition, as herein described.
The applicant agrees to Comply with all applicable laws, ord nantes, building code, housing code, and regulations, and to
admit authorized inspectors on premises and in buildings for necessary inspections.
(Address of applicant)
State whether appli~ner,, I.~ee, agent, architect, engineer, general contractor, electrician, plumber or builder.
................................. ........................... . ........ :. .................................................................. .....
Name of owner of premises ........ ~....~./......~...I. ...... .~.....~..~...~...~....~.. ....................................................................... iiii.
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 ...............................................:) No.:~ ~
Location of land on which proposed work~ill be done. /v~al .................... No
Street and Number .~...~..~:~O .........................
......................... C,;,aeo. z,g..a-.Z:......~...,~.z.~ ...........................
Municipality
State existing use and occupancy of premises and intended use and occup?ncy of proposed construction:
a. Exisiting use ond occupancy ......... /.f. ff~'~......~~...: .......................................................
b. Intended use and occupancy ......... ~....~,Z~..~..~ ........ . .~...~..~...~... .......................................................
3. Nature of work (check which applicable): New Building; ................. Addition .................. Alteration ..................
Repair .................. Removal .................. Demolition ........ . ........... Other Work ......................................................
~C~'2 .~;/? Fee /~'"~, c_._~ (Description)
4. Estimated Cost ............. ~...~ ............................................................. ; .............................................................
(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 on~[ extent of each type of use ............................
7. Dimensions of existing structures, if any: Front ........................... Rear .............................. Depth ....................
.eight ...~.~..' ............ Namer 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 ......... ./..r..~y'...~./~ ............................... 4....~-~. ................................. /'"'~:-' ..............
9. S,ze of ~ot: Fro. t ....... ----~'~'~'~:' .............................. (///Rear '"'~'~'~":~-/T;Z" ......... Depth ...~.~.~.:..)..~..:~.;; .....
]0. Date of Purchase ......... ~t.(~.,~.,9.~- ............................. Name of Former uwner .............................. r ........ ~.~,~ ........
1 ~. Zone or use district in whic~h~/' ~"premises are situated .............. ~,x~ ~.~ .~..~. ..................................... J ..............
12. D~s proposed construction violate any zoning law, ordinanc~ or regulation: ........................................................
13. Will lot be regraded' . ........ ~ .......... Will excess fill be remov~ from praise: ( ~ ' ( } No
]4. Name of ~ner of premises '"~"'~'"~'~'~'~~1~ · ~ .................. ~. A~re~ ..~.?..~ ....... "...v..~.~ No .......................
Name of Architect .............................................................. A~re~ ................... , ........
,.~. o~ ~o,,r.~,o~ ...~...~.,..d~:,..~ .................. ~re~~;.~.C~,"o: ......................
PLOT DIAG~M
L~ate clearly and distinctly all buildings, ~whether existing or proposed, and indicate all ~t~k dimensions from
pmpe~ lines. Give street and bilk number or description according to de~, and show stm~ names and indicate
whether interior or corner lot.
STATE OF N~Z~ {SS tt~ /
COUN~ O~,.:..~~...:~ "~d~oses and soys
...................... t.;~.~~ ................... ' ................. b ' g d y , ~ t~t he t~e epplic~nt
(No~~I signing contmc~
above nom~. /~ ~ /.
He is ~he ................................... ~.~.T ...... ; ..............................................................................................................
(Confrocfor, ~g~, co~r~e officer, etc.)
o~ s~id owner or owners, ond is dui7 ~u~horized ~o per~orm or ~ve performed fhe s~id work ~nd ~o ~ke ond ~ile
~his ~pplicotion~ fhot all s~temen~s con~ined in tMs applicofio~ ore fr~e ~o the best o~ his knowledge ~nd belie~; ond
that ~e work will be performed in fhe monner 5e~ ~h in f~e application filed therewif~.
Swam to before me this , ~ ,
................... o, ........ ...........
ou. ............. ...........................
JUDITH T. BOKEN
No. 52-0344963 SuffoJk Cou~
FOBM NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N~ Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 7184 Z
Date ................... ~k{~l-'l- .......... ~ ......... , 19~,...
Permission is hereby granted to:
ea...~c~b~....A/C..~o..~i~te ..........................
~Mtl~ ~ ad~tio~ ~ e~ting dvell~g
c$ ~m~s ~a~ed ~$ ..... ~..~....~~..~$ ..........................................................
............................. ~2~....E~..~Awa ............. ~t~t~ ..............................................
Fee ~J'.,~.~ .............
Building Inspector/
FORM NO. 6
TOWN OF $OUTHOLD
Building Department
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-ex'sting"
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
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 occupancy $1.00
Date ....~....~......~......~....Z...~.. .............
/
New Building ................ Addition ................ Old or Pre-existing Building ................ Vocont Lend ..............
Z - .......
Location Of Property ...... ¢...~....~. ................... /. · : C.~. ..~.. . ~ .../. ....
Owner Or Owners Of Property ..d.: ...... ..~..,........~.../.~ .?..~?...~.. ..........................................................................
Subdivision ../~.~z~ .~.~..~.~......~.~.~
..........~Lo' Nora ~1~ ...... Block NO ............. House No...~.~..~...~..
Permit No..'~.L~.?.. ~ Dote Of Permit~.i]./..~.:'.~...~......Applicont ~'~..¥.. ~', ...~...~'..:]..~...~..~..
Heolth Dept. Approvol ............................................ Lobor Dept. Approval ................~...:....~.. .....................
Underwriters Approval ............ .~...;.....~.. ..................... Planning Board Approval ....... /~...:..~..~.. .....................
Request For Temporary Certificote ........................................ Final Certifieote ....................................
Fee Submitted $ .~ ............................
Sworn to before me ~3is
· O.~day of .~~ ~ ~/ .~ .......
Notary Public .................................... County
Construction on above described buildin~,,~,~rmit meets all applicable codes and regulations.
(stamp or seal) ~ ~-~'? ~-~
7'7-/~/ .... c/C/z.