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Home My WebLink About9523-zNO, 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Cerli{icate O{ Occupancy THIS CERTIFIES that the buildin located at ~/~ ~, _ g .~.~ .................. Street ...... ..... conforms substantially to the Application for Building Permit heretofore filed in this office dated ...... ~.~..~.~Y., 19. ~. ~ pursuant to which Building Permit No. ~a ~ dated ...... ~... ~..., 19~7, was issued, and conforms to ali Of the requke- ments of the applicable provisions of the law. The occupancy for which this certificate is The certificate is issued to .~~....~ ..... ~ ............. (owner, lessee or ten~t) of the aforesaid building. Suffolk County Department of Health Approval ~. f~ ............................. HOUSE NUMBER../. ~O~ ..... Street. ~ .. ~ ..... ~J~. .. TOWN Of SOUTHOLD BUILDING DEPARTMEHT TOWN CLERK'S OFFICE SOUTHOLD, N.Y. BUILDIHG PER~IT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 9523 Z Permission is hem~y granted to: A ~--.ae~.l.:~e. ~..~.. e~ ...]:r,Q...A/43. ......... l~att~.tuel~ ................................................ ~ .-.l~[.ld...e~..e~td.~ t.~e~..em.. ~x~.s~ .t~ll..d~e~ .............................................................. pursuant to aapI]cation dated .......................... .~.(~..~...~. .............. , 19....~., and approved by the Building Impector. Fee $.1 ~.~.Q ........... FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Clerks Office Seuthold, 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-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: 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 ./...~../.Z .~,/~.~ ....................... New Building ................ Addition .....~. Old or Pre-existing Building ................ Vacant Land .............. .....---- -' .............. .............. Location Of Property Owner Or Owners Of Property ........ ~...,t~../~..g.~.. ....... .~......C..~../. ............................................................. Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Health Dept. Approval ...~,M~,,:..: .......................Labor Dept. Approval Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate ~/~- Fee Submitted $ ........ .~...:.~...~.. ............ Construction on above described building and permit meets all applicable codes and regulations. Applicant ...~...~.~ ....~./... ~ .............. .~ ...................... otory Pub,,c ............. County TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Approved ......................................... 19 ....... Permit No ..... ::~ ........ ........................... ~'i~uild' .... i'~ I nsp~""~ '" ;;~¥;';i ................................ APPLICATION FOR BUILDIN:~MIT INSTRUCTIONS a. This application must be completely filled in by typewriter ol~ 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 lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout ofproperb/must be drawn 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 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 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 Bu.ilding 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 ir~ buildings for necessary inspections. (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ................................................................................... ................................................................................... Name of owner of premises / (9 / <- If applicant is a corporate, signature of duly authorized officer. ........ .......... ,marne and ~i~'l'~";~"~)';~;;;'f;";~c';'~i ......... Builder's License No. /5 Plumber's License No.....~..L..~..: .................................. Electrician's License No.../.! .......... ? ............................ Other Trade's License No ............................................... 1. Location of land on which' A,..,,.,., ~pr°D°sed work will b~ done. Mo? No.: ..... .~....?......J. ....................... Lot No.-.~.~. ............. Street and Number ....... ~f?.C..,...~~ ................ ~.~..~.~.~(~..~ .......................................... Municipali~ State existing use and occupancy of premises and intended use and occuponcy of proposed construction: o. Exisiting use and occupancy ............................ :,.. ................................................................................................. b. Intended use and occupancy ........ .~Z.~'K¢l.4~.....~ff .......w~.~':'..?..~..~.~Z~..~s(~ .............................................. 3. Nature of work (check which applicable): New Building'. ................. Addition .... ./ Alteration .............. Repair . ................. Removal .................. Demolitior. ................... Other Work ................................................. (Description) 4. Estimated Cast .......................... .~..~.~.q,..~.~ .............. Fee ~ (~'' ~ (Io 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: Fron~ ............................ Rear ................................Depth .................... Height ........................ Number of Stories ................................................................................................................. Dimensions of same structure with alterations or additions: Front .................................... Rear ............................ Depth ................................Height ............................ Number of Stories ................................ 8. Dimensioas of entire new construction: Front ............. /.~ .................Rear .......Z.~ ............... Depth ..... /~ ............. Height .................... Number of Stories ..................................................................................................................... 9. Size of lot: Front ........................................................ Rear .......................................... Depth ................................ 10. Date of Purchase ........................................................Name of Former Owner ........................................................ 11. Zone or use district in which premises are situated ..................... ~ ............................................................................ J2 Does proposed construction violate any zoning Jaw, ordinance or regulation: ........................................................ 13. Will lot be regraded ......... ~.~ .............Will excess fill be removed from premises: (~es ( ) No 14. Name of Owner of premises ...~.~.~ ....... ~ .............. Address ..X¢?.~.~[i.g. lt..4~ ...... Phone No ....................... " Name of Architect .............................................................. ~ Address ................................Phone No ................... .,.., b~om~ of Contractor ..... ~..~.~.~.%~/~/~.~.....Z~.~Address ...... ~..~..~.~ ....... Phone No. ~ PLOT DIAGRAM Locate clearly and distinctly all buildings, ~hether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block number ~r description according to deed, and show street names and indicate ~hether interior or corner Io~. ~.~ / . / ~_ ~-A'J'E...OF NEW. YORK, ~ c S ~ ~ f'"~ ' ~~bm dui sworn, deposes and says at he s the app c~~ LgLJN' i~ OF ................................ ............. .....: ...... ................ y . (Name of mdlvldual s,gn,ng contract) /~~ above named, ~ He is the ...........................~.~.Z)..~..~ ................................. :'"~ ..... r~ ........................................................... (Contractor, agent, corporate officer, etc.) oF said owner or owners, and is duly authorized to perform or have p~formed the s~work and to make and file this c~pplication; that all statements contained in this applicetion are true to the best of~J~.knowledge and belieF; that the work will be performed in the manner set fo~h in the appJicqtion filed therewith. Sworn to before me this ........................ day of ............................................ , 19 ........ ~.~ ~ Nota~ Public, . ................................................... Coun~ ..... ).~?.~ .... ( ................... (Signature of appiica~t)~ REVISIONs