HomeMy WebLinkAbout8164-zFOB~ NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Cerfi[icate O[ Occupancy
No. ZD. Date
THIS CERTIFIES that the building located a~ 7 ..................... ~ ~0 [ ~K~ ~ ~l L~. ...... ~'~ ~ Stree~
Map No Block No ~ Lot No
conforms substantially to the Application for Building Permit heretofore filed in this office
dated .............. ~.C~ .'~ ~ 197~. pursuant to which Building Pemit
dated ............. ~U.~..~(~., 19~'., was issued, and conforms to ~1 of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is .p..F¢., ~.~.~v ~ .....~.'V f. .... (~ ~?. ~'f ....P~ ~. (~.~. [' ~k[ ~ ......................
The certificate is issued to . ~.~...~. 7ACT
(owner, ~t)
of the aforesaid building.
Suffolk County Department of Heal[h Approval ...... ~:. ~'..' ........................
UNDERWRITERS CERTIFICATE No ........ ~: .{~ .................................
HOUSE NUMBER .... ~.~ .(~ ~... Street ~ I~ ~-~
Building Inspector
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFHCE
SOUTHOLD, 14. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 8164 Z
Permission is hereby grented to:
..... ~..r~a=.ta~l. ia .........................................
.............. .Tr,[ om t..au,. ~a. ......... S~Al~h~lc[ ..............
to .. ~ t~ .. e~..~d~ t&~ oa-.44t eek.~ .. Gn.. e~,i.t.i~g..~el.l ~ .............................................
at premises located at ....~[D~-_O_q.. ].aD, e .............................................................................................
....................................................... ~t,h~Id.....~,.¥ .........................................................................
pursuant to application dated ........................~g..-..2~ .............. , 19...~.~, and approved by the
Building Inspector.
Fee $..t.~.~0 ....... ;...
/ ~,
u i
FORM NO. 6
TOWN OF $OUTHOLD
, Building Deportment
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.
~. Final approval of Health Dept. of water supply and sewerage disp0sal--(S-9 form or equal).
~ Approval of electrical installation from Board of Fire Underwriters.
,J( Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and
installations, a certificate of Code compliance fram the Architect or Engineer responsible for
the building.
~. 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. 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:
1. 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 B~ilding ................ Addition ...../.. ........ Old or Pre-existing Building ................ Vacant Land ..............
Location Of Property ..... ~..~./~...(~..~,~......J~..~.., .........~..~. ~'..~..~.(.~, ...........................................
Owner Or Owners Of Property ...... ~Jf~)~../~ ........ .~.~./~..~.~....~. .....................................
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No...~../.~.~.Z~.. Date Of Permit .~./~../~.~..Applicant ..................................................................
Hearth Dept. Approval ........................ ~....'~-Z .............. Labor Dept. Approval .......... ~ ................................
Underwriters Approval ............. ..-7..7. ......................... Planning Board Approval ......... --~ ..............................
Request For Temporary Certificate ........................................ Fincg Certificate .......................................
Fee Submitted $ ...... .~..t..~....~. ..................
Construction on above described building and permit meets all applicable codes and regulations.
Applicant ....~.~ ................................................
Sworn to before me this
....... day of
Notary Public
County
AGNES S. BALLINGER(~ Itc _~
otary Public, State of New York
No. 52-4 ,D;992, Suffolk County
Corarnis~ion E~pires March ~0, 197~/
FOBM NO. 1
TOWN OF SOUTHOLD~
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N, Y.
Examined ........ ~.} ............. ' 19.~,~Y Permit No. ~./.~
~proved ........................................ , ...............................
Disapproved ~
APPLICATION FOR BUILDING PERMIT
Date .............. ..~.,.~Z ......... 1~..~ .......
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building
Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to schedule.
b. Plot plan showing location of at and of buildings on premises, relationship to adjoining premises or public streets o:
areas, and giving a detai ed descr pt on of layout of property must be drawn ap the diagrc~m which is port 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 will issue o Building Permit to the applicant. Such permit
shall be kept on the premises available for inspection throughout the work;
e. No building shall be occupied or used in whole or in port for any purpose whatever until a Certificate of Occupancy
shall have been granted by the Building Inspector.
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, additions or alterations, or for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances bud ~g code, hogsing code, and regulations, and to
admit authorized inspectors on premises and in buildings for neces~4
(S~
~ure of applicant, or name, i a corporation)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises .....'.~:..~.;(~l..~.:......~.~.~.:...-.~,-, ,.~,,.,¥.~..,L4. ............ .~..~..~..~..~.' ....... ~.....~...1~..~...~.~.~:.!..~. ....
If applicant is a corporate, signature of duty authorized officer.
(Name and title of corporate officer)
Builder's License No .....................................................
Plumber's License No .................................................
Electrician's License No .............................................
Other Trade's License No ...............................................
1.
Location of land on which proposed work will be done. Map No.: .................. .~r; ....... i ......... Lot~ No .........................
Street and Number ...~.~.,':,.~,..0. ....... /..~.:..~.~....~(~.~., ~.~.~...~...~....~.:. ...........................
Municipality
State existing use and occupancy of premises and in~ended use and occupancy of proposed construction:
a. Exisiting use andoccupancy ''''l~: ' ~[' ~
b. Intended use and occupancy X~*/& ........ ~/¢~ .............................................................
%
3. Nature of work (check which applicable): New Building ................. Addition ....... '7~"~'LAl~erati°n ................
Repair .................. Removal .................. Demolition .................... Other Work ..... .~-r.....,4~<. :..-z. ....................... ....
(Description)
4. Estimated Cost;~......,ZgL...~....~. ......................................... 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 ,....,."~, ............. x .....
7. Dimensions of existing structures, if any: Front ........~..~'. ............. Rear ........ .~..~. ................. Depth
Height ........................ Number of Stories .......... /. .....................................................................................................
Dimensions of same structure with alterations or additions: Front
Depth .......... ~...?. .............. Height ............................ Number of Stories ........ ../ ......................
8. Dimensions of entire new construction: Front .......... L.~.. ................... Rear .......... /..~.../. ......... Depth ....... ~...~. ..........
, ! /
Height ...... ~ ........... Number of Stories ........................................................................................................... .~ .........
9. Size of lot: Front ................/...~...'~.......~..:,~ ............ Rear ...~..'. .......... ~. .. ~. ... ./. ......... Depth ........ ./...7....~ ..............
10. Date of Purchase ............ /..,..~.~...~ ....... ./. ..................... Name of Former Owner ......... Z ............................................
11. Zone or use district Jn 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 premises: ( ) Yes ( ) No
14. Name of Owner of premises .......... ~r~.......~..:....~....~.......~ress.~one~l~lo.......................
Name of Architect .............................................................. ~ '"Address r~~... Phone No .......................
Name of Contractor ............................................................ Address ................................ Phone 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,
Lit'Il:L:'
STATE OF'NEW YORK, ~ S S
COUNTY OF ....... ~ ............ I' '
................ .~... ~/~.. ....... P. ....... 7..~T...j~...~.~. ......... ;:/...~.:. ........... being duly sworn, deposes and says that he is the applicant
(Name of individual signing contracf)
abow~ named.
He is the ...................................................
(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
thor the work will be performed in the manner set forth in the application filed therewith.
Swam to b~fore me this
............. ~Oy of ....... ~,.....~,.,~....., 19Z~..
Notary Public,. ................. ~,~,~. County ........ ~ ....... ./,...~~ ......................