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Home My WebLink About8169-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte Of Occupancy No. Z666.0 ...... Date ............. A..1~. .... ~.? ......, 19.7..~. THIS CERTIFIES that the building located at .P.?.~...Rd..~....I~..r.~.o..n..La.... Street Map No. AC..D. $.a.m.o. ri..d~Block No ........... Lot No ..... ..... .N,/.3..S..o.u~..d., y.t.e.w., .Ay.~.,, Peoonie conforms substantially to the Application for Building Permit heretofore filed in this o.ffice ~uly 2 7~ dated ............ AUld. 29.-., 19.7.2 pursuant to Which Building Permit No....~.~.~.9.Z dated ........... °..~..][U~...29, 19.7.~.~, was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is . P~.iva.t.z.. 0~.~..fa~l~lY. ~l.w.~l~ng..wl.th.add.~,ti.o~s ................... The certificate is issued to .. F.~.~ J,.s..1~. $~.t~'.., .(~$~' .............................. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval ...... I~:.g.: ......................... UNDERWRITERS CERTIFICATE No.. p.e.n.d..~, g ................................... HOUSE NUMBES..~.PO. ........ Street. ?..~...~....~. ~. ............................ Building Inspector FOE~I NO. 2 TOWN OF $OUTHOLD BUILDING DEPARTMENT TO~VN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING i~ERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 8169 Z Date ........................ A.~{~ B.t. ....... 2.~ ...... 19..,~.~. Permission is hereby granted to: ....~!~.e. ~..s....~!~.~. ............................................. ............... ~.e e.o~-~.e ................................................ to ...~.~-;L~..~..~,.~t~,..~.~,g~...o~..e~,~.~L~...~.~3,Z~,~ ............................................ at premises Iocoted at ...~;.,.~ ................. A~,~e.~,..c~..~g~.~c~ ................................................... ................................................... Le,~an...I~.o...(.pv.~.)...o~.£...S~un~..:~/.:Le~;..Age ........ pursuant to application dated ............................ Allg.....2.~ ........... , 19.~.%.., and approved by the Building Inspector, Fee $..:L~...OD. .......... Building I ndpec~r 0 0 ~3 o ~ c 0 ITt FO~ NO. $ TOWN OF SOUTHOLD , Building Department Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CEKTIFICATE 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 I~cation of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewerage dlsposal--(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 far 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. 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 formation required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existir~ dwelling or land ~use $5.00 3. Copy of certificate of occupancy $1.00 .~./ , Date New Building ...~ ........ Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ................................................. ~ ..........K ....................... ~ ....... r' ........................ t~ Owner Or ~ners Of Prope~y ....~.~].~:~.~~:....~~Z....~-~., Subd~ws~o~ ...................................... ~: .......... 7 ............. Lo~ No ............. B ~k No .............House No ............. Health Dept. App~owl ........ ~...z.:~. .......................... Labor ~pt. Approval ......... ~[. ........ , ........................... Onderwriters ApOrovol ......... tJ.~.~ ........................... ¢l*nnin0 ~mrd Apprm~l ......... J..2 ......................... Request For Temporary Certificate ........................................ FinaJ Certificate .......................................... Fee Submitted $ ...... ~...~. ................... Applicant ......................... ~.~ ...................... ~/~ ~......, ........................ Sworn to before me this , v/"~Y~ ................ y ......... .t.....~)....~,. .......... : ...... ~ p or seal)/,, FORM NO. 1 TOWN OF SOUTHOLD BUILDING 'DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined ....... .C~....S.~......~....t. .... Approved ............................. C~.....t..., 19..'~..~.~-Permit No. · Application No ............................. Disapproved a~...]~ ........................ APPLICATION FOR BUILDING PERMIT INSTRUCTIONS Date ................................................ , 19 ............ AmiJl~e~ 29~h, 75 a. This application must be completely filled in by typewriter o? in ink and submitted in triplicate to the Building Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according to sched~ule. b. Plot plan showing location of lot and of buildings on premises, relatioDship to adjoining premises or public streets or 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 be~ore issuance of Building Permit. d. Upon approval of this application, the Building inspector will issue a Building Permit to the applicant. Such permit shoJl 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 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 Jaws, ordinances, building, code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary ir)sj~j~ctions. (Signature of applicant, or nome~ 'kfr~' corporation) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises .............. .0.I~1,~'.~ .......................................................................................................................... If applicant is a corporate, signature Of dul~ua~&~ea~o~f~,ly' (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.: ........................................ Lot No ......................... Street and Number ........................................... ~..-,~-,,,,..aZ.,~D,~ll~t0~ ................................. aO0 _~lvate Roa6! t~ ~, ~eo~e, ~ ~or~ Municipali~ 2. State existing use and occupancy o~ premises and in.ended use and'occupancy of proposed construction: a. Exisifing u~ and accupancy ....................................................... ~ ................. ~ ...................................................... ~e f~ly dwell~ 3. Nature of work (check which applicable): New Building,. ................. Acldlflon .................. ,~,JteratJon .............. Repair Removal Demolition .................... Other Work (Description) ?00 o 00 4. Estimated Cost ............................................................ Fee .......................................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ............................ Number of dwelling units on ebch floor ............................ If garage, number of cars ................................................................................................... ~ ........................................ 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ............................ 7. Dimensions of existing structures, Jf any: Front ............................ Rear ................. ~ .............. Depth .................... Height ........................ Number of Stories ................................................................................................................. Dimensions of same structure with alterations or additions: Front ....................................Rear ............................ Depth ................................ Height ............................ Number of Stories ................................ 8. Dimensions of entire new construction: Front 25t 2'5~ .................................... Rear ............................ Depth ........................ Height ...... Number of Stories ........... ,O?. .................................................................................................. 9. Size of lot: Front 7-St Rear ~.8~.~)1 Depth ....J..8.~.....1~....1..~..~ .... 10. Date of Purchase ........ .~./.'J.{~/.~ ............................... Name of Former Owner ...... ['.{O,Z~...,~t~flk ......................... 11. Zone or use district in which premises are situated 12, Does proposed construction violate any zoning law, ordinance or regulation: .................. .~,.O. ................................. 13. Will lot be regraded . ......... ..~..O. ............. Will excess fill be removed from premise.s: ( ) Yes ( ) No **' 2 ' ] .~ 460 14. Name of Owner of prem sas-.~.',:.,'.,.~:'~.,]:.]:.~, ........................ Address ..~.~...~.....~...~.,~.,..~... Phone No..~..6.~..'.~...6..1..1... Name of Architect .............................................................. Address ................................ Phone No ....................... Jame~po~¢,N.]~,. 72~-49~7 Nome of Contractor Gabz'ielsen Builders Address ................................ I~none 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. / STATE OF NEW x~l~t]~:: tS.s COUNTY OF ..... :~Z,e.~.~B'"~';'"~ell~'_ _~ ................................................................................................. being duly sworn, deposes and says that he is the opplicon~ (Name of individual signing controcf) above 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~he best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filg,a/herewith. Sworn t~,b~ore me this / J .......... day of ..... ........................ , 7 /h _, Notary Public,. ................................................... County ..................... .~...:~....~...~ .......................... (Signature of opplican~i~-