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Home My WebLink About8978-z · 01~ NO. S 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 fallowing; 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 disP0sal--(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: 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 D te ........... New Building ................ Addition ...... ~. Old or Pre-existing Building ................ Vacant Land .............. · ocat on of Property ........... .......... ................................. Owner Or Owners Of Property ....~7....~x.: ...... ~-~.&./R...~.~...~. ....... .~..~.~..~£?.. ................................................ Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Of ~ ~J Permit No. ~..~.2.~.?.Z_ Date Per m it ~. (~.2../..?.../e/.. Applicant ...,..~.~.. ~ .~. ........ ~ ............. Health Dept. Approval ...... ..~...:..'..~,. ......................... Labor Dept. Approval ....... ~.~...:.....~.. ........................... Underwriters Approval ............................. 1 ................ Plann,ng Board Approval .... ./~..:..~.~.. ....................... Request For Temporary Certificate ........................................ Final Certificate .......~ .................... Fee Submitted $ ....~..,...~..0. ................... Construction Applicant......~.~z.......'~........~...~ ........................................................... on above described building anti_permit meets all applicable codes and regulations. Sworn to before me this Notary Public ...~..~~?..~.~.~ County TOWN OF SOUTHOLD ~/ BUILDING DEPARTMENT ~.~.~' ~r>-~ . TOWN CLERK'S OFFICE ~ ~ ................~ , ..- ~pp]icotion ~o..~.,.~.. ..................... Examined Dote ................................................ INSTRU~IONS o. This application must be completel~ filled in by ~pewriter o~ in ink and submitted in triplicate to the Building Inspector, with 3 sets of plans, accurate plot plon to ~ole. 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 o detailed description of layout ofproperty must be drown on t~e diagram c. The work covered by this opplicotion may not be commenced before issuance of Building Permit. d. Upon ~pprovol of this application, the Building Inspector will issue o Building Permit to the oppHcont. Such permit shall be kept on t~e premises ovoiloble for inspection througNout the work. e. No building shall be occupied or used in whole or in port for any purpose whatever until shall ~ove b~en granted by the Building Inspector. APPLICATION IS HEREBY ~ADE to the Building Deportment for t~e issuance of ~ Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Lows, Ordinances ~egulotions, for the constru~ion of buildings, additions or alterations, or for removal or demolition, os herein described. THe applicant agrees to comply witN oll applicable lows, ordinances, building code, housing code, and regulotlons, and to admit authorized inspectors on premises on~ i~ buildings for n~esso~ in~ections. ' ,' (Signotur~ .of applicant, or nome, if o corporation) (Address of applicant) State whether applicant is owner, lessee, agent, orcNitect, engineer, general contractor, electric~on, p~umber or ..... ....... .................. :.: ........ ...,....:..,., ............. :,.,. ................... ........................ 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 ............................................... Location of land on which proposed work will be done. Map No.: ........................................ Lot No ......................... Street and Number ..~:'::~,.4..:. ....... :~:~...,~..,.~..;....Z.~. ....... .-. ..... :. ..~ .......... :i~i~:.'M...',. ....... ~..:...;-..4.! ...... i .............................. Municipality State existing use and occupancy of premises and intended use ond o~upancy of propased construction: a. Exisiting use and occupancy ......... L.~.......;;..;.~Z:Z~:.4..(...~; .......... ~/.~J..~;.~.....(...'.'...;....%~ ................................................. b. Intended use and occupancy ........ :.f:~..,~;...'..-. ............................................ ;;:::. ...................................................... 3. Nature of work (check which applicable): New Building'. ................. Addition .~...2....d..~. Alteration ................ Repair .................. Removal .................. Demolition .................... Other Work .................................................... /~,-~ 00 (Description) ¢¢/..o./ ~ o 9 ....... Fee .......................................................................................... 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 and extent of each type of use ............................ 7. Dimensions of existing str~cLctures, if any: Front ........ ~..6...J ......... Rear .......... .t....~.*....:_ ....... Depth .................... Height ./.:,-5'.. ................. Number of Stones .... ~ ........................................................................................................ Dimensions of same structure with alterations or a,d,dit:l.e,~.~: Front ........ ..~...¢.. ................... Rear ...... ./..-~. ................ Depth ................................ Height ...~r..9...4>. .............. Number of Stories ...... ~ ..................... 8. Dimensions of entire new construction: Front ...... ..'~....~. .........Rear ........ J..:~... ........... Depth ........................ Height ..r~....t. .......... Number of Stories ...... .~. ........... , ................................................................................................. 9. Size of lot: Front ........................................................ Rear .......................................... Depth ................................ 10. Date of Purchase ........................................................ Name of Former Owner ........................................................ 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ...../~.....~.. ............................................ 13. Will lot be rearaded ..../~... ..................... Will excess fill be removed from premises: ( ) Yes ( ~ ,. , - ] 4. 1~4ome of Owner of pram sos ...~:..~...~..e.~....~..~...,....~...(.?:~...~.~.~.. Addres~,.(:~'~/..%.~.~....~.~hone No ....................... Name of Architect .............................................................. Address ................................ Phon~ Mo ....................... Name of Contractor ............................................................ Address ................................ Phon~ Mo ....................... 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 shaw street names and indicate whether interior or corner lot STATE OF NEW YgRK~ I c c cou OF ................... ),.k ........ ....... .~.~¢~.....~,.~..~ .................................................... being duly sworn, deposes and says that he is the applicon! /~ (NamCfof individual signing contract) abdve named. He is the ..................................... g..o..n...L..r...~.c}.~..o..r. .................................................................................................................... (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 ali statements contained in this application are true to the best of his knowledge and belief; end that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this . ......... :~.~.ql,.... day of ........... ~py.~r:~b.e.r .............. , 19....'Z6 ~ (~y. _~, Notary Pub c ............................. ~,~-ff.9-]~ ...... County .......... .~a~;...:....~ ............................................. ~/ ~ignature of applicant)