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Home My WebLink About8872-z l~O~I NO. ~ TOWN OF SOUTHOLD BUILDING ,DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N.. Y. BUILDING PERJ~41T (THIS PERMIT MUST BE KEPT ON THE PI~EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) No. 8872 Z Permission is hereby granted to: .~.q~L~&..;f.. ...... ~c.~.~.c ......... ~..~...u.~.~.~ a,r premises located at ................................ ~./...~....H..~..H~.U~.~. ...... ..-~...D....~...~.. ........................................ ~to oPpl}~c~tJon da~ed ............................... ..,,.~.,~...../..~......, 1~...~...., and approved by the TOWN OF $OUTHOLD , Building Department Towtt Clerks Office $outhold, N. ¥. 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: I. 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. (5-9 farm 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 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 ....... ...':~...~.. ........... & .................. New Building ................ Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property .................... ,L~.(,.~..~...I.~.~..~).~..~. ......... .T'~.~.~,~...! ....... .l....~.{~.l,~..T..~O..~.,..K.~. ............ Owner Or Owners Of Property ..... ,?...0...S'...~...~...,H. ...... ,.~ ...... ,,~....,E...~,.?.,...L.,. ....... .~..,.~..,.U..,,.~...,H...,.~... ........................... Subdivision ....................................... ~ ..................... Lot No ......... "-.... Block No......-': ...... House No..!....~... .~'..~ ~ 1~/7k . ). L/~-~. Permit No .....~..7..~.....Z'Date Of Permit ~: ............, Appl,canr' .......................................................... Health Dept. Approval ......................~...2....~.,..: ......... Labor Dept. Approval ................... ..~,.:..,.~..: ................. Underwriters Approval ..~.21./..~..~....~., .................... Planning Board Approval .......... ~,:..~.,.~. ............. Request For Temporary Certificate ........................................ Final Certificate ......~ ...................... Fee Submi.ed $ ....... ~...:~... ................ Construction on above described buildin~ermit n~ets,all applicable codes and regulations. Applicant .................. ~ ...................................................... Sworn to before me this Nota~ Public ......... ~~:,.. Coun~ (stomp or seoO 7- 7 Z Examined ....~..~ c~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. Thi:, application must be completely filled ,n by typewriter o¢ in ink and submttted in tnplicate to the Buildin,._ Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule b. Plot plan showing locahon of lot and of buildings on premises, relationship to adjoining premises or public streets areas, and giving a detailed descriphon of layout ofproperty must be drawn on the diagram which is part of this applicahon 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 msue a Building Permit to the applicant. Such permp shall be kept on the premises available for inspection throughout the work. e No building shall be occupied or used in whale 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 ~ssuance of a Building Permit pursuant to th, Buddmn ..Z~one Ordinance of the Town of Southold, Suffollr. County, New York, and other applicable Laws, Ordinances o Regul~.-~. ;F, for the construction of buildings, additions aria]rotations, or for removal or demolition, as herein described The applic'~nt agrees to comply with all applicable laws, orftinances, building code, housing code, and regulations, ~nd t, admrt autho~rized inspectors on premises and in buildings four necessary inspections. - ' '(~'~~~'~~"rn' 'e',' 'i ~' ' 'a' ' ~ 'o'~ '~ 'o'~ 'c~ i'; 'n'i ....... kt~aaress or appncont) State whether apphcant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder Name of owner of premises .......... ~'~,j~h ~ "]~l~'~"~ililO~i~ ........................................................... If applicant is a corporate, signature of duly authorized officer. (Nome and title of corporate officer) Builder's License No ..................................................... Plumber's License No ................................................. Electrician's License No ...~,.~..~-...~., ...... .-~.,:,.,~..~,~.~.~? Other Trade's License No ............................................... 1 Location of land on which proposed work will be done Map No ......................... Lot No. Street ond Number ~/~..~l~.~/,~l,O~ll~..M.i~y*.,~...,,~O~¥~l#..A.~o~h~,~;ii,~r;. 2 State existing use ond occuponcy of premises ond intended use and occuponcy of proposed construchon: a Exisiting use and occupancy ~l~8.,~:~lOe .................. b Intended use and occupancy t~O~;~.~...~i,~e..Ml~t..~01~..;]~t~.,l~;lO~///~ ........................................ 3. Nature of work (check which applicable) New Building ............... Addition ~ ............ Alteration .......... Repair ................. Removal ................ Demoht~or ................. Other Work .......................................... / ~ (Description) 4 Estimated Cost ........ ~20~-~O .............................. Fee ~~t o. :~. - ;~ ~ [~ · ~.- ¥~i-[r~-~- · ;¢~ · .~.~i~ ~,~i ~i ........... 5. If dwelhng, number of dwelhng units ......................... Number of dwelhng units on each floor ........................ If garage, numSer of cars ................................................................................................................................ 6. If busmness, commercial or mixed occupancy, specify nature and extent of each type of use ..................... 7 Dimensions of exlstmng structures, if any. Front ...... '~...I~.. ............ Rear .... .?~...~..'~. .................. Depth ..~.~..'-~. .......... Height ....... ~ ........... Number of Stories ..... ~ .......................................................................................... Dimensions of same structure with olterabons or additions: Front ...... ...'~......~-~... ............... Rear ..~.....~. ......... Depth ...... .~.~... .................... Height .... ~ .............. Number of Stones .....~-~... ..................... 8 Dimensions of entmre new construction. Front .... ,~. .......................... Rear ...~! .....................Depth . ..i~ ....... Height ~..I.~.. .......... Number of Stories ................................................................................................. 9 S,ze of lot Front ...... .~3(~k~. ................. ~:~.~. ........ Rear .[~ ............................... Depth ...[~u(~ ................ 10 Date of Purchase .... .~/~r..~ ..................................... Name of Former Owner ..J~r~te~.~..Z,~.O[~,~O~ ........ 11 Zone or use d~stnct in which premises are s~tuated ..... ~l~il.S,~l't,~.], .................................................. t2 Does proposed construction violate any zoning law, ordinance or regulation ..... l~.(~ .............................................. 13 Wdl ~ot be regraded .-l~ ..................... Will excess fill be removed from premises: ( ) Yes ( ) No 14 Name of Owner of prem~ses~'o~l~l~t~..~~ ...... Address 'I~l~l~l(Y~e"~ Phone Nc~,,...~)l~:~ ..... Name of Architect ... ~. .......................................... Address ................................Phone No ....................... Name of ContractorSl~]~. ............................................ Address ................................Phone No ....................... PLOT DIAGRAM Locate clearly and distinctly all buddings, whether ex~sting or proposed, and red,cate all set-back d~mens~ons frorn property hnes Gwe street and block number or description according to deed, and show street names and in&cate whether interior or corner lot STATE OF NEW YORK. [ S S COUNTY OF ........z~..c~'..~.~ .... ~.~.~..~........./~.......~.?.~...~..~ ........................... be,rig duly sworn, deposes and says that he ,s the opphcam (Nome of md~wdual signing contracf) above named He ,s the ..................... ~.~~ ...................................................................................................................... (Contractor, agent, corporate officer, etc ) of sa~d owner or owners, and ~s duly authorized to perform or have performed the sa~d work and to make and file th~s application; that oH statements contained ~n thts opphcot~on are true to the best of his knowledge and behef; and that the wo~k will be performed in the manner set fo~h m the apphcation filed therewith. Sworn to before me this ........... o, ................ ......... , Nota~ Pubhc, ~~~z//~ . (Signature of applicon,) ........................ ....... ..... .................................... FRAhK D'ANDRIA NOTARY PUBLIC, State o~ NeW Yell Quaiff~e~ m Nassau County ~ ~lSSIO~ ~r~s Malch 3D~