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Home My WebLink About7684-z FOI~M NO. ~: TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL CQMPLETION OF THE WORK AUTHORIZED) N? 7684 Z Permission is hereby granted to: Building Inspector FORM NO. ~ TOWN OF SOUTHOLD , Building Department Town Clerks Office Sonthold, 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 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 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. 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 Dote New Building ................ Addition ................ Old or Pre-existing/Building ................ Vacant Land .............. Owner Or Owners Of Property ....................................................................................................................... Subdivision ................................................................ Lot No ............. Block 1'4o ............. House No ............. Permit No. ,.:.:...'....::.. Date U* I~ermit .................... Applicant ........... ; ...................................................... ~eolth Dept, ^pprova~ ....................~ ....................... L~or ~t, AppraYa~ ........................~ ....................... Underwriters Approval ..... ::......'....:....:.....:......~ .......... Planning Eloard Approval Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ ..................... Construction above on described building and permit meet,s~LI applicable codes aocr'T~3ulations. / ................ day of ...... x~ ......................... (stamp or seal) Nota~ Public ........ ~ .......... Coun~ / (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 &~'~'~-¢'~t ¢.~ ,. . , ......................................................... 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use .......... ~....~... ...... 7. Dimensions of existing structures, if any: Front ............................ Rear ................................Depth .................... Height ........................ Number of Stories ..........................................................~ ....... L~ ......................... ..~..,..,..t* .... Dimensions of sam~l structure with olteratioj~ or gdiJitions: Front'. ........... ..'~....~...~..~. .......... Rear .... ...'~'...~.." ~ . Height .....~....~. ........ Number 9f Stories ...................................................... ., .......................... i ................................ I aa I o o $oc~ ' 9. Size of lot: Front ........................................................ Rear .......................................... D_e2t. h ~ ............ ~.?¢, ........................................................ iN . wne ................... - ..................................... 11. Zone or use district in which premises are s tuated ~ ...................... 1'2. Doer proposed construction violate any zoning la~; ordinance or regulation: ........................................................ 13. Will lot be regraded' . ........... ~ .............Will excess fill be removed from premises: ( ) Yes ~,_( ~ Nome of Architect .~.? ~ ~ ArM .... ~&~'/~£~ ~"~/' Phone, No. Name of Contractor J~O ~ ~' . ' ' Address ................................ Phone 'No. PLOT DIAGRAM " ' Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dJmenfi, ons. from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. 3. Nature of work (check which applicable): New Building .................. Addition. ........... ~. ..... Alteration Repair .................. Removal .................. Demolitian .................... Other~/Vork ................. i ................ J~.~ ._ _ .- ~ (Description) ...... . , ~st meteor L, osr ............................................................ tee .............................................................. ........................... that the,,~(orl.~ will be perf&l~med Sworn tdj/b~f~re me this Notary Public, ....,-.... ............ STATE" OF NEW YORK, lc c COUj~TY OF ............................... f~"~ .' \¢-, . ............................................................................................... oe ng duly sworn, deposes and sey~ }hat ,he is the applicam (No ~.divid~l ~ con~D, 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 .s-ta~ ~nts contained in this application are true to the best of his knowledge and belief; and Tnner set forth in the application filed therewith. ............... ............................. NOTARY PUBLIC, StMo of New York ~