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Home My WebLink About7930-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, BI. Y. Certificate Of Occupancy No..2~6. 8.6.8. ..... Date ............ ,~al~ ...~ ..... , 197.6. THIS CERTIFIES that the building located at .... Fa~ifi¢..at;re.e.t; ....... Street Map No. x.x ......... Block No...x.~r, .... Lot NoX:~..Iga.l;.titugk.. N.,.~, ........... conforms substantially to the Application for Building Permit heretofore filed in this office dated ......... l~y...1.~., 19.~]~. pursuant to which Building Permit No.. dated .... .M..ay.. J. ~ .... , 19~.., 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 .Private..one. l~.~iLy..d~eXllng, with. an addition .................. The certificate is issued to ....E.d.~.~..I*.d..&...]}.e.~.~h..a..l~..t.l.e.e.a.s.k.~. ...... .~n..~.r..s .......... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . .N,R, ......................... UNDERWRITERS CERTIFICATE No..N26.1.$1+1 ..... De~.. 16..19~.~ .............. HOUSE NUMBER . .1~?~ ....... Street .. Pacifle. St;~.eet ....................... FORM 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) N? 7930 Z Permission is hereby granted to: pursuant to application dated ................................. , 19 ., and approved by the Building Inspector -- Building Inspector FOILM 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 Budding Inspector w~th the following; for new buddings 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 installat~on from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar bu,ldings and installations, a cemficate 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 lines, streets, buddings 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. 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 Date ............................................ ,.. New Bcldding ................ Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Subdivisioa ................................................................ 17et No ............. Block No ............. House No....~...~...~ Permit ~o ....~...?..~..,C.~..~ate afL ' ~Perm~'"~'/'L'~'~'~Applicant ..~.~.%(..~_.~ ....... Health Dept. Apprbval ........ ...~....!..~z... ....................... Labor Dept. Approval ............. .¥....~.~ ..................... .............................................. Planning Board Approval "~ /~ . .......... Underwriters Approval ~1~'~ I I ~ t ............................ Request For Temporary Certificate ........................................ Fined Certificate .......................................... Fee Submitted $ z¥ Construction on above descr,bed building and~r~, ?e~ets..~l ~,,c~bl.e ~d~ ~s. an~ ~g~lations Sworn to before me tl~i,s ........... ~ .... clay OT "i'.,-'-'~ ............. ~"'"~"/ ............ Notary Public ............ County (stamp or seal),'~j , ~-.... 't~-/~ APPROVED AS NO1ED~ DATE: ~ ~ ' ~3{0 ~AM TO 4PM FOR REQUIR- OR CON- Approved ........................................ , TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Disapproved a/c ............................................................................................ INSTRUCTIONS o. Th~s application must be completely f~lled ~n 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 location of fat and of buildings on premises, relationship to adjoining premises or public streets oi areas, and g~ving a detailed description of layout ofproperty must be drawn on the diagram which *s 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 a Building Permit to the applicant Such permi~ shall be kept on the premises available for inspection throughout the work. e No building shall be occupied or used m whole or in part for any purpose whatever until o Certificate of Occupanc~ 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 thc Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances o Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described The applicant agrees to comply with all apphcable laws, ordinances, build~ng code, housing code, and regulations, and t~ admit authorized inspectors on premises and in buildings for necessary inspections. ....................... (Signature of applic;ant, or nan,, if o corporation) ....... .............................. State whether apphcant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder apphcant ~s a corporate, s~gnature of duly authorized officer. (Name and t~tle of corporate officer) Builder's License No ........ ~ ...................... Plumber's License No .... Electrician's License Nol i~i~i~iiiiiiiiiiiiiiii Other Trode's License No ............................................... Location of land on which proposed ~work will be do~e Map No ............................... Lot No .....~ ............... Street end Number ............ . .~.....~r.~i ...... ~.....6~...~.~...~......~..~..~..L.~..-~'... ............. ~.....~..~..~../~........~..~.~.. ~' Municipality ~/ State existing use and occupancy of p~ended use and occu. pancy of proposed construction: a Exis~ting use and occupancy ........................ ~.~ .............. x~. ................................................................... b Intended use and occupancy .................................... .....~'..~....I .......... ~ ........................................................ ? ~3. Nature of work (check which applicable). New Building ................ Addition ..... ............ ~ Alteration Repair ................. Removal .................Demohhor. .............. Other Work ................................................. / ~' (Description) (to be pa~d on fihng th~s apphcat~on) 5. If dwelling, number of dwelhng units ............ r,/. ......... Number of dwelling 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 Dimens,ons o__f ex,st,rig structures, ,f any' Front ....~ (~...~...~.. Rear . .~../.....~ ................. Depth ....... ~.~.. ..... Dimensions of sam/e~tructure w,th alterat,ons or/p_.dd,t,ons Front ............. ..'~...~'...'./....~.. ....... Rear .........~....~. '.~c... Height ....... /. ~ .... Number of. Stories ........~ ................................................ ~ ........... ~.... .............................. 11 Zone or use d~strict in which premises are situated ...................................................................................... 12 Does proposed construction violate any zoning law, ordinance or regulation .................................................. 13 Will lot be regraded ..... ~ ..~m~..~ ........... Will ex_cess~fdl be~r, emoved from prem. ises:~ ) Yes ( ) No 14. Name of Owner of premises .... Address ~. Phone No. . . Name of Architect .................................... Address ................................ Phone No ...................... Name of Contractor ........................................ Address ................................ Phone No ...................... PLOT DIAGRAM Locate clearly and d~stmctly all buddings, whether ex~sting or proposed, and ~ndlcate all set-back dimensions fron property hnes Gwe street and block number or description according to deed, and show street names and ind~cat: whether interior or corner lot STATE OF COUNTY 0~' .~d/._q(.....ISf $ .................................................................................. being duly sworn, deposes and says that he ts the applicon (Name of ~nd~wdual s~gn,ng contracf) above named He ~s the .......................................................................................................................................................... (Contractor, agent, corporate officer, etc ) of said owner or owners, and ~s duly authorized to perform or have performed the sa~d work and to make and fil this application, that all statements contained m this apphcotion are true to the best of h~s knowledge aed behef; an, that the work w~ll be performed ~n the manner set forth in the application fjJ~d Sworn to befo~ me this .~_ // .......... o,,. .... ,, Notary Pub h c~/~/~..~../L....~./...~.~...~, z~.. 4....~. County .~<~......-.~ ...................................................................... ~ JUDITH T BO~<EN (Signature of applicant) h~ctary PuLhc, State cf New York t,;o 52-0344963 Suffolk Counl~,/j Commtsston Expires Ma[ch 30, 19.~_~ !