HomeMy WebLinkAbout7871-zTOWN OF SoIYrHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificnte Of Occupancy
No. Z69.~a .... Date ........... .I,k. r0k..~3 ..... , 19..7.6
THIS CERTIFIES that the building located at . .N./.,~. }!i.~&..lc..R..vg.d..~ .C.~.~.). Street
Map No...x~. ....... Block No...x~. ....... Lot No, . .~. ...... 5. c~..t.h.P.~.d...~:.~.: ......
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ........ L'c y.. l., 19.. 7~ pursuant to which Building Permit No.. ?~%lZ
dated ..... .l;a. lr . .! .... , 19 75., was issued, and conforms to all of the req,,ire-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is .P. l'l.v.r.~..o.n. ~. f.~,~-~Z .d.~;L.],~ .ha A~-.~.h.. {ll~ .a .d.d.i.~.!..o!1. ..................
The certificate is issued to . .~..e.]..e.s.p.h.o~.e.. ::lqla..n.~.k.i.. &. '.d.f.f~e. .... ~.:m.~?.~. ...........
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval },'.-.a ~ ........................
UNDERWRITERS CERTIFICATE No. . .N23369.~ ..... ~llly.. 2 .~ 97.5 ..............
HOUSE NUMBER . .~.0~?.~, ..... Street .... .Ui.d.d.!.~. ~p.~4..(.C.R.~?) ................
...... .... .....
Building Inspector ~,
FOF,~ NO. ~
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)
7871 Z
Permission is hereby granted to:
..%' ~.! ~.,s p.L~ ~ ::.~. .;.:. .o l ~.r.~.~ } :.~ .............................
Southold
premises located at .... .~,~.~.~.'...~.'.,..o..~..~..~.~...~.o.~.~ ....................................................................................
Southo!d 1 .~ ·
pursuant to application dated ............................. }',~.][I: ....... ~ .......... , 19.~.~...., and approved by the
Building Inspector.
Fee $..152...0..0. ...........
FORM NO. ~
TOWN OF SOUTHOLD
, Building Deportment
Town Clerks Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This applicahon must be filled in typewriter OR ink, and submitted in DUPLICATE to the Building
Inspector with the following; for new buildings ar new use'
I. Final survey of property with accurate location of all buildings, property lines, streets, anti
unusual natural or topographic features
2. Final approval of Health Dept. of water supply and sewerage d~sposal--(S-c) 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 s~te 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 hnes, streets, buildings and unusual natural
or topographic features.
2. Sworn statement of owner or prewous 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. Cert,ficate 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
Rte ...... ~....:~.~.~.Z.~ ..............
New Building ................ Addition ~ Old or Pre-existing Building Vacant Land
Location of Property ........... ~l-/.. ........ ~~.....~ ............. ..~ ..... .~ ............... ~ ........
Owner Or Owners Of Property ....~./.~....¥T...~~'~''l~ ....... ..~.......~.../..~~.. .....
Subdivision ................................................................ Lot No ............. Block Nv ............. House No ...........
Pe~m,t No ..~.Z~Z.....~ote of Perm,t' ...~.~ /-?~',con; .... ~..2...~.~' ~ ..................
Health Dept. Approval ........... ./~.....!....~ ............ Labor Dep*. Approval ....... ~..~.../.~ .............................
Underwriters Approval .............................. 4, ............. Planning Board Approval .... '.....'.....,. ........................
Request For Temporary Certificate ........................................ Find Certificate ..........................................
Construction on above described building and permit meets all applicable codes and regulations.
Applicant ........................................................................................................
Sworn to before me this
.......... ~.~do~o~....~.~ ....... .2?..
· ~.~'~ ~';7~"')'
Notary Public ......~./~... County
(stamp or
Exammed
Approved
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
19.?..~ Permit No Z..~......~../..~.... ...........
Application No ..... .?. .?. . . ?. ./. ...............
Disapproved a/c ...........................................................
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
Date
a Th,s 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 Iocahon of lot and of buddings on premises, retahonsh~p to adjmnmg premises or pubhc streets or
areas, and gw~ng a detailed description of layout of property must be drawn on the d~agram which is part of thru application.
c. The work covered by this application may not be commenced before ~ssuance of Building Permit
d Upon approval of this application, the Building Inspector wdl ~ssue a 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 ~n 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
Budding 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 apphcant 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 inspections.
(S~gnature of apphcant, or name, if a corporation)
Sguthold N.Y.
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
................................................... . .ld ........................................................................................................
Name of owner of premises Telesphore Wolanski
If applicant ts a corporate, signature of duly authorized officer.
(Name and t~tle of corporate officer)
Builder's bcense No ...... .o.]f~....e.~. ...................................
Plumber's License No .................................................
Electrician's License No. ...~.$..~..o..b...,e..1.,.~. .......................
Other Trade's L~cense No ...............................................
1. Location of land on which proposed work will be done Mop No
...... ~ ........................ Lot No.X...z~.. ................
Street and Number ....... ..N..°...~.~h..~.°..a..~...~..C.~2..~.) ......... $.o..~.~h.o.~.~ ...........................................................
Municipality
State existing use and occupancy of premises and ~ntended use and occupancy of proposed construction'
a Exisitmg use and occupancy ...... .d...~..e..~.]..~.~.j~ .............................................................................................
b. Intended use and occupancy .............. 8f~f~...~,r,C.~t...a:~s. Ct-~l.i.~'ig~ ..................................................................
3. Nature of work (check which apphcable) New Budding ............. Addition . ....~... ....... Alteration ...... ..-~....,.
Repair ................. Removal .................Demolmor~ ........... Other Work ...............................................
(Description)
4 Estimated Cost ........................................................ Fee ...1.~,,.QD. .................................................................
(to be pa~d on fihng th~s apphcabon)
5 If dwelling, number of dwelhng umts ........ ..o.b.e.. .......... Number of dwelhng units 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,sting structures, ~f any Front .................... Rear ................................ Depth ..................
Height ........................ Number of Stones .......................................................................................................
D=mensions of same structure with alterabons or addmons' Front .................................. Rear ....................
Depth ............................... Height ......................... Number of Stories ..............................
8 D~mensions of entire new construction Fron'tb¢ .......................... Rear ........... J.~. ........... Depth . . .~.?. ........
Height .................... Number of Stones .... D~e ...........................................................................................
9 Size of lot Front ................................................. Rear ................................... Depth .........................
10. Date of Purchase ..................................................... Name of Former Owner .....................................................
11 Zone or use district m which premises are s~tuated . t!~!]..~zLsJ; ......................................................................
12 Does proposed construction v~olate any zomng law, ordinance or regulahon .......................................................
13. W~II lot be regraded ..... .tl.O ................ Will excess fill be removed from premises. ( ) Yes ( ) No
14 Name of Owner of premises .Te.-'i.e.s~o~.e....~q.]:.~.s.~$ ..... Address ....... ~.0.~!,~f~ ...... Phone No ......................
Name of Architect ............................................ Address ................................ Phone No ......................
Name of Contractor ............9.W~...gZ' ......................... Address ................................ Phone No ......................
PLOT DIAGRAM
Locate clearly and d~stmctly all butld~ngs, whether ex~sting or proposed, and mdzcate all set-back d~mens~ons fror~
property lines G~ve street and block number or description according to deed, and show street names and ind~cat~
whether interior or corner lot
STATE OF NE-~V Y~RI~. __ [
COUNTY OF ....... .?.~.ZZ..O.~ ....... f S S
.............. .~.f~,~.~.~rkQz~...~/.Q'l¢?t.?~.ZL ............................ being duly sworn, deposes and s~ys that he ~s the opphcan
(Name of ~nd~wdual sigmng contracf)
above named
He ,s the ................... 9~.e..~.....'?....b..~.~.~..~:.e...~. .........................................................................................................
(Contractor, agent, corporate off,car, etc )
of so,d owner or owners, and ns duly authorized to perform or have performed the said work and to make and ill.
th~s applicabon; that all statements canto=ned ,n th~s apphcahon are true to the best of h~s knowledge and behef; an,
that the work w~ll be performed m the manner set forth m the apphcat,on filed therewith
Sworn to before me this
Notary Public,. ................................................... County Y (Sign;~ure of"applicant) ....