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HomeMy WebLinkAbout7863-zF~RM N~. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupnncy THIS CERTIFIES that the building located at . .~,J ~ ~,~0. c~ Street conforms subst~tially to the Application for Budding Permit heretofore ~ed ~ ~ office da~ed ....... ~ . ~.~.., 19. ~.~,~as issued, =d confo~s to ~ of ~e req~ men~ of ~e_applicable prov~io~ of t~ law. The occ~p~cy for w~ t~ ce~icate is The ce~ificate is ~sued to ~~. ~~ .~ ............................ ~ (owner, lessee or ten~t) of ~e ~ores~d b~ld~g. S~olk Co~ty Depa~ment of He~ Approval ..~.~ HOUSE~BER..~.~ ~.. S~eet...~~...~~ ................ Build~t~g Inspector / FOR~ NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 7863 Z Permission is hereby granted to: Building Inspector, Fee $..../...,~...,~.... Building Inspector FORM NO. 6 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, ann 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 buil&ngs, Industrial buildings, Mulhple 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 cond,tion 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-existing dwelling or land use $5.00 3 Copy of certificate of occupancy $1.00 /, .... ................. New Building ................ Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Loco, ion of Prope. ...................................................... Owner Or Owners Of Property .......'~.~.~l~.~ ...... ~%~'..1.~ .................................................................... Subdivision ................................................ ~'""!' ....... Lot No ............. Block No ............. House No ........... Permit No .7.~'..~...~.. Date Of Perm,t .~.~...~.~..Applicant ..~. .... .~O~.r~..~. ..... ..~....~.,~. ......... Health Dept. Approval ............................................ Labor Dept. Approval ............................................... Underwriters Approval ...................~..... ..................... Planning Board Approval ........................................ Request For Temporary Certificate ........................................ FinaJ Certificate ........l~..... ............................ Fee Submitted $ ...~.~....0~.. ..................... Construction on above described building ap,d permit meets all applicoble_c~gtP, s~and regulations. Sworn to before me th~ ~.....~. da,, of _- t BUILDING DEPARTMENT SOUTHOLD, N. Y. Exam,ned ................. Application No Pe,m t No. ' ............................ ~prov~ ................... ED..~.. .................................................. Di~opproved .~.~OV~P 4s ~e ..... ;~;'27~' ......... ~ ~/'~ ........... r~ .................. : ......... '~ ......... ED INSPECTIONS: ZION ~. BEFOEE COVE~NG pIpELiNE Date .............................................. --~.., 3. f{NAL wHEN lOB COMPLETED ........... Noz ~SPO~S~SLE ~o~ D~S~ O~ CON' INSTRU~IONS a. This application must be completely filled in by ~pewriter or in ink and ~bm~tted in triplicate to the Buildin Inspector, w~th 3 sets of plans, accurate plot plan to ~ale. Fe~gr~ b. Piot p{an showing I~otio~ of lot and of buildings ~ premises, relationship to adjoining premises or public streets areas, and giving a detail~ description of layout ofproper~ must be drawn on the diagram which is pa~ of this applicatior c. The work covered by this applicahon may not be commenced before ~ssuance of Building Permit. d. Upon approval of this application, the Building Ins~ctor will issue a Budding Permit to the applicant. Such perm shall be kept on the premises available for inspection throughout the work. e No building shall be ~cupied or used in whole or in port for any purpose whatever until a Ce~ificate of ~cupanc 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 th Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances c Regulations, for the construction of buildings, additions or o~terations, or for removal or demolition, as herein describer The apphcant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and t. admit authorized inspectors on premises and ir~ buildings for necessary inspections. State whether applicant is owner, Name of owner of premises ......... If apphcant ~s a col:porate, signature of duly authorized, officer. ...... .... }, (Ix~ and title of corporate offic'Cm) (Signature o£ap$~li~;ant, or name, if a corporation) ..... ~.-.~i q'_,_~' ,, I, I~ ~- ~ ....... ...... s .............................. essee, agent, architect, engineer, gene?al contractor, electricmn, plumber or builder ~,.~. ~ ........ ~ ............................................................................................. Builder's LIcense__.Nn ............ _.~.~._~.....,,,..-,.w,w~.,:~-/..] ....... fi'q, ) ~'~'-JJ: ' " .... ~i?~J Plumber's Lic-,,*- kl, ,, ... Electrician's License No ............................................. Other Trade's License No ............................................... Locatmn of land on which p,roto, o. sed work w~jll be done. Map No ..................... ~ ............. Lot No ........................ Nu~eer Street and Municipality State existing use and occupancy of premises an~.~ended use and occupancy of propased construction' a Exisihnguseandoccupancy ..... ~1~?~'~~ ........ ,~c~'~.t.~.:..k~...~__~,k-~.~.~.~.!.~...~..~ ..................................... b Intended use and occupancy ............. .~.C(..~.~.~-., ......................................................................................... 3. Nature of work (check which applicable). New Budding ............... Addition .......... Alteration ........... Repair ............... Removal ................. Demohhor ............. Other Work ................................................. o o (Description) 4 Estimated Cost .............. ...~,..'..~......~ ................... Fee .......---~~...~.........'~...... ......................................................... (to be pa~d on filing th~s opphcohon) 5. If dwelling, number of dwelling units ........... ~..... ....... .... Number of dwelhng un~ts 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. D~mensions of ex~stmg structures, if any Front ..................... Rear ................................Depth .................. Height ........................ Number of Stones ............................................................................................................ D~mensions of same structure with alterohons or add,hans. Front .................................... Rear ...................... Depth ............................... Height ................ Number of Stones .............................. 8. Dimensions of ent,re new construchon Front .~v~ .......................... Rear 'F'~"~ . .................................. Depth .... I...~.'. .... Height ................... Number of Storms .._.II ................................................................................... 9 S~ze of lot. Front .................................................... Rear .......................................Depth ............................. 10 Dale of Purchase ....................................................... Name of Former Owner ...................................................... 11. Zone or use distnct m which premises are s~tuated .............................................................................................. 12 Does proposed construchon violate any zomng law, ordinance or regular,on ....................................................... 13. W~II lot be regraded ............................ Will excess fill be removed from premises: ( ) Yes ( U)~No 14 Name of Owner of prem,ses ....~....C?...~...~......./...~'~.~.t....~.. ............. Address ................................Phone No ..................... Name of Architect ....................................... Address ................................Phone No ..................... Name of Contractor .......................................... Address ................................Phone No ..................... PLOT DIAGRAM Locate clearly and dmtmctly all buildings, whether ex~sting or proposed, and mdzcate all set-back d~mens~ons fro~ property hnes G~ve street and block number or descnpt~on according to deed, and show street names and indicat whether interior or corner lot STATE OF NEW YORK, COUNTY OF ............................. ~S S .......... ..... .......... of"~'~'~'~" '~'~1,,,~,,,~ 's,~'V~'ZZ"~ontrac;:~~,,,.~ - ............... be,rig duly sworn, deposes and says that he ,s the opplica. (Name/ above named He ,s the ........................ C,F~. J:'....e~.~.:..~.. ..~(~4:.. ..... : ....... .~ ~.~...c::...,~....,,~.. ................................................ t~onrracror, agent, corporate or~lcer, ere of sa~d owner or owners, and ~s duly authorized to perform or have performed the sa~d work and to make and f~ th~s applicahon; that all statements contained in th~s apphcohon are true to the best of h~s knowledge and belief; thor the work w~ll be performed m the manner set forth m the apphcahon filed therewith Sworn to before me this ..... of ........ ...... , Notory Pubhc, . ................................................... County · ~..~.m ~.. .