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Home My WebLink About8339-z FORI~ NO. ~ TO~N OF SOUTHOLD BUILDING DEPARTJ~ENT TOWN CLERK'S OFFICE SOUTITOLD, N~ Y. N? CrHIS PERMt TH//!wORK COMPLETI~;)N pF $339 Z BUILDING PER,~IT MUST BE KEPT ON THE PJ~EMISES,0~N-rlL FULL AUTHORIZED) Permission is hereby granted to: ~ ,.-.laJea.-&;.~me-~l~,a~-.'~e3,1a~.~ ................ FORUM NO. 6 TOWN OF SOUTHOLD ~ Bulfdlng 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: 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 d~sposal (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. Swam 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 ......... ............. New Bqilding ................ Addition ................ Old or Pre-existing Building ........~...... Vacant Land .............. ocat on Of Property ...... Owner Or Owners Of Pro erty ......................... Subdivision ................................................................ Lot No.../..~..... Block No ............. House No ............. Permit No ..~'.r.~..~.~.~.. Date Of Permit~r, ff~./~..j.../..~...Applicant ...?/..f~....'Z~.~.~;...'~,..:....'~....~.:J..L~,...,~. ............... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Fincd Certificate .......................................... Fee Submitted $ .................................... Construction on above described building and permit meets all applicable codes and regulations. Applicant ......................................................................................................... Sworn to before me this ................ dayof ............................................ (stamp or seal) Notary Public .................................... County FORM 1~0. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. / Approved ..................... :) ......... /..~, 19.~.?..'~. Permit No. (~....~...~..?.......~....": ......... ........................... ................................. ~P~U~TIO~ ~OR ~l~l~ ~lT INSTRUCTIONS Date ................................................ , 19 ...... a. This application must be completely fdled ,n by typewriter or in ink and submitted in triplicate to the Buildin~ Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relahonsh~p to adjoining premises or public streets areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this application c. The work covered by this application may not be commenced before issuance of Building Permit. d Upon approval of this application, the Building Inspector wiJJ issue a Building Perm,t to the applicant. Such permil shall be kept on the premises available for inspection throughout the work. e No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupanc} shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of o Building Permit pursuant to th, Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances o, Regulations, for the construction of buildings, additions or olterabons, or for removal or demolition, as herein described The apphcant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and t, admit authorized inspectors on premises and in buildings for necessary inspections.. // /'/(Signature of applicant, (~ nci~e, if a corporation) (Address of applicant) State whether applicant is owner, less~5 agent, architect, engineer, general contractor, electrician, plumber or builder ........................................................ ............................................................................................................. Name of owner of premises ..~...~/.~...../~....c~...~...'~..~....~.~....~...~.~..~/./.~...'./~..'~..:~.~...~4~....~.../...~..~..~.~.~./~.~.~ ........................... If applicant is a corporate, s~gnature of duly authorized officer. (Name and t~tle of corporate officer) Builder's License No ...... J~~ .................. Plumber's License No ................................................. Electrician's License No ............................................. Other Zrade's License No ............................................... Locot,on of land on which proposed work will be done. Mop No......~...~... ~/97 Lot No.,r~ Street and Number ................................................................................................................................................. Municipality State existing use and occupancy of premises and in.~ended use and occupancy of proposed construction: o Exisitlng use and occupancy .....~(..../..'..~./.."~'7~f~'..~../..~?~.../.~..~....~..~ -- '"~ -- .......................................................................... b. Intended use and occupancy .................//~'¢~"c~7 ...................................................................... 3. Nature of work (check which apphcable). New Budding .................. Add~tJon .................. Alteration ...~% Repair ............. Removal ................ Demolit,or ......... Other Work .~.~*.~.::f.(4':.~...~.~.....~.~""~ .. 4 Estimated Cost ........................................................ Fee ./...'¢ ............................................... ~../.../~..~.~ ....... ...~...'~ (to be pa~d on filing th~s apphcahon) 5 If dwelhng, number of dwelling umts ...... ~ .................. Number of dwelling un~ts on each floor ......................... If garage, number of cars .......................... ~ ....................................................................................................... 6. If business, commercial or m~xed occupancy, spec~ nature and extent of each ~pe of use .......................... 7 D~mens~ons of ex~stmg structures, if any Front ........................ Rear ................................ Depth .................... Height ........................ Number of Stones ............................................................................................................ D~mens~ons of same structure with alterations or additions. Front ................................... Rear ................... Depth .............................. Height .......... Number of Stories .............................. 8 D~mens~ons of entire new construction' Front ................................... Rear ............................ Depth .................. Height .................Number of Stories ....................................................................................................... 9 S~ze of lot' Front ....................................................~__ Rear ...................................... Depth__s/. ......................... ; .... 10. Date of Purchase ...~C.../.~.~.~ ........................... Name of Former Owner ~.~.~..~/~Z ] I Zone or use district in which premises are s~tuated ........................................................................................... 12 Does proposed construction violate any zoning law, ordinance or regulation .... ~ ............................................. 13. Wdl lot be re. raded /~0 ' dl ex fill be re e fro g ........... ., .............. ~ v~ cess ' mov d m premises: ( ) Yes ( ) No 14 Name of Owner of prem,se ~YZ~.~~ [.~..'~r~ss .~. .~. Phone No. Name of Architect ............................................ Address ................................ Phone No ...................... Name of Contractor ....................................... Address ................................ Phone No ...................... PLOT DIAG~M Locate clearly and d~stmctly all buddings, whether ex~sting or proposed, and in&cate all set-~ck dimensions fron propcrty hnes Gwe street and block number or desc~pt~on according to deed, and show street names and ind~cat. whether inte~or or corner lot ~/0 ~"- I~,~ STATE OF NEW YORK, COUNTY OF ..~Ltf~oJ~ .......... ~-S S ................... ~ll~.e~ .~.....qe'l '1 ~'t.s ............................. being duly sworn, deposes and says that he is the apphcar (Name of individual signing contract~ above named He ~s the ............................................. O.'~'ke,~? ............................................................................................................ (Contractor, agent, corporate officer, etc.) of so~d owner or owners, and ~s duly authorized to perform or have performed the sa~d work and to make and fd this opphcat~on; that all statements contained m th~s apphcat~on are true to the best of his knowledge and behef; an that the work wdt be performed m the manner set forth m the apphcation filed therewith Sworn to before me this .......... .J.~.~q- .... day of Dec~.z~ez'. ................., 19 Notary Public, . ....................... ~!.J~.O.~ ..........Coun~ ~,~N NEVILLE NOTARY PUBLIC, State of New York ,No 52-8125850. Suffolk County lr~m dxp~res ~afch