Loading...
HomeMy WebLinkAbout9099-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) N? 9099 Z Permission is hereby granted to: ..... liln~ new one famzly dw,, f~outhold pursuant to application doted ......................~:u~,r........2..~. ................. , 19.~.~'..., and approved by the Building Inspector. Fee $.55.,,6.5 ........... first floor only THE NEW: YORK' BOARD OF FIRE,UNDERWRiTERS ; :. ' BUREAU OF ELECTRICI1Y STREET, NEW only the electrical equipment ~ deserlbed below and int~duced by the applicant na~ed o~ the above aPPlladon ~umber 'Thomaso ~ ~_, - - J~ Elak, No~th B~ view Rd., 1/hmi. South, Ceda~ Rd.~ '~...~'~.,i.~do~ October, 17-,. 1977~ andfoundto~ei~compliat[ce~thtltereqttlre~entsofthisBoard. I G.F.C.I. 1- smoke- detect Alex~der G. Hubb~d Box 222 . , '; ,%quebogue;'N.Y.. i1931 , TOWN OF $OUTHOLD , Building Depmtment 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 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, /Vtultlple 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 os 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: I. Certificote of occupancy $5.00 2. Certificote of occuponcy on pre-existing dwelling or Iond use $5.00 3. Copy of certiflcote of occuponcy $1.00 Date ...... ....................... New B~ilding ..... /~. ....... Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ~.~.~..~.....~.~Q~~.`%`7~.~;~~:~`~.~J~`~ .................... Owner Or Owners Of Property .~...~....~.~,.~ ~ ....~....'.....~.~:~..~.......~..~..~.~.~..K~.~. ~ ~,~,._ Subdivision ................................................................ Lot No ............. Block No ............. House No,..~..~,..O.., Permit No. c~O°t..~.'~-- DoteOf Permit .~.i.~..I .')..-J Applicant ........................................................ ....... ..... Health Dept. Approval ....... /..!./../..H....~.~ .................. 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. Sworn to before me this _ ~'/,,~;~,~ _ / ' f / ...... · /..~... day o ..~:..,~.....~ ........... (stomp o~) ~,,~ .._~ Examined .............. ~.~..~.~.~.~....., 19..~../. ~ .... .~.._ App'l~ation No. ~:E.[.fi. ............. ~prov~ ........................................ , 19..~...~. Permit No. ~..T..~....~....~...i~ .. ,x . Dsap roved a/c . , ~.~ ~ ~x~ ~ - ....................... (Building Inspector) ~'" /*'~1 AP~U~ATION ~OI iUI~IN~ FE~MIT ~ ...... ...... , INSTRUCTIONS a. This application must be completely filled in by typewriter o~ in ink and submitted in triplicate to ~he Budd[ng~ Inspector, wi~h 3 sets of plons, accurate plot plan to ~ale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship ~o adjoining premises or public streets o~ areas, and giving a detailed description of layout ofproper~ must be drawn on the diagram which Js pa~ 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, ~he Building Inspector will issue o 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 Occuponcy~ shall hove been granted by the Building Inspector. APPLICATION IS HEREBY MADE fo the Building Department for the issuance o~ a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Lows, Ordinances or Regulations, for the constru~ion o~ buildings, additions or alterations, or ~or removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and admit authorized inspectors on premises and in buildings for n~essa~ in, actions. ....... ........ .................... (Address of applicant)[ / ~7/ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. 7 ........................................................................................................................................................................ Name of owner of premises .~.~.~ g~.~...~..'...~.~?~.....~..7~.~... ~.%.~.~.~ ..................... If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ..........~...hc.~ ........... P~umber's License No ................................................. Electrician's License No .... ~....S.O..~,..'7.~. ............ Other Trade's License No ............................................... Location of land on which proposed work will be done. Map No.: ........................................ Lot No .................... Street and Number ~.~`.~/~!~x;!~?~.~.~.~:~%~NC~.c~..k~.`~..N~.~.~.~/~..~g...~:~ ................................ Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: o. Exisiting use and occupancy .....¥.]..~%%~.~..:~..~.~........~. !~:'.~..,~..~.. ....................................................................... b. Intended use and occupancy 9x,¢x~,~ CL~ \ C,,k~,C...~. . . . .. 3. Nature of work (check which applicable): New Building. t~ Addition Alteration .............. Repair .................. Removal .................. Demolition .................... Other Work ................................................ .... · ~ '~, . ~".~" ~ ~/,,~ (Description) 4. Estimated Cost ..,,f,l..~...~.~,()'~b .................................... Fee ......'=...--:..J.:]. ......... :...~...,.~..v.. ..................................... (to be paid on fiJing 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 ................................ - ' ~i~i~'~ 8. Dimensions of entire new construction: Front ....... (~.~i.~.I .................... Rear ....... 6~,~ ..............Depth .. ... .~.,.,.,.,.,.,.,.~m.. .~.'. h< .... I-bight .................... Number of Stories ..................................................................................................................... 9. Size of lot: Front .......... -.,: ,., . ........................ Reor ............/../,'~ ......................... Depth ..... :..:'..';.'..,~ ............... / ..... ..~ ............................... Name'~ ' of Former Owner ......... ~ ........................................... 10. Date of Purchase ......... : .~. '\ %\· ~' ~' \ ~' 11. Zone or use district in which premises are situated ....... '.'.J.'].. ........ X ....... '..:.L}~-...'..L~..,..;...\ ................................................ 12. Does proposed construction violate any zoning law, ordinance or regulation: ...... [::..f.a ........................................... 13. Will lot be regraded .......~.~.~. ............... Will excess fill be removed from premises: (~) Yes ( ) ~ '--C ~. . ~, " .;, x ,,..~ Addres~ .n:~.~.~,\}.....*.~ ......... Phone No. 14. Name of Owner of prem ...... . .............. Name of Architect . .............................................................Address ................................Phone No ....................... Nome of Contractor ............................................................ Address ................................Phone No ....................... PLOT DIAGRAM .. ~ocote dearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions frore Property lines. Give street and block number ar description according to deed, and show street names and indicate whether interior or corner STATE OF NEW YORK, ]S S ^ ' ~..~ be n duly deposes and says that he is the app[icam .............. Z. zl.~ ....... /~ ........... ~ ............................. g sworn, (Name of individual signing contract) above n~med. He is the ~ ~ ........................... - .............................................................. (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and .file this application; that ail stmements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set fodh [n the application filed therewith. ' Sworn to before me this ......... of ... ....... ~ ..... (Signoture of opplicont) ~ ~ E~K ?~i;:'"" , ~:bm of No~ York ":.~ ~p, ' , { ~:re~ ~ln;c~ :~, 19 ]~ ','