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Home My WebLink About8500-zFOBM NO. 4 TOWN OF SOUTHOLD BU~.BING DEPARTMRNT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at . ¥~. Lane .......... ~ ..... Street Map No..~X ......... Block No~ ....... Lot No, .. ~. 9~q~p.o.r.$...~.,.~.., ........ conforms substantially to the Application for Building Permit heretofore filed in ~hi.~ office dated ...........~pr:l~ ·. ~ .~ 19..76 pursuant to which Building Permit No. ~00. ~ dated ..........Apr...1.~ .... , 19.76., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which thi.~ certificate is issued is ...P~';l,.?a..t.e...~..e..f.a.~..~.ly..d..w~..]~l.~.~g ...................................... The certificate is issued to . .~.e~'~,~. ~..~;~V~.o.r$ .~,~ .k~..o~ ....... .0~e.~*e .............. (owner, lessee or tenant ) of the aforesaid building. Suffolk County Department of Health Approval .Z)~..~.y...~?...~.~?.~...~.y..R.:..V~.I.I.$... UNDERWRITERS CERTIFICATE No, .l~e..n~.g ................................... HOUSE NUMBER .. ~.~ ........ Street .....~/.o..o.d...I~.r~. ..... .G..~...~.~.R$ ........... Building In.~pector / FO~ 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? 85OO Z Date ........................ A~..~ ,~ ....... .1.~. ....... , 19..~7.~. Permission is hereby granted to: C~.:,:;.~^...L-~lo~.:~LJ......;J.C..Denr, is..&..Y.a~:J.a ZervoB ................. ~u.t~heg~e ......................................... to .~.$.1 i..:~.~.w...~lx~.. ~:~,m~ 1.~... ~el ~ In~ ..................................................................................... at premises located at ~J,~.,%.i;o~cL.~a~e ............................................................................................. ............................................. ~enpo~t.....K.~o ............................................................................... pursuant to application dated ...................... ~nr. il ....... 1.%. ......... , 19.76.., and approved by the Building Inspector. Fee $.2,~DD ........... ouuomg inspec[r FOF,~I NO. ~ TOWN OF $OUTHOLD ~ Building Department Town Clerks Office Southold, N. I'. 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: ]. 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 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" ~and uses: 1. Accurate survey,of property showing oil 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 o certificate. C. Fees: I. 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 ........... New B~ilding ..... ..~.. ...... Addition ................ Old or Pre-existing Building ................ Vacant Land .............. ........ ., Owner Or Owners Of Property ./.~~...d~..~.o.~.~....~~.t: Subdivision ........................... ~ ................................. Lot No...m. ........ Block No...,.~z. ...... House No....~.. ....... Health Dept. Approval ..~%-/.,,.~...~.~'...~.,.~. ........ Labor Dept. Approval ..~. ............................................. Underwriters Approval~-~.~..~....''~' ~.~..'...,.,Planning Board ApprovalS. ................................. Request For Temporary Certificate .../~ .......................... Fin~ Certificate ~ ................................... Fee Submitted $ ..~.,..~..-~ ................... Construction on above described building and permit meets all opglicable codes and regulations. Applicant ..... ~..... ](,~..~. ..................................... Sworn to before me th~ ,'~'~'/~' '~'7/ ....... ~...~ day of ....~...~.~...~.Z.~] ........ (stomp or sec~ Notary Public ........ .~./~, County ~ ~ro. z ~'~ ~ TOWN OF $OUTHOLD ~ BUILDING DEPARTMENT ~/~,~/~ &~'~ TOWN CLERK'S ~OUTHOLD, N. Y. ............. ~/' .............................. ~'- ................................ ~...~.., ly.l.~, rermir ~o. '¢~"'~'"~;'~"~'"...c~c~, Disapproved a/c .................... ~ ...................... ......................... = ................ ................. ; .......... APPLICATION FOR BUILDING Dote .... :..../....~i ..................... , I ............ INSTRUCTIONS % a. This application must be completely f ed n by typewr ter 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 I lb. Plot plan showing location of lot and of buildings on premises, re at onship to adjoining premises or public streets or areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which s part of this application. )- c. The work covered by this application may not be commenced before issuance bf Building Perm t. ~ 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. ft shalle' haveN° buildingbeen grantedShall bybe the°CCupiedBuilding°r usedlnspector.in whole or in part for any purpose whatever until a Certificate of Occupancy APPLICATION IS HEREBY MADE to the Building Department 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, add tions or alterations, or for removal or demolition, as herein described. The applicant agrees to comply with oil applicable laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in, buildings for necessary in~pectionf. (Sign~e of applicant, or name, if a co~l~'~';i;n) ...... (Add r~[~' g~"~ii~a ~q'fi"7 - · ...................... State whether apl~JJcant is owner, lessee, a_clent architect, engineer, general contractor, electrician, plumber or builder. ........................................... . ............ . Name of owner of premises . ..~..... .c;t~O~.. ~ ............................................................ If applicant is a corporate, signature of du y authorized officer, v ~ (Na~'~ ~,d ~itle o~' cor~'~rat~'"~ffi~'~'~) ........ Builder's License No ...... ...~....2...~.......H:....~. ........... Plumber's License No ..... .~.i.../..7...~..~...~......~... ......... Electrician's License No..~......'..~....~. ......~ .......... Other Trade's License No ............................................... \ /) /~ Location of land on which proposed work~il' be done. ~ap No.:~.~..~.~... Lot No .... (] (j Mu~cipali~ State existing use and occupancy of premises and [~ended use and occupancy of proposed construction: ...... ............................................ .... b In ~/~ - ~ ~ ................ . tended use and occupanc ~ ~~ ' ~ 3. Nature of work (check which applicable): New Building~ ...)f~ ........... Addition .................. Alteration ............... Repair .................. Removal .................. Demalitior. .................... Other Work ................................................ .... (Description) 4. Estimated Cost .... ~...~./...~..~..'~Z~. ............................ Fee (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 .............. '-T ............. Rear '---'-- Depth "'-" Height ........................ Number of Stories ................................................................................................................. Dimensions of same structure with alterations or additions: Front ....................................Rear ............................ Depth ..................... -";. .......... Height ................. ~ .......... Number of Stories ............ "-:. ............. /. ..... ~, 8. Dimensions of entire new construction: Front ...... .~.....~...,~. ............... Rear ......~....~....C~. ........ Depth ..,y.~ ............. Height ...../....~...f... Number of Stories ....... ~ ................................................................................ 7 ............. 9. Size of lot: Front ....... .~...~,,...( ................................... Rear ......... .~...~...../. ....... w~ ....... Depth .~....~ .................. 10. Date of Purchase ....~..~ ......... /..../....~r...~. ........... No_me of Former Owner i..I..,..~..~,~....~..~ ........ 11. Zone or use district i~)which premises are situated ........ f' ' '~ ~'~/.~,,,~-~....~.....X................v_~'- ...,......................'- ......... 12. Does proposed construction violate any zoning Iow, ordinance or regulation: .... Jfl.~z.......: ....................................... 13. Will lot be regraded ......L,J..~..... ........... Will excess fill be removed from premises: (~') Yes ( ) No 14. Nome of Owner of premisfs ~..~...~.~~.~ddress .~.,~,.a.?~z..~......~f~"J~oned'~ ,~ N~.~..Z..,].~.~.:?.~,./..7 Name of Architect ..,,~,.,* ............ ~ ...~ ................................ Address ..~.~....? No ....................... Phone' h' Name of Cantracto ................... Address . hone 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, ~ c c COUNTY OF ...~uf~olk ............ ............................ .C[h.e.s.'~e~'...0~'l o.~.~J. ............................. being duly sworn, deposes and soys that he is the applicam (Name of individual signing contract) above named. He is the ........................................................ CD~.'P~.D,e~.~.O.1~. ................................................................................................. (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 bis knowledge and belief; and thor the work will be performed in the manner set forth in the applicatiog~f~iled therewith. Sworn to before me this ............ ............................. Notary Public, . ................................... ~t~;~.~'4)~ County ............................................................................................. ~ ' ' ~g'b,'~,/-,~z~ (Signature of applicant) ~ANN NEVILLE NOTARY PUBLIC, State of New York No. 52-8125850, S~fffelk County.. Term rx~ire~ Marc~ 30, EA~TM ~DEPART~ENT Chief of ~enera1 Engin~ Services ,? ? Tile LAND SO~,V£¥OR'$ INK,.D SiAL OR '