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HomeMy WebLinkAbout7741-zFOruM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certi[icate O[ Occupancy THIS CERTIFIES that the building located at ./..f".~f)...~!/). f~.-'.~fff.(., f:,~,, ,! Street Map No. ~' Block No ........... Lot No .................................. conforms substantially to the Application for Building Permit heretofore filed in this office dated ............. ~;?.~.~ ~ l~(~pursuant to which Building Permit No.~ dated .............. ~. ~ 19~ was issued, and conforms to an of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is . .~..~; 5Y?/L~(... ~ I~.~: ~ J .ff .(~ .... ~ ~.~ ~.. ~. ~.~ The certificate is issued to 7~1 ~ ~ ~ ?(~'~ (owner, ic~ of the aforesaid building. Suffolk County Dep~tment of Health Approval ......... ~. ~ ~. .................. u~v~wm~s C~CA~ ~o ............... ~: .~ .~ ..................... HOUSE NUMBER ... ~.~... Street ~/~L~O-~ k ~ IV~ Building Inspector TOWN OF SOUTHG~D i! BUILDING D~PARTJ~!~N~ TOWN GLERK{$ OFFICE SOUTHOLD, N, y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) ' ' Permission is hereby granted to: Building Inspector. Fee $ ....................... · Building Inspector FO~ NO. $ TOWN OF SOUTHOLD , Building 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 disposal--(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-ex'sting" 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. /Zertificate 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 Building ................ Additio~ ............ ~... Old or ~e-existing Building ......... .,,..... ,V_ocallt Land ..... ~ ...... Location Of Property ..... /. .................... .............. ' " Owner Or Owners Of Property .................................................... ~ ...................... Subdivision .................................................. ~....~ ...... Lot No ............. Block No ............. House I~1o ............. 7 7'//'Z- XTM Permit No .............. '.. ..... Date Of Permit .......... : ......... Applicant ............................... ~ ....................... Health Dept. Approvo[ ............................................ Labor D~pt. Approval ................................................ Underwriters Approval .............................................. P|onning Board Appro¥~l ....................................... Request For Temporary C~rtificote ........................................ Fir~ Certificate .......................................... Fee Submitted $ .................................... //,//~ Applicant ..................... ..F~.....~ ............................................................. Sworn to before me this / ................ day of ..~ ....................... Notary Public ................... ~County (stamp or seal) FOB, M[ lqO, ! TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined to proved ,,......s.. .... Disopproved o/c .............. ~ ................. ....................................... Application No ................. Z. ........... (Building Inspector) APPLICATION FOR BUILDING PERMIT ................. ~ ............................ ~....-Z.~7 INSTRUCTIONS o. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate to the Building Inspector, with 3 sere of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of Iot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout ofproperty must be drown 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 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 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 laws, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary/i/~spections. .,.~.~ ~_ ......... i~ ig'A'~';;;~"~' '~'~'&~'~/4~7'~' ';~'~Tif '~"['~';~'~';~ i~;;~ ........ (Addre~'~'~f ap~ i~''"'"~' ........ ~ ....... If appJicant is a corporate, signature of duly authorized officer. (Nome and title of corporate officer) Builder's License No ..................................................... Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............................................... Location of land on which lp~roposed work will be done, Mop No.: ...................... ~ ......... Lot No .............. Street andNumber .......... ............................................. *'/4a'~';~i;;;ii~ ....... State existing use and occupancy of premises and intended use and occupancylof proposed construction: a. Exisiting use and occupancy 3. Nature of work (check which applicable): New Building'. ................. Addition .................. Alteration ................ Repair .................. Removal .................. DemolitJor ..................... Other Work ..,~:~.. .......................... . .... (Description) / 4. Estimated Cast .................... /....~....~....:. ........................ 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 ............................ 7. Dimensions of existing structures, if 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 ................... , ................ Rear ............................ Depth ........................ Height .................... Number of Stories ..................................................................................................................... 9. Size of lot: Front ........................................................ Rear .......................................... Depth ................................ 10. Date of Purchase ........................................................ Nome of Former Owner ........................................................ 11. Zone or use district in 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 .................................................... Address ................................ Phone No ....................... Name of Architect .............................................................. Address ................................ Phone No ....................... Nome 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 Iol. ST^TE NEW s couNTY oF ................................................. :- ............................................... oemg duly sworn, deposes and says that he is the applicam (Name of in~Jividual signing contract) above named. He is the ................................................................................ ~ ................................................................................... (Contractor, agent, corporate officer, etc.) of said owner or owners, and is cJuly authorized to perform or have performed the said work and to make and file this application; that all statements contained in this applicat:ion are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application fite~rewith. ~ Sworn to before me this ~ z/ / / ~ - ................... .?.~.. ,day of_ .,~ ............ ~.,,-z'2....,,~....=11~...~._.~19.~...~. ~ /,~ "~'~~ Notary P u b, ~' (-~,~--~~~:u~n~Y~'~, ................... /~..~...~...J....:..~ ..... /z/ ~ - JUDITH Z. ~OKEN (S gnat re o apphca t) NotaJy Public, State o~ New York No.52.~0344963 Suffolk County~ Commissien Expires March 30, l~]