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Home My WebLink About9295-z FORM 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) 9295 Z Permission is hereby granted to: FORM NO. 6 TOWN OF SOUTHOLD , Building Deportment Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This apphcation 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, end 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 state 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 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 ........ lNoecl t i~oUl ' d '0;g ................................ , O ner Or Owners Of Prope .......... Subdivision ......................... ~ ................. Lot No.~' ~J.~... Bkx:k No .~. .... House No...~.. ....... Permit No...~..~;.~-Date Of Permit b.~.....~......~...Z~pplicant .... iii:;:.~:!..Z. .................................... Health Dept. Approval ....... L.~.....!..~.. ......................... Labor Dept. Approval ............. .~.'...:../...<. ...................... Underwriters Approval ...../~//.;. ..................................... Planning Board Approval Request For Temporary C. erti, ficate ........................................ Fin~ Certificate .......................................... Fee Submitted $ ......~... ............................ Construction on above described building and permit meets all applicable codes and regulations. Applicant ......................................................................................................... Sworn to before me this ....... ..~.,,..~. dayof .... ~:~.~..~.../..2 ....... Notary Publi~: County (stamp or Seal) Approved ........................................ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Application No..Z..c~.../~...~.'~... ........ D,sapproved a~....~...~ APPLICATION FOR BUILDING PERMIT Date ............ INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Buildir 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, relat~onship to adjoining premises or public streets areas, and gwing a detaded description of layout ofproperty must be drawn on the diagram which is part of th~s applicatio, 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 ~ssue a Building Permit to the apphcant Such perm 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 Occupant 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 Budding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances · Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein describe~ The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and t admit authorized inspectors on premises and in buildings for nece. ssary inspe~ions. . ( i~ature o{~ol~pli~nt, or nome, if a corporotion) (Address o{ opplicont) State wh,~?er applicant is owner, lessee, ~ent, ~rchitect, engineer, ~ener~t contractor, electnci,n, plumber or builde ............ .......................................................................................................................................... N a me of owner of premises. ~C~ ~... ~4 ~Z ~¢Z~.~ ~.....~ .......................................................... if apphcant ~s a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ...... ~.i ................... Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............................................... Location of land on which ro osed work will be done Map No ~ Lot No .............. Street and Number ..... ~ ~'~ Municipality State exishng use and occupancy of premises and intended use and occupancy of proposed construction: --/ a Exis,ting use and occupancy ..1~..~.,,~......~.-- ................................................................................................. / ~-~/..~ .~ /'} // ~..~ '~ b Intended use and occupancy ....~....~....~...(~.....~..../~...F.c.'..M't:.....V~...~...~.~.....~...../.. ..................................... v' 3 Nature of work (check which applicable) New Budding · /..%. .........Addmon ................. Alteration Repair ............... Removal .............. Demolmor ............... Other Work ........................................... (Descriphon) Est,ma ed C:n~t ~ '-~ ~)' O (~ //D 4 t ..... ~ ............................................... Fee ................................................................................. (to be pa~d on filing this apphcation) 5 If dwelhng, number of dwelhng umts ....................... Number of dwelling umts on each floor .................. If garage, number of cars .................... 6 If business, commercial or m~xed occupancy, specify nature and extent of each Wpe of use ........................ 7 D~mens~ons of ex~stmg structures, ~f any Fro~,t .................... Rear ................................ Depth .................. Height ..................... Number of Storms ................................................................................................... D~mensions of same structure ~ith alterahons or addmons Front ................................. Rear ................ Depth ......................... Height ...............___ Number of Storms .................... 8 D,mens,ons of ent,re new construct,on' Front .... ~.Y ~ ........... Rear.. /.~ ....... Depth ..~-- --~. Hmght ~ ~..~ .. Number of Stones Date of Purchase / ~ ..................................................... ........................................... Name of Former Owner ~~ Zone or use &strmt m which premises are s~tuated ............................................................................ Does proposed construction wolate any zoning law, ordinance or regulahon ....................................................... W~II lot be regraded ...... ~ ..............Will excess fill be removed from premises: ( ) Yes (~ No Name of Owner of w ...................................... ~ ~aaress ................................................ Name of Architect . Mo~ ................... Address ................................ Phone No ..................... Nome of Contractor ...~ ................... Address ................................ Phone No ..................... PLOT DIAGRAM Locate clearly and distinctly all buddings, whether ex~stmg or proposed, and md~cate all set-back d~mensmns fror properly hnes Gwe street and block number or descnpt~on according to deed, and show street names and in&cat ,hether interior or corner lot . . 9 10. 11. 12 13 ,.14 STATE OF NEW YORK, COUNTY OF ~Ee~ ....... J (N~me of mdwidu~l s~gnmg ~bove homed He ,s the ..... ~.~.~.~ ........................................................................................................................ (Contractor, ~gent, corporate officer, etc ) of s~d owner or owners, th~s ~ppl~c~hon; that ~1 statements conf~m~d m th~ the ~ork wdl be performed ~n the m~nner set ~o~h m t~e ~phc~t~on filed therewith. .......... ......... of ....... , 2 Nota~ Pubhc~ ............... ~ .......................... Coun~ .................... I ~ARY E ~A~/PUBLIC, State of New Yor~ No 52.4643721, Suffolk Cau~ Te~m Expue~ ~arcb 30