HomeMy WebLinkAbout8109-zFORM NO, 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. Z14160 Date January 16 1986
THiS CERTIFIES that the building ..... .A.d.d.i..t.i.o.n. .................................
Location nfPrnn~rtv 37700 Rt 25 (Main Rd. ) Peconic
House No. Street Ham/et
County Tax Map No. 1000 Section . . 9.8.5. ...... Block . .0..3 ........... Lot .. 0..0.7. ...........
Subdivision ........ X. ...................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore flied in this office dated
..... J.u..ly..2.8. ........ , 19.7.5. pursuant to which Building Permit No....8.1.0..9.Z .............
dated ...... J..u.ly..2. .9 .............. 19.7.5., was issued, and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is .........
..... -.77'7.-.-...A.d.d.i..t.ip.n...o.n..E.x..i.s.t.i..rig..D.w..e.l.l.i.n.g..-.-77..-7.-.~ ......................
The certificate is issued to KONARSKI, MICHAEL
..................... ......................
of the aforesaid building.
Suffolk County Department of Health Approval N/R
UNDERWRITERS CERTIFICATE NO .................. .N/.R. ............................
Building Inspector
Rev. 1/81
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTH'OLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
No. $10§ Z
Permission is hereby granted to:
at premises located at ....~../..~,...~.~...~..~..~.. .........................................................................................
...................................................................... P.e~i~ ....... N...Y.. .........................................................
pursuant to application dated ..........................a.~. ....... ~.~, ......... , 19.2.~...., and approved by the
Building Inspector.
Fee $...~,~..?...~... ..........
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:
]. 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 compl6ted site plan requirements where applicable.
B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing"
land uses:
I. 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 / ~/--~
~ J ~
Dote ............. ~ ..........
New Building ................ Addition ....~.. ......... Old or Pre-existing Building ........... =... Vacant Land ..............
Locat.on Of Property ....... ~)~/~,~ ...... ~/~., ............. ~ ......................................
Owner Or Owners Of Property . ~,~.. ~ ........... ~,~ ....... ~/¢~.~4 .........
Subdivision .................. ~ ......................................... Lot No ........ J~. Block No .......... %.. House No ...... .%-.
Permit No..~3~...~. D~te Of Permit ~...Apphcant ' ' ~ ' ~ ~ '~
Health Dept. Approval .~ ........... ~Z?/~¢~.Labor Dept. Approval ................................................
Underwriters Approval ..~¢~& ............................... Planning Board Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate ..~ ..................................
Fee Submitted $ ..~ ......................
Construction on above described building and permit meets all applicable codes and regulations.
Sworn to before me this
................ day of ............................................ (stamp or seal)
Notary Public .................................... County
TOWN OF SOU~OLD
OFFICE OF BUILDING INSPECTOR '
P.O. ~
~,OX
TO',VN HALL
SOUTHOLD, N.Y. 11971
TEL. 76~q 802
~1 a ~x.-o '~ _ Applicant
T,his is to advise Fox vh-~ ~ - ~ .
on ~%~%~ for ~ ~ ~'-~. ~-~~ I~l~a ~'~'
a f~~ectSo~ '~ ~ ~ ~ -~ :b,..p~e~ and
.... *'-~ d / ~,~s nob Z boen
In order to complete ~ ~
. -~ ~h_s file, it is necessary t.hat
a Certificate of Oct .... ~
.... ~-11 out the
check fou $5.00 payable to the Town of Southold. F!e~se
indicate to whom the Certificate of Occupancy is to be
and azuanEe with ~hls office fo~ an inspec$ion date.
Thank you fo~ youu pPompt attention.
VL:ec
Enclosures
Very truly yours,
Vic%or Lessard
Adminis 5r~ tor
/ / - ~ · ~ ~ ~ ~7//r-.~ ~
~....~.''~ -- ,~..2.~-~ / ~.-~- '~.~ ~
......... ~,~,~ ~. ....... ,. ...............
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~,~ ~ ............ ~ ......................... ~~ .......... ~~-~~
.................... ~ ......................................... ~ d,.,I ~1 N
......................... .......
~t~ ....................... ~ ............ ,1~.~ ....
IN~RU~I~S
a. This ~lic~ion mu~ be c~pletely fill~ in ~ ~writer ~ in i~ a~ ~mi~ in tripl~ ~ ~e Buil~i~~
In~r, wl~ 3 ~ of p~, ~cum~ ~ pl~ ~ ~le. F~i~ ~ ~h~ule.
b. Pl~ pl~ ~ing I~ati~ of lot and of buJldi~s~ premis~, ~lationship t0 ~jo n ng prem ~s or public str~ o~ ~
areas, and givi~ a detaJl~ ~ription of I~ of~ must ~ drown on the diagram which is ~ of ~is applicafl~, c
c. The wo~ C~r~ ~ this a~licati~ ~ n~ ~ c~me~ be~m ~u~ce of 8~lding Pe~it.
d. U~ appeal of ~ls a~licafl~, ~e Building Ins~tor will issue a Building Permit to the ~plicont. Such permlt~
shall ~ k~ ~ t~ premis~ ~ll~le ~r in~i~ ~ ~ ~rk.
e. No buildi~ ~11 ~ ~cupi~ or u~ in ~ole or in ~ ~r any pu~e wh~er until a Ce~ifica~ ~ ~c~ncy
shall have been gmnt~ ~ the Building Ink,tar.
APPLICATION IS HEREBY MADE to the Building Departme0t for the issuance of a Bu Id ng Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk 'county, New York, and other applicable Laws, Ordinances or
.~gulations, for the construction of building?! addltlons Or dlterations~ or fc~r removal' or demolition, as herein described.
· applicant agrees to comply with all appl,cable laws, ordinances, building code, housing code, and regulatior~, and to
edmit authorized inspectors on premises m~d li~ buildings for necessary ir-mpections.
(Signature of applicant, or name, if a corporation)
6a~ddress of app cant)/
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
..... ~.~. e~. ~:~'.~cZ~. .................................................................. : ....................................................................................
Name of owner of premises ../~t~.....~.~,~f~.-~.....,~O~(~.~::~,,.~[,: .......................................................................
If applicant is a corporate, signature of duly authorized officer.
.... .~a~.. ...... ~.~~... ......... ~.e..~) .....
(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 ...~../...~/~'..~...~7'J'~/~....~,_~..::....~.,t~,~.~g~.~'~...
Municipality
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Exisiting use and occupancy ....~/~1~'~... ............................................................................................
b. Intended use and occupancy ...~./~.~.~ .......................................................................................................
!.~. ~3. Nature of work (check which applicable): New Building.. ........ ~ ....... ~ Addition'....~ .... Alteration ....:..~ ........ '.
~ Repair .................. Removal .................. Demolition .................... at.her Work .....................................................
,-.--..- O-0 , .~ (Description)
4. Estimated Cost ................... ./..~.).~)m~ ........................ Fee ..../..~...~.i ..............................................................
(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, pecify nature and extent of each type of use ............................
7. Dimensions of existing structures, if any: Front ...v.~,~.~ .............. Rear ...... ,~. .................. Depth ...~.....o.. ..........
He ght ......... /..~..,...,. Number of Stories .J. ....................................................... ~ ", ........................ ~ ........................
Dimensions of same structure with alterations or additions: Front ............ ..2....~.. ................. Rear .....~..~.. .................
~ t ........ ~..~.. ............. Number o~f Stories ~l~4~./J~/.....J..~'.~,~
Depth ......... .'~.. · .................. Height
8. Dimensions of entire new construction: Front .................... · ............... Rear ............................ Depth ........................
Height .................... Number of Stories ......................................................................................................................
9. Size of lot: Front ............. ~.~..:..'~.. ............................... Rear ............ I~. .......................... Depth .~l~...~..e--~.~.. .......
'T~\~ Date of P~d~,. ....................................................... Name of FOrmer Owner .......................................................
Does proposed construction violate any zoning law, ordinance or regulation: ....... ~ ....................... ~ ................
Will lot be regraded ............. ~.... ........ Will excess fill be removed from premises: ( ) Yes (~ No
11.
12.
13.
14.
Name of Owner of premises .Z/~.~....../~'.~d~Z..~ ddress ..~./~. Phone No. ......................
Name of Architect .............................................................. Address ................................ Phone No .......................
Name of Contractor .~.~...4..4~...../~....~...~/j,~.ef'...~/.~ ....... Address .~"~,t'~J..~./~... ........ Phone No...'7.~....Z...."~..~..~...
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all sat-bc~k 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,
COUNTY__ ~ OF ............................... '
...~.~4(~'...~--~'~.....~.~../~.~..../..~.....'~.. ............................ b~ing duly sworn, ~es a~ says t~t he is the applicant
(Name of i~ividual signing ~tmc~ ·
above name.
He is the ..~ ....... ~.~ ............................................................................................................................
(Contractor, ag~,.co~orote officer, etc.)
of ~id owner or owners, and is duly aut~rized to perfor~ Or have p~r~ormed the ~id work a~ to ~ke and file
this application; t~t all statements contoin~ in this applicoti~[e t~e .to the best of his kn~ledge and ~lief; and
that the work will ~ perfor~ the manner set forth in the application 'fil~ ther~ith.
Swam to ~fom me this
............. ........ .