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HomeMy WebLinkAbout7492-zFOI~M NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's ORice Southold, N. Y. Certificate Of Occupancy No. $?~J~ ...... Date ..............~t,.. 1~1 ...., 19.~!~. THIS CERTIFIES that ~e b~di,g l~at~ at ... D~p. ~e. D~ ....... S~ Map No. ~ ......... Block No. ~ ....... Lot No, . .~..~~..h,f::, ........ confo~ subst~y to ~e Application for B~g Pe~it here~fore ffl~ ~ ~ office dat~ ........... ~.. ~.., 19. ~ p~u~t ~ wM~ B~g P~t No..~. dat~ ......... .'. ~.. ~ ..., 19.~., was ~sued, ~d co~o~ ~ ~ of ~e ~ men~ of ~e applicable pro~siom of ~e law. ~e occup~cy for wM~ ~ ce~ca~ h ~sued ~ ...~r$~W. ~. f~$~y..~ ~.i~.g .v~$~ .~..~c~ ................. ~e certificate ~ issu~ ~ . ~ff~ .& ~. ~ ..... ~ .............. (o~, lessee or ~n~t) of ~e ~ores~d b~d~g. S~o~ Co~ty Dep~ment of He~ Approv~ .. ]~, f,, ............................. U~WRITERS C~T~ICA~ No. ~y~ ....................................... HOUSE N~ .... ~ ...... SMut .. ~ee~ ~o1~ .D~ ......................... B~dm~ ~n~p~r ~ FOB.~ NO. ~ 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? 7492 Z Permission is hereby granted to: at premises located at .~[~..D~I~..]J~I~.,~t~B. .............. . ..................................... ; ....................... ...................................................... II~t,t,,t, tm~r,... IleZ,..: .......... , ........................................................ pursuant to application dated .......................di~l~lg~ ......~ ...... 19~..., and approved by the Building Impector. Building Inspector Examined ................. ........................... · ' ~ ' (Building Inspector) APFUCATION FOR BUILDING PERMIT Date .................... , 19 ............ INSTRUCTIONS a. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate to the Buildi~ Inspector~ with 3 set~ of P!~., acaurate. L~ plan to scol~ Fee ~ng to ~-Jsedule, b. Plbt plan shOWing location of lot and Of buildings on premises, relations~.to a~ljoining prem ses or publ c str. eets m areas, and giving a detailed description of layout ofpraperty must be drawn on thlJ dla~lram which is part of this apphcation. c. The work covered by this application may not be commenced before isr~nce 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 Buildi~ng Permit pursuant to the ~Build!n.g. Zon,e O~inance of the Town of Southold, Suffolk County, New York, and other applicable LaWs, Ordinances or~. .~u at!.o.m., ~r the construct[on of. bu!!dings, additions or alterations, or for removal or de~ol~ on, as herein described. V appliconragrees m cor~ply with a. applicable laws, ordinances, building code, housing codlj, and regulations, and ~a/~ admit authorized inspectors on premises and ir~ bullding~ f~' (Signatur~f appllc~t, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ' ..'~..~/..x~/...~'.~,~.~. ~ ..,~../.'.~.,~.~ ,~..~../.,~'.,~..~,6~... ....... If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's Liconse No ........ d~..~.~¢~..4~. ......................... Plumber's License No .... ~..~.~"~.."~.. ......................... Electrician's License No...,~J..~./J~..~.. ......................... Other Trade's License No ..... v~..~'4~.. ........................ Location of land on which proposed work will be done. Map No.: ........................................ Lot No ......................... Street and Number ...~'.,~...~.....~...~.~...~"~....~q~..~....~./.~'..~//~,~..X~..~../...,~...~'..~..~ ....................................... Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: o. Exisiting use and occupancy ..... ~.~-~.~.~r.~.. .............................. ~..~ ........~ .............. ~J~w.~.....I......~' b. Intended use and occupancy ....~.~..,~..~,~....~:~.~....~...~..~.~....~'~../.. ........ ..~./....~..~...~ 10~ 11. 13. 14. 3. Nature of work (check which applicable): New Building.. ................. Addition .....~ ..... Alteration ................ Repair .................. Removal .................. Demolition. .................... Other Work ................................................ . .... (Description) 4. Estimated Cost ...~,~.~..:..~....*?. ........................ ~ ......... Fee ...... ../...4~..,..~..~.. ...................................................................... (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 .......s~.~..~. ........... Rear ..~'...s~..~.......r.~: .......... Depth .~..../.. ...... Height ..~'.,~...~ ........... Number of Stories ...'.. :~....d~,.a~[~il~,,~L ............ ~ ................................................................. Dimensions of same structure with alterations or edditions; Front ..... ~i~..:~..,et~;~... Rear ...~..~.'.~...J~ Depth ....~....~....~.. .......Height .....~..~..'. .............. ~Number of Stories ...... ~'......~..~ ......... 8. Dimensions of entire new construction: Front .~.,,~. .........................Rear ...~.. ................ Depth .../....~......i ........ Height ....~....~.~.... Number of Stories ............~ ..................................................................................................... Size of lot: Front ..... ~..~...x. ........................................ Rear ..... ~..X~...~.. ........................ Depth ..~...~...~..../. .............. Date of Purchase ...~..~...~. ...................................... Name of Former Owner ....~.../...~..~..~..~..~....4~....~..~ ............... Zone or use district in which premises are situated ....~lJ,~.~.~..~'~'.Z'~'~i~.6~. ................................... ' .......................... Does proposed construction violate any zoning law, ordinance or regulation: ...... ~..~.. ........................................ Will lot be regraded ..... .~.~ ............. Will excess fill be removed from premises: ( ) Yes ( ) No Name of Owner of premises ...~..~....~...~'..:.....~...~/~.... Address Name of Architect .......... ~..~P~t~..~... .................................. Address Name of Contractor ........ ~.~.~ ................................... Address PLOT DIAGRAM. ................................ Phone No ....................... ................................ Phone No ....................... Lacote 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 NE COUNTY OF .............................................................................................. ~..being duly sworn, deposes and says that he is the applicam (Name of individual signing c6ntraC-D above named. He is the ................................................................................................................................................................................. (Cont~ctor, agent, corporate officer, etc.) 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 oil statements' contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to~b~fo~e~e this ........ Notary Pub lic, ~:~:~c:~,'X~.. ~~nW .............. ~.....,~r~..~..~ ........ ~ .............................. ~ignotur~/of applicant) JUDITH T. BOKEN Netory Public, State of New York No. 52-0344963 Suffolk Co~un, ty Commission Expires March 3~ ~,'~ FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall 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 Inspec- tor 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 installa- tions, 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 peoperty showing all property lines, streets, buildings and unusual natural or topographic featu res. 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 informa- tion required to prepare a certificate, C. Fees: 1, Certificate of occupancy $5.00 Certificate of occupancy on pre-existing dwelling or land use Copy of certificate of occupancy $1.00 $5.00 Date ..... .~$¥..~3,. ,I, 9 .SQ ....... New Building ............. Old or Pre-existing Building ............ Vacant Land ............. Location of Property ........ ?..~, .0, .~.e,e.p..~.o.~, 9' .~.1~.: ................. ~...a~j;..-I~..c.~.,..~...Y.,. .... House No. Street Ham/et Owner or Owners of Property ......... Cl±ffor. d .&. M,~z;3r. Egi~3tpn ....................... County Tax Map No. 1000 Section ...115 ......... Block ....... '~;~ ...... Lot ...... '] .'1 ........ Subdivision ................................. Filed Map No ........... Lot No .............. Permit No. ?~,;~ ..... Date of Permit .~/.?.L~ .... Applicant ............. .0.'~..e.l~. ............... Health Dept, Approval ........................ Labor Dept. Approval ........................ Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate ....................... Fee Submitted $... J...QQ..(.C.o. py) ............. Construction on above described building and permit meets all al;~icable codes and regulations. Rev. 10-10-78 FOI~M NO, 6 TOWN OF SOUTHOLD 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 oil 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 noturol 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 $5.00 3. Copy of certificate of occupancy $1.00 Date 9/10/76 New Building ................ Addition ....~ .......... Old or Pre-existing Building ................ Vacant Land .............. t¢/.~ D~.~.n Hole Drive tr~t,t, it, uck N.Y. Location Of Property .......... , .................................................... z ............................................................... Owner Or Owners Of Property Clif£ord & l~r EgLnt, on Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No. Z..~..~..~. .2. . Date Of Permit ..~/.~/..~....Applicant .................................................................. Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .... ~. .......................... Fee Submitted $ 6.00 Construction on above described building and~e,,rm.~,t~eet~li.cable codes and regulations. Sworn to before me this Apphcant"/~' '~"~'"~ '-Z/0"~'~?~.~'"i'"'"'"'"'"'""'"" doy of ' .................... ~ ..................... (stamp or sea,l/j_J /. Notory P,b c ...... County , ~~ ......