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Home My WebLink About9128-zTOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N*. Y. N°. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 9128 Z Dote ........................................... Permission is hereby granted to: . ^ , I ! , ............. iiiii~i~.~'~...i ..................... .~..?~ ................................................................................ at premises located at ...... ~ ~ ........~...(~..~ff..-~.. .... .' ..................................................................... Building Inspector. Fee $~5,~'~ Building Inspector I TOWN OF $OUTHOLD , 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 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 New B~lilding ...... ~ii Addition~ ........... Oldor Pre-existing Building .....~ ........ :..Vacant Land ........~ ...../ Location Of Property ................ .~..~../2~/././../..~.~.......~/...~../....~....~-.. ......... ...~....~..¢~...~. ........ Owner Or Owners Of Property ......... :....~Q../.~:.....~/.......~..~../~....-~....'~..'~...~..~.~./... ....................................... Subdivision ............. ,,:~-<x~..,C.J~...,f .......................... Lot No ............. Block No ............. House Permit No...~.../~.,.~....~.....~'.. Date Of Permit ..~.'..:~..:.,~,~pplicant .~'~.~...~./-~.//..'./.~.-..~..Z(,~..~ Health Dept. Approval ....~..>...,~.....~....:./~....O... ............. Labor Dept. Approval ......./~...' ..................................... Underwriters Approval ............. ,r...: ............ ......... Planning Bo~rd Approval ........................................ Request For Temporary Certificate ........................................ Fined Certificate Fee Submitted $ '-'~' O c~ Construction on above described building and permit meets all applicable codes and regulations. Applicant ~ .,~.~.../.~'~.... ~,~...~.-~....~.; .................................... Sworn to before me this ..:..>.-..'Z. : '.(. ................ day of ................. Notary Public: ,.o.~,,~.~.d,;~...~../''~ County (stomp or ~'~" / 3 7 ~% X :THE NEW YORK BOARD OF FIRE UNDERWRITERS q~etEi~ql equipment ~s des~Nbed belq~ a~d i~oduced~by the applican~ ~d on the a~ve.appl~ca~io~ ~u~er ~ the premises of Lois SwaneY~:-'355 Su~it: Rd,} So~hol~,:L.i; ,-.. ' ".:~. the follotvi*~g location; B~qmen~ . 1st Ft., 2nd F{:. - outside Section Blbck l . ~ Lot : :' ~,,~ ~a,,,~,,~d o~ JulY' 7~':1977' ~ anafoundtobelncompllancewiththerequlrementsofthlsBoa~d . FIXTURE OUTLETS [ - ' FIXTURES SWITCHES INCANDESCENTiFLUORESCENT RANGES , OVENS EXHAUST FANS 'G.F.C.I.' Smoke Detectors l- 4.5kw Hot water heater Paul Burns, Town Harbor Lane, . This certificate must not be ,[tered in any m=nner; ro~urn to the office of thb Board if incorrect. Insp~dor, gay be identified byL~e~;~,. 19..... Z ~proved ........................................ , 19ZZ. Permit No. Disapproved a/c~~ .......................................................................................... ~~ ............................................................................. ......................... d.....~......~ ......................... ..... ~G., ~,-~' ..... IN'RUCTIONS a. This application must be completely filled in 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 lot and of buildings on premises, relationship to adjoining premises or public streets al 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 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. APPLICAT ON IS HEREBY MADE to tine Building Department for the issuance of o Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other app icable Laws, Ordinances or Ragu arians for the construction of buildings, additions or a~terations, or for removal or demolition, as herein described. The applicant agrees to comp y with all applicable laws, ord nonces, building code, housing code, and ragu arians, and to admit authorized inspectors on premises' and in buildings for necessary inspections. .......... .......................... (Signature of applicant, or name, if a corporation) ............................. , ........ .. ................ , ........... ~ ............... ~Y./.. .... (^d&:ess of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ............................... .......................................................................................................... of ................................................................................................................. If applicant is a corporate, sigr~ure of duly authorized officer. ~/ (Name and title of ~'orporate officer) Builder's License No. Plumber's License No ................................................. Electrician's License No ...... z..l~ .................. Other Trade's License No ................................................ Location of land on which~roposed ,work will be done. Map No.: ..... ...~..~/.~.(¢.~.~...-~....~.. ......... ~Lo~/~o./~ .................... Street and Number ....~(~'¢/~../.~.../.~.....~....,~.'/dd.~, ............................................................. '~'~¢'"'?' ............................ Municipality State existing use and occupancy of premise~, and intended use and occupancy of proposed construction: o. Exisiting use ond occuponcy ....................................................................................... b. Intended use and occupancy ............................................... ~ .......................................................... 3. Nature of work (check which applicable): New Building.. ...... ...~......, Addition .................. Alteration ................ Repair .................. Removal .................. Demolition .................... Other Work .................................................... 4, Estimated Cost ........................... ..O...~.0..:..~.0 ............... Fee : ~' ~ (Description) .......................................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ............ ./.. ............ Number of dwelling units on each floor ........ ./...d~)..'~...~... 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 ...... . ..,~...4,(....~:.. ....... 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 ..~...~. ................ Height ....... .~....~.~.,. Number of Stories ........... ..~..., ..................................................................................................... 9. Size of lot: Front .................. .~'.~.......O. .......................... Rear ......... ~....~..'..0.. ...................... Depth .../...~...O..0. ............. o e 10. Date of Purchase ...................................................... N m of Former Owner ........ ,,/~.~..~..Z~.~.C ........................... 11. Zone or use district in which premises are situated ........... r~..~.~j(~.../..~.. ............................................................. 12, Does proposed construc~iolate any zoning law, ordinance or regulation: .... 12 ........................................... 13. Will lot be regraded .../..~Z..~..Z;~..--~ ............. ._.Will excess fill be removed from premises: ( ) Yes ~No 14. Name of Owner of premises ...~...O.../~,..r~.....~ff'..~'..~.¢.~. ................... Address ..~...O...~...~..,~.9.../...~.. ........ Phone No..,Z..~..~...'../.?..~.~'.. Name of Architect .............................................................. Address ................................ Phone No ....................... Name of Contractor ~,,~?:.~.,~,d~'~d~...~.¢,4¢¢~-~ ................Address ....~..~.K¢../...~..°.../..~...... Phone No. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate ail 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. CTA'iE OF NEW ~O1/,Lq~'~z~. lcS COUNty OF ...,~[.~.~.~.. ......... r /~2~'-/~, ~ .................................................................................... /. ......... oemg duly sworn, deposes and says that he is the applicon (Name of individual signing contract) above named. '~2 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 tg,~m~ake and file this application; that all statements contained in this application are true to the best of his knowl~e a~d belief; and tha~ the work will be performed in the manner set forth in the application filed therewith. ........................ ..- .......... ...... OWNI[I~ SUFF. CO. H£A~,11"I DEPT. APPROVAL \ \ i ,,,<o'u-r~oLD NYC"". ' :'. J ' : ' RODERICK 'VAN TUYL P. C. J LIC. LAND SURVEyoRs-GR~NPORT, N. , J STAMP SEAL J FOR APPROVAL OF ~N~RU~ION ONLY ~ DISPOSAL gYSTEMS FOR THIS RE~I- -: - STAND~RD8 OF SUFFOLK CO. DEPT. AP//P~R..OV~D A5 NO~'I:I:D ~o~ o P