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Home My WebLink About9185-z FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 11971 765- 1802 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted m',,-=~I to the Building Inspec- tor 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 featu res. 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 installa- tions, 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. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of p~Operty 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 informa- tion required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling $15.0 0 3. Copv of certificate of occupancy $1.00 4.Vacant Land C.O. $5.00 ~..c~ ~ 5.Updated C.O. $15.00 Date ... · .................. NewConstruction ...... Old or Pre-existing Building ............ Vacant Land ............. Location of Property .................... ', · ~ .............. ~ ..... Owner or Owners of ~roporW ................................... County Tax Map No. 1000 Section ~"~(~ ~' Block Lot. Subdivision ................................. Filed Map No ........... Lot No .............. PermitNo. ~'/~,5"~ D~e of Permit ,~/Z.;' .... Applicant ~..~.'r. Health Dept. Approval ........................ 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 app.. ble codes and regulations. Applicant...~'-*~..~.....~.~ ......................... Rev. lO-lO-7e 765-1802 BUILDING DEPT. INSPECTION [ ] FRAMING REMARKS: FOUNDATION 1ST []ROUGH PLBG. FOUNDATION 2ND []INSULATION []FINAL DATE ~//~ INSPECTOR FOUNDATION (1st) FOUNDATION (2nd) ROUGH FRAME & FLUMBING INSULATION PER N. STATE ENERGY CODE FINAL ADDITIONAL COMMENTS: TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined ...........~ ......................... , 19..../...f 19 I/ " ' Approved ' [ ~( Permit No. '/ /'~ Application No. / ~ '~ Disapproved ~~~ .................... ~ ................ {Building Inspector) / ........................ APPLICATION FOR BUILDING PERMIT INSTRUCTIONS I't 77 Date ................................................. 19 ............ a. This 'application must be completely filled in by typewriter o~ 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 pram sss or pub c streets o~ areas and giving a detailed description of layout ofproperty must be drawn on the diagram which is 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, the Building Inspector will issue a Building Permit to the epplicont. 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 shell have been ,granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Perm t pursuant to the Building 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. Yhe 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. (Signature of applicant, or name, if a corporation) (Address of applicant) t ~ ~/ ;tare whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ~ame of owner of premises ......................................................................... . f applicant is a co~orate, 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 ............................................... ~-~-r ~ t:-* ~:: ~]:::~ ~^ Location of land on which proposedwork~iU be d~ne. Ma~ No.: .................... .Lot No · , ~;~'I:/D~7 ~.::_~, ('OU~q-( ;~ C~ L/~)~.~VF~.7;:F""hV' Street and r~umoer .................................................................................................................... / Municipalit7 State existing use and occupancy of premises and intended use and o~cupancy of proposed construction: t F/'~I''lf~-- "Y a, Exisiting use and occupancy ................................................................................................................................ '~P, ~xt If, ~^/! -T t~ /~ t~c' t: -~. ~ C, N:' b. Intended use and occupancy ..................................................................................................... 3. Nature of work (check which applicable): New Building,. ................. Addition .................. Alteration ................. Repair .................. Removal .................. Demolitior ..................... Other Work ..................................................... (Description) / 4. Estimated Cost .................................... .~.-2...~.....td.. ......... Fee (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 ........................ Height .................... Number of Stories ...................................................................................................................... 9. Size of lot: Front ................................. (...~.:....'¢.~. .......... Rear .......................................... Depth / /'2 (5' 10. Date of Purchase ......................... ./..?......~....~.. .............. Name of Former Owner ......... / 11. Zone or use district in which premises are situated ......................... ~,../:...-e.'.../....D...~...~.....:../../..~...L.:.-~. ............................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ........................................................ 13. Will lot be regraded. ........ .~......~. .......... Will excess fill be removed from premises: ( ) Yes ( ~'~o I4. Name of Owner of premises ......... f..~.. ........ ?..!.);..t:..:F.~ .......... Address ...~...0..t.~.[,['..!:/..O..~..~.... 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 from ~roperty lines. Give street and block number or description according to deed, and show street names and indicate vhether interior or corner lot. :]'ATE OF NEW YOB :aUNTY OF ....... ~L..eLt.'.:~f ~'~ ............................ ......~.t.k.~:..~:..~ .................... being duly sworn, deposes and says that he is the applicant (Name of individual signing contracO ~bove named. ........... g . . .. He is the .............................................................................................. ' .................................................................. (Contractor, agent, corporate officer, etc.) Z said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application; that all statements contained Jn this application are true to the best of his knowledge and belief; and ~haT the work will be performed in the manner set fo~h in the application filed therewith. Sworn to befor~ me this ...................... of .................................. c,., ....... ....................... '/~ /7,~,~_¢ ~ k /~ (Signature of applicant) ELIZABETH ANN N~IL[~ NOTARY PUBLIC, State o~ New Y~k N& 52.~Z25850, Suffolk Cou~