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Home My WebLink About8929-zFORM NOo 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No.Z~.)60 ....... Date ............. ~.C)V .... 8 ...... , 19.7.6. THIS CERTIFIES that the building located at ...]Bayshore. Road .......... Street Map No....1-$2~ ..... Block No .... :F~ ....Lot No, 23 .&-23 .... / Gl~.eor~p.ort .......... conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ 0c.t .. 18., 19.76. pursuant to which Building Permit No..8.92~Z.. dated ............. Oct.. 2.1.., 19. ~6, was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is . p.l~:~,vate .one..famt~l,~t. dwell~,g, ~.$th. add~.fz[ol~ ...................... The certificate is issued to .~-anette..Golde~ ..... Ownzr ............................ (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .. N.,.R, .................... ~ ......... UNDERWRITERS CERTIFICATE No. N,I~, ........................................ HOUSE NUMBER .... ~t~ ..... Street .. 2ayshor®, Road ...... G~.eenpart ....... Building Inspector I TOWN O~ S~u~r,oL~ BUILDING DEP~RTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 8929 Z Permission is hereby granted to: .~..~..~...~.,o..=...e....z...,~,~.....~./..c..,.~.e,..t.~..e... ...................... .~..~.~.~ .................................... at premises located at LOt 22 &23 ~..m. ffe.~.~...~.?.~..e..~:.ay...~.~.~ .... ........................................... ~...~.o.~.~..~..o.~.~ ..... : ........ .o.~.~. ................................................. pursuant to application dated ......................... .0.~.......~..~. .............. , 19..?~.., and approved by the 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 dlsposal--(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 Aprll 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: 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 $l.00 Date ......... ..C~...~..-.. ~..~..:..! ..~..-t'..~ ...... New Building ................ Addition .'~)..~..e¢.~.... Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ....~.~...~..~.Y.~.......~.~...: ......... .I~..~;L..~...e.o,..~.~..~...~. ............ ~.~.~.....~..~ ...... .~..~.....~....Z..~ ...... Owner Or Owners Of Property ........ /~}.l~..~.~..Jc..~ ......... .~.~..~..~ ............................................................. Subdivision ................................................................ Lot No...~-.~,.~....Z.~lock No ............. House No ............. Permit No ..................... Date Of Permit .................... Applicant C.~?fl~.t~l ....... ~.~ ......... ~. .............. Health Dept. Approval ............... ~ ......................... Labor ~t. Approval ................................................ Underwriters Approval ................... ~ ....................... Planning B~rd Approval ........... ~ ............................ Request For Temp~.Ce~ificate ........................................Fin~ Ce~ificate .............~ ................ Fee Submitted $ ...~.~...~. ................. Construction on above described building and permit meets ail applicable ~s~f.r~ulations. Sworn to before me this _ FO~ NO. ! TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. INSTRUCTIONS o. 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 oF areas, and giving o detailed description of layout ofproperty must be drawn on the diagram which is port 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 o 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 port for any purpose whatever until o Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Deportment 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 afl applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in, buildings for necessary inspections. (Signature of applicant, or nome, it: 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 .................... I:~r./M.M..~..~..~..~ ....... .~..~.!~.~../~. ......................................................................... [f applicant is o 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 ............................................... Location of land on which proposed work will be done. Mop No.: .......... !..!...~...,.~ ................ Lot No ....... ..~.....-~....4-...~..~. Street and Number .[,~.,L~..~.b.o,,l~.~-- - ....... ...~.~..,. .................................. ;........~.Y..~.L~.,~.. ............. Munic pa ty State existing use and occupancy of premises and intended ~se ?nd occupancy of proposed construction: o. Exisiting use and occupancy ......... J ........ .'~.~:~.~....~y ......... ,,~0.~.~.~.~..~. ....................................................... b. Intended use and occupancy ........... ~..l~..~.~x .............................. 3. Nature of work (check which applicable): New Building'. ................. Addition .................. Alteration ............... Repair .................. Removal .................. Demolitior ..................... Other Work ...... .~... ~...C=. L..~.. .......................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ............. ~. .............. Number of dwelling units on each floor ............-Z. ............... 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 ......... ~...~...~. ............. Depth .....~ ..... Height ...... ./~..~. ......... Number of Stories ........ ..~.. ..................................................................................................... Dimensions of same structure with alterations or additions: F'ront ............... ~ ................. Rear ........ '-= ................... Depth ................. '~. .............. Height .......-T. ................. '..Number of Stories· ................................ 8. Dimensions of entire new construction: Front ........... .~,.~.., ................ Rear ........... ..~..¢. ........... Depth Height ...... f.¢. .......... Number of Stories ...... ~ ...... b..¢.~..¢..~$ .................................................................. ; ................. 9. Size of lot: Front ................./.../..~.. .............................. Rear ........... I..f..~.. ...................... Depth ....................... 10. Date of Purchase ........................................................ Name of Former Owner ........................................................ 11. Zone or use district in which premises are situated ............. .~..~..~...~-.~).....~..q'~.L~.. ...................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: .......... ..~....O. ....................................... 13. Will lot be regraded .......~.~..~ .............. Will excess fill be removed from premises: ("~es ( ) No Name of Architect .............................................................. 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. Lo1- STATE OF NEW YORL(, ~ c c COUNTY OF ,...~.q.~...k. ........... ............................ f~i~j,g..~...~f~ .............................. being duly sworn, deposes and says that he is the applicam (Name of individual signing contract) abow) named. He is, the (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 and file this application; that all 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 before me this ~ · / ........... .2..~.,,~.~.... day of ............ .O.g.,~,,o.~...e..~.. ............... , 19~ .... Notary Public,. ........... ~z, ............. ~:~,~ '~.~ 'g.~. ,~ ..... County ................~ ....... ~/./..~. · · .~. · .~. · .~. ~ ( ignature of applicant) Lf H ANN N[VItIE I NOT/~I~y ~U~II£, Stale of New