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Home My WebLink About8341-z FOR3f NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN GLERK'$ OFFICE SOUTHOLD, bi. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 8341 Z Permission is hereby gronted to: at premises located at .... ~.t, fL~...~.QJ3,~..~a33.~ll ................................................................................ pu~uant to amlic'ation ~dbtod .... ~:..'..: ~**:].-,i~ ............ · ]tT-~.-, and approved by the - Building Inspector. , -, . - ...... .~' . Foe $ ............. .... ......................... [ ~" ' Building In~ecto FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 11971 765- 1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted ~m~ to the Building Inspec- tor 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 disposel--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters.- 4. Commercial buildings, Industrial buildings, Multiple Residences and sifnilar buildings and installa- tions, 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. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of pz"operty 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 informa- tion required to prepare a certificate, Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling 3. Copy of certificate of occupancy $1.00 4.Vacan~ Land C.C. $5.00 5. Updated C.C. $15.00 $15.00 May 23, 1986 Date .......................... New Building ............. Old or Pre-existing Building ............ Vacant Land ............. Location of Property ..... 3. .[.0..0.~..s.~.e.~...2.o.~.~..~.~.~.e. ............. .0.~.~e.~..~ .................. House No, Street Hamlet Owner or Owners of Property .... ~. ?.~?..~..~..~..~..o.~.a.s...~.~?.a. ~. ?.~.~.~. a..~ ........................ County Tax Map No. 1000 Section ....2.4. ......... Block ..... ~ ......... Lot ...... ~. ......... Subdivision ................................. Filed Map No ........... Lot No .............. Permit No..~ '.~P-tflJ.%Date of Permit .......... Applicant .................................. Health Dept. Approval ........................ Labor Dept. Approval ........................ Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate X Fee Submitted $ .... .5;.0. q . . . .~/. ~..~.~..'-~.. ...... Constr,uct~on on above described building and per~:p~-~ets all_ ap i_~¢j~_.~odes~and regulations, R~. 10-10-78 Examined ...... ~ ....... ~ ............. : ....... Approved ............................... (..~......, TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. 19 ..... ..~ 19..:~ .... Permit No..~ ....../. ...... ~ ........... Application No ................................ Disapproved a/c ............................................................................. ? ~Y' (Building Inspector) APPLICATION FOR BUILDING I~ERMIT Date ....................... ,.q~ ......... .'i.E..., 19...~.~{... INSTRUCTIONS a. This application must be completely filled in 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, relationship to adjoining premises or public streets o 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 Build~ng Permit. d. Upon approval of this application, the Building Inspector wtll ~ssue a Building Permit to the applicant. Such permi 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 NL~DE to the Building Department for the issuance of a Building Permit pursuant to th. Budding 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 alterations, or for removal or demolition, as herein describe, The applicant 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, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or budde, Name of owner of premises .... ~L~-..¢, ...... :g6;...,,.:L.~LZL.~.a.~..~,sJa~o.~.t,h. ............................................................................ If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ..... ~^ .... ~q.~:OZ'. ............................ Plumber's License No...~ ..... 2.'~.bg.z: .......................... Electrician's License No .~.,...P~D}~D~. .................. Other Trade's License No ............................................... 1. Location of land on which proposed work will be done. M~p No ........... ~ .......................... Lot No.:~C. .................. Street and Number ..C~r.~:L.p..~...r.,)~cL~..~8. ................................................................................... Municipality 2 State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy .~l~e.]~,:~ ........................................................................................................ b. Intended use and occupancy ...... !! ................. .~,.~'1J~.~..~.~..~.~D~ ..................................................................... 3. Nature of work (check which applicable). New Building .............. Addition .....~ .... Alteration .......... Repmr .................Removal .............. Demolit~or .............. Other Work ................................................. (Description) 4. Estimated Cost ...........1. tD.01~..'k ............................ Fee .'J.~'. .............................................................................. (to be paid on filing this apphcat~on) 5. If dwelling, number of dwelhng units ....... .o.b.e. ............. Number of dwelhng umts on each floor ......................... If garage, number of cars ..................................................................................................................................... 6. if business, commercial or m~xed occupancy, specify nature and extent of each type of use ......................... 7. Dimensions of existing structures, if any' Front ....................... Rear ................................ Depth ................... Hmght ........................ Number of Stones ............................................................................................................. D~mensions of same structure with alterations or addmons' Front .................................... Rear ...................... Depth ................................ He,ght ....................... Number of Stones ............................... 8 D~mens~ons of entire new construchon' Front ........... 6 ..................... Rear ....... -6 .................. Depth .-.1.2. ......... Height ................... Number of Stories ...~.AO .......................... 9. S~ze of lot Front ...~.~. ................................................ Rear ........... ~.~ .......................... Depthl..91~ ....................... 10. Date of Purchase .................................................. Name of Former Owner ...................................................... 1 1. Zone or use district in which premmes are situated .... .~JJ'~?...c~,J;~.~.t ......................................................................... 12. Does proposed construchon wolate any zoning law, ordinance or regulation ........... ~o ....................................... 13. Wdl lot be regraded ....... ~O ................ Will excess fill be removed from premises: ( ) Yes ( ) No 14 Name of Owner of premises ~ ..... A.,~u~o~.t,~ ...................... Address ......... (.iZ'fi-e~:..t ......... Phone No ..................... Nome of Architect .................................................... Address ................................ Phone No .................... Name of Contractor ...... ~.~....r.r~l~.or. ........................... Address ...... .~'.~.¢'x'1~. ........... Phone No .................... PLOT DIAGRAM Locate clearly and distinctly all buddings, whether ex~sting or proposed, and red,cate all set-back dimensions fro. property Jmes. G~ve street and block number or descnpt~on according to deed, and show street names and induce whether rater,or or corner lot. see attached plan S'FATE OF NEW Y~OP,~ ,, l¢ S COUNTY OF ..... ~.z..~..o&~ ......... f~. ...... ~.~l~.....~s~.Q~t~ ........................................ being duly sworn, deposes and says that he ~s the apphca: (Name of individual s~gning contrac0 above named. He ~s the ................................ ~r~e~ ........................................................................................................................ (Contractor, agent, corporate officer, etc.) of sa~d owner or owners, and ~s duly authorized to perform or have performed the sa~d work and to make and fi this application; that all statements contained in th~s apphcotion are true to the best of his knowledge and behef, ar tha~ the work will be performed in the manner set forth in the apphcation filed therewith. Sworn to before me thru .......... .1..~ ....... day of ....................... .D.p.~ ............. , 1~.... Notary Public, . ..................... ~..1,1~.~,'.Q.'i..1¢.-. ............. County ~ ELIZABETH ANN NEYtLLF. ROTARY PUBLIC, State al New York (Signature of applicant) I 5TOP-Y I=~. ' STATE