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Home My WebLink About8742-z FOI~I NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, iq.. Y. BUILDliqG PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 8742 Z Permission is hereby granted to: .~..~!~...~..T~ ........... ~...:.....Z.!L~i~./..~.~. ....... _Z.......&..u..~..~.~.~..~...~ ...................................... at premises located at ~' ~' tgO ~A//.) BI I'd ~ ~ ~ ~ J~' ~..~..~.. ~ pursuant to appJicotion d~ted dULY /Y 19~ and approved by the Building Inspector. Building Inspector TOWN OF SOUTHOLD , Building Department Town Clerks Office Sou~old, 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-9 form or equal). 3. Approval of electrical installation from Board of Fire Uoderwriters. 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 comRleted site pJan~, requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: ]. 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: 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 Date ...~..../~.~.'./~.....~.-: ..,~.../..~'.Zz. New Building ................ Addition ................ Old or Pre-existing Building Y Vacant Land Location Of Property ......... ~.../../..~....~../~..~......~.~..Z.~....~... ................... : ..................................................... Owner Or Owners Of Property ...... ..................................... Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No..tZ..~.?/.~ Date Of Permit .~.l..2T~./..?..~..,Applicant ...~.~.,~...~.~T~..~..~........' ..~....~../.~..~f.~.......~..... Health Dept, Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Fined Certificate / Fee Submitted $ ....... ~.~i.~./...~.....~... ............ (stamp or seal)~/d~'~ 2~g ~ 3~ Nature of work (check which applicable): New Building'. ................. Addition .................. Alteration .............. Repair .................. Removal .................. Demolitior, .................... Other Work .................................................... d' , ~ (Description) 4. Estimated Cost .~.~. ............................ Fee ..~Z..?.~...~ ............................................................ (to be paid on filing this application) 5. If dwelling, number of dwelling units ........ /. .............. Numbcr 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 ....... : .................. Height ...~.....,~ .... Number of Stories ......... ~ ................................................................................................... Dimensions of same structure with alterations or additions: Front ..... ~. .................. Rear ...~Zf. ............. Depth ......~A,~ ............. Height ....~...,~ ......... Number of Stories ...........~ .................. 8. Dimensions of entire new construction: Front ........... ~..,.~ .................. Reor .~.,.~. ............ Depth ....................... Height ...Z~,.. Number of Stories ............ ~ ...................................................................................................... 9. Size of lot: Front ........ /~.? ..................................... Rear ....~..( ......................... Depth ..~.~.~../...~-. ......... /0.,: Date of Pzchase ..... ~,~t.,.Z~C~.~ ............... Name o~Former Owner ..~~ .................... 11. Zone or us~ district in which premises are situated .................~~..~ .................................. 12. Does proposed construction violate any zoning law, ordinance or regulation: ............... ~ ............................. 13. Will lot be regraded ......~ ............. Will excess fill be removed from premiss: ( ) Yes (~ premises ~..~~ 14. Name of Owner of ..... Address ...~~. Phone No. ~.~.Z~.~.~¢.~ Name of Architect ........................... ~ ............................ Address Phone No ....................... of Cont , o .................Aad ,,, hon, PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from properly lines. Give street and block number or description according to deed, and show street names and indicate M~ether interior or corner lot, STATE OF NE¥~/~z'O__~I~- z ~ ~ c c COUNTY OF .,..~....~,,~w/.?. C!~ ~ ~'~ .............. :,..~'/~'ZD.".Z~Z~.Z:~ .......... : ........ being duly sworn, deposes ~nd s~ys that he is the ~pplic~nt (N~e of ind,ividu~l signing contmcf) ~bove n~med. ,s .........................- ........................................................................................................................ (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 tha~ the work will be performed in the manner set fo~h in the application filed therewith. Sworn to before me this ~. ..... ~.... day of ............... ~)..~.(:~ ......... , 19..,7.C ~ fl ~__~~ n Nota~ Public, . ....................... ~..~.t..~.., CounW ..... L.(~.~