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Home My WebLink About9036-z FORM 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? 9036 Z Date ...................... ~e]~ ......... .)$ .............. , 19....~.~ Permission is hereby granted to: E a ~ %~.,,i~.. ~I.. ~,~es.....A.ffJ.. ~x~ed.. .Ro~et.. ~-..~¢1 fe ................ Snu.t~,~i~d ............................................. at premises located at ..... .l'.:.O....~....~..,~. ....... ..~.~.b.,o,..~....~..~.$...~..~.~. ....................................................... ................................................. ~..r.$~,.n..~n~..~.~ ......... ~.o.~a~l.~t ................................................... pursuant to appfication dated ............................ ~.e.b......L}. ............. , 19..~.~'.., and approved by the Building Inspector. Fee ~. !.+.?. )!:.0. ............. FOR~ NO, 6 TOW~ OF $OUT~OLD , ~uilding Department Town Clerks Office Soutkold, 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-g 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 1057), 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 os 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 Dote ................................... 7 ........... New B~ilding ................ Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property I ~'~.~.. ~'~)~'A~,/TI.~J .~... ~.~./~. .... -~DL/'71..fc) Lb Owner Or Owners Of Property ....... ...~..?...,.~....~.. ............ ,~.!.~.~.~?..~.,,.L:,. ......................................................... Subdivision ............................................................... Lot mo. ~ Block No. House No ./~,~'~7c L~ a-/4~-~ , _. . ................................... FL;~' % /qZ7 Permit No...?...~..,-~.~,....'~.. Date Of Permit .................... ~pp icant .................................................................. Health Dept. Approval '~.:~(~..7.....:.~.~/..~.?.~,~.~::.(/,....Labor Dept. Approval A Underwriters Approval .............................................. i~lanmng Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate Fee Submitted $ ........~. ......................... ................ day of ............................................ Notary Public .................................... County Construction on above described building ap'~l per./.~l_ --mit meets all/,~plicable/// codes and regulations. Applicant ..'/....~....,.~,,..Z~....~..:.~...(~.....;CC~... Sworn to before me this ~C¢~ Og~J~,~ ~ ~. (stamp or seal) BUILDING DEPARTMENT TOWN CLERK'S OFFIC~ ~UTHO~D; N. Y. D sopproved a/c ..~ .... / ~/;h725~ ~ - ... .......................................................................... 7 ....................... , ..... ..... / APPLICATION FOR BUILDING PERMIT .............. INSTRUCTIONS a. This ~pplic~tion must be completely filled in by typewriter oc in ink and submitted in triplicate to the Building Inspector, with 3 sets of pMns, accurate plot plan to ~le. Fee ~ccording to schedule, b. Plot plan showing location of lot ~nd of buildings on premises, relationship ~o adjoin ng premises or publ c streets areas, ~nd giving a detai ed description of layout ofproperty must be drawn on the diagrom which is paff of this ~pplication. c. The work covered by this ~pplic~tion may not be commenced before issuance of Building Permit. d. Upon approwl of this ~pplic~tion, the Building Inspector will issue a Building Permit to the applicant. Such permit sholl be kept on th~ premises awilable for inspection throughout the work, e. No building shall be occupied or used in whole or in part for any purpose whatever until a Ce~ificate o{ ~cuponcy shall have been gronted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issu~nc~ of ~ Building Permit pursuant to Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other ~pplicable Lows, Ordinances or Regulations, for the construction of buildings, ~dditions or olter~tions, or for removal' or demolition, as herein described. The applicant agrees to comply with ~11 applicable I~ws, ordinances, building code, housing code, ~nd regulations, ~nd to admit authorized inspectors on premises and in buildings for n~ess~ inspections. ............... (S~n~ture of oppllcont, or n~me, i{ ~ corporotio~) " State whether applic~c~pt is owner, lessee agent, architect engineer general contractor, e ectr c an, p umber or builder ............................ ............. . ............. Name of owner of premises ....././,/,~..~. '.././//~'..~..../~,.'.~.../.~,.~.~..,..~.~....' L" . ~,~ ...................................................................... If applicant is a corporate, sianot~of duly authorized officer, ... ~ (Name and title of corpor~:~e officer) Builder's License No ..................................................... Plumber's License No. Electrician's License No...~....~..~Z.-~..~ .............................. /-/.Z:). /~::~ ?-~'o- II Other Trade's License No ............................................... ~ ~/'~ Location of land on which proposed work will be done ,Map No' ~ Lot No ~ Municipali~ State existing use and occupancy of premises and intended use and occupancy of proposed construction: a Exisitinguseandoccupancy ....... ~~.~ ........... b. Intended use and occupancy ...... ~..~C~ ~ .'~...... ~...~.. ~. .......................................... 3. Nature of work (check which applicable): New Building'. ................. Addition .................. Alte ion ............... Repair .................. Removal .................. Demolition .................... Other Work ................................................ .... z.~,~ MO (Description) ooo aa .... ................................................................. 4. Estimated Cost ............... ~ ........... : .................................. e (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, s~p~cify nature and extent of each type of use ............................ 7. Dimensions of existing structures, if any: Front ....../.~....~...~.....~Z. ....... Rear ................................ Depth .................... Height ........................ Number of Stories ................................................................................................................. / Dimensions of same structure with alterations or additions: Front ..r'~..'~..v~.....(~.. ................... Rear ............................ Depth ................................ Height ............................ Number of Stories ................................ ;.~_~/6//7 ......... · .'~...~... .......... Depth .....~...~. / 8. Dimensions of entire new construction: Front .....~..f~'..../....., ................ Rear .................... Height .......?...6'. ....... Number of Stories ..................................................................................................... ? ............. 9. Size of lot: Front ..../...~..~..:..~. ........ ~. ............................ Rear ...../...~.~.~-../~..~. ............... .~. Oepth~/',',~,.~..~?/~.~.:..~,~. 10. Date of Purchase ................. ~7.,.~.. ....................... Name of Former Owner ...~.(~..~.~.(~.. ........... ,/. ................... 11. Zone or use district in which premises are situated .......... .~'"~.~.~...(~ .~.x~./..~.. ............... ~;~,~. ......................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ...... ./.~...'.~..~...~. ................................. . / 13. Will lot be regraded .~.'~.~. ..............Will excess fill be rem~)ved from premises: ( ) Yes (~No J Name of Architect ................ . ............. . ....... ~,,,? ..................... Address ................................ ,~,//---- Phone No ....................... Name of Contractor .... .,~'~.,f~.~.~./~/,~..~.~_,,~...~m ~ ' .~.. Address ..... .q~...'.~../~..~.~..... 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. STATE OF NEW YORK, [ S S ............................ ~~.~t.ra~c~.~'~ "~-~'~' ............ being duly sworn, deposes and says that he is the eppl icom (Name ' d'v' 'gn' g co above named. (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; and thor the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this . ' SUFF. GO. HEALTH DEffT. APPROVAL ~ H. S. NO. L~C. ~ND SU~VE~RS-GREEN~, N. Y. TEST HOLE SUP'F. CO, DEPT. OF HEALTH $~RVIC, E$ STATEMENT OF INTENT ' , APPROVED' __~,~ ~~ ,