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Home My WebLink About9064-z ~OR~ NO. ~ TOWN OF SOUTNOLD BUILDING DEPARTMENT TOWN CLERKS OFFICE $OUTHOLD, N.Y. BUILDI~qG PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) No. 9064 Z Permission is hereby granted to: Goldsmith Bldg ~' Cons~$ ~.C Jq~ Pacelli ................ Sou.th~ld ............................................. to. 2u:Lldu ..nmw.. acc e z so~.y...buil$~g ....................................................................................... at premises located at ....Qed~...~v.e..~..~....Ba.y~r~w...R~ad ........................................................ ...................................................... S~u:Lho.lcl ....................................................................................... ...... ~.,,~...,......~.~....~..~..:...:.. ....... .~..,~..y~/..~.,~.~,~..c~ ...... ~..~.~..../... ........... pursuant to application dated .........................].4air ....... .1: ............ , 19..'~.~.., and approved by the Building Inspector. Fee $.J.g. aQ~ .......... FORM NO. 6 TOWN OF $OUTHOLD Building Department Town Gle~s Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted in triplicate 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 dispcsal--(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 Dote ...... ~..~-.~....:~'../....~..../..~..' .~. Z. New Building .................... Old or Pre-existing Building ............................ Vacant Land ............................ Locotlo. Of Property .... ......... ....... Owner Or Owners Of Property ..... :~.~'.~,2~..C;; .-~.,.~.~ ........... /'2~.~,~...~.~.i ..................................................... Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No ..................... Date Of Permit .................... Applicant ................................. ; ,.~. ........................... Health Dept. Approval ...... ~.~.~f...c=~.. ................... Labor Dept. Approval .................... 7.,..~ ..................... Underwriters Approval ........ /.~/~../ff..~ ......... Plannina Board Ao~rova Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ ....... ~,.~.,..f~. ................. Sworn to before me~fl3is ....... :; ...... aay or ...~,......,-~., .......................... Notary Public ~.'i~ ~ ........ County~' ~ ~ Construction on above described building and permit meets all applicable codes and regulations. Applicon, ..... )' .... "....' ..... ~~ ...... :'.'"'~ ..................... FORM NO. 6 TOWN OF SOUTHOLD BuJJdJng 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 triplicate 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 oT 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 $I.00 ate ....... New Building // Old or Pre-existing Building Vacant Land Location Of Property ................................................................................................. Owner Or Owners Of Property ....... .~/.."~..~..-~'.'.'.'.'.'.'.'.'.~.../' ........... ./.?~.~'..~.¢~.i .................................................... Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No ..................... Date Of Permit .................... Applicant .................................................................. Health Dept. Approval ........ /~¢.Gx~_....¢..-..'~. .................. Labor Dept. Approval ................................................ Underwriters Approval .......... /..~t./~.~.. .................... Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ ........~..~..~ ................ Construction on above described building and permit meets all applicable codes and regulations. Sworn to before me this Applicant ....... ................ day of ............................................ Notary Public .................................... County (stamp or seal) FO~M NO. 1 Approved ................... .c.} ............. , 19 Permit No ............. ( ' 'g pct~ APPLICATION FOR BUll.DING I*ER~IT INSTRUCTIONS o. This application must be completely filled in by h~pewrlter o~ in ink and submitted in trlplicete to the Buildinoq~ Inspector, with 3 set~ 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 o~r areas, and giving a detailed description of layout ofproperty 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;?¢c shall be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or Jn 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~l 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 inspections. C~-'c~ ~'/2//21 ~ . _~ (Signature of applicant, or name, ifa corporation) (Address of 6pplic~'nt) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. . . . Nome of owner of premises ... ~..~ ............................ ;...~. ............................................................... If applicant is a corporate, signature of duly authorized officer. ..... ........ (Name and title of corporate officer) Builder's License No ..................................................... Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No of land on which proposed work will be done. Map No.: ~2..~......~ :.. Lot No ~ 1. Location Street and Number~.....~.~.......C~.~.....~.~...~..~~..~~'~.~.~:~ ~' / ~ Municipali~ 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ................................................................................................................................ b. Intended use and occupancy ..... ~,',~.,./,,~,./, .~/.. ......... ~,~.~z'~.; ............................................................ ............ / 3. Nature of work (check which applicable): New Building'. ................. Addition .................. Alteration ................ Repair .................. Removal .................. Demolition .................... Other Work ..(,/.~7..,&./,/Z~/¢ ....... ~<~.~.,,,,,...,, /(Description) 4. Estimated Cost ......................... .¢~.~-~.,....~.. ................. Fee ..L..~....~ ..................................................................... (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 ..../.¢2 ............... Height ......~. ............ Number of Stories ......... / .......................................................................................................... 9. Size of lot: Front ................~,.,¢.O. .............................. Rear ............... Z..~...¢. .................. Depth ....... ,/.¢:.~.~......-~.. ........ 10. Date of Purchase ........................................................ Name of Former O?er ........................................................ 1 1. Zone or use district in which premises are situated ...~.~-.~,L .~....~..~/~..~....~....~.. .......................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: .... ~...8. ............................................. 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 ....................... Name of Contractor ............................................................ Address ................................ Phone No ....................... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions frorn property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NE~------~J~ TM rl~ COUNTY OF ..'%.~....~$..~T..O./.t~. ...... ...~/%~.~ ........ ~~....~./~ ........................ being duly sworn, deposes and says that he is the applicam (Name of individual signing contract) above named.~ ~ He is the ................................................................................................................................................................................. (Contractor, agent, corporate officer, etc.) of soid owner or owners, and is duly authorized to perform or here performed the said work and to make and file this application; that all statements contained in this applicetion are true to the best of his knowledge and belief; and that the work will be performed in the manner set fodh in the application filed therewith. ......................... .......... {Si~norure or oppHc~nt) NOTARY PU}~LI~, State of Hew York Term Expires Marc~