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Home My WebLink About10004-z FOKM NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTH'OLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 1000~ Z Permission is hereby granted to: ~6/7~ ,'-~ c~ v z: . ................................. .~.~.:..... '....:..:~. .......... ~.:.:..~.: ............. .z.-.~ :.c : .................... .:..~..4z..~..~..: ............... pursuant to application dated ............................. ...~-...~.........~...~.,,.., 19,~.,.~.., and approved by the Building Inspector. /_~ Fee $ ........................ Building Inspector FOF,,M NO. 6 TOWN Or SOUT~OLD Building Delm~tment Town Clerks Office Southold, N. ¥. 11971 APPLIGATION FOR CERTIFICATE OF OCGUPANGY Instructions A. This application must be filled in typewriter OR ink, and submitted in t~J~i~te 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 o'f 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 3. Copy of certificate of occupancy $1.00 Date ......... i ....................... New Building .................... Old or Pre-existing Buiid~p. ............~1~ .......... Vacant Land ............................ .~. Location Of Property. ...~......~...~...~..~...~ ................... ', ............................ ...e~,..~. ...................... Owner Or Owners Of Property .~/1~**~** ................... Subdivision ................................................................ Lot No ............. Block~i~. ............ House No ............. Pe,..,it N ...................... Date O m~t ..I .............. ,~ · ........................................................... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ ...... .S.... Construction on above described building and permit meets/oll~pplicable codes and regulations. Applicant .......... ~ ......... (J**.**~***~ ................................................. Sworn to before me this ................ day of ..... Notary Public ..... ..~,~U...F.~.O..~,~...... County ANET V. STEWART NOtARy PUBLIC~ Stole o~ Ne~1 No, 52-4663485 Qualified in SUffo/~ Coun~ (stamp or seal) TOWN I-IF SOUTHOLD r"IFFI~E DF BUILDING INSPECTOR TOWN P. LEI~K'S OFFICE SnUTHOLD, N. Y. t1971 TEL. FORM ~qO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. ~proved ...................... ~... ............ , 19 ........ Permit No ............................... Disapproved ~ ' ' g spector) Application No ..... /...~...~...~...Z. .......... APPLICATION FOR BUILDING PERMIT Date ..... ............... , INSTRUCTIONS 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 premises or publ c streets o 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. 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 Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. The applicont agrees to comply with all applicable laws, ordinances building code, housi~l.,ee~e, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections, f/ ..................... ( ................................. (Signature of applicant, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ..................... ;'J..~:.,....~......Z~ ....... h:-..,:~.:....;;.'.?.'/.~..:..~..~:~. .................................................................... 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 ............................................... 1. Location of land on which proposed work will be done. Map No.: ......... L.~.~g ....................... Lot No. ~ / ~ Street and Number ..................... ~:,.,~.,...,~,~.¢.....,.~ ........ :.~,......~ ......... ~....~ ......... ,..~, ...... , ........ ,: ................................. Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ................... J¢,.:,_;. ................................................................................................... b. Intended use and occupancy ~ ~ ' r 3. Nature of work (check which applicable): New Building.. ................. Addition .................. Alteration ................ Repair .................. Removal .................. Demolition .................... Other Work ................................................ . .... (Description) 4. Estimated Cost ..................................... ] ...................... 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, s~e~ify, nature and extent~ofLeach. L type of use ............................ 7. Dimensions of~xLsting structures, if any: Front ~ Rear ................................ Depth Heiflht ..... Number of Stories ............................................................................................ _ · .................. ~ ~ Dimension~of s%me structure with alteratiogs~or additions: Front .......... .; ....................... Rear ..... : ...................... Depth ................ ] ............... Height ........................... .~um~er of Stories ..........~;, ...... ~. ........... B. Dimensions ,~f e~}ire new construction: Front .................................... ~ear ............................ uepm ........................ Height ............... Number or,Stories ......................................................................................... ~ '"'?.. .................... t~ ~ " ~ ~e-th 9. Size of lot: Front ........................................................ ~ear .......................................... u p ................................ 10. Date of Purchase ........................................................ Name of Former Owner ........................................................ 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: .............. ~¢. ..................................... ......... Wdl excess fill be removed from premises: ( ) Yes ( ) No 13. Will lot be regraded . ......... ~ ....... ~ ~'~ 14. Name of Owner of premises ~ -,~,~,t ~..~"~ .....< ........ .................................................... Addre~ ................................ Phone No. Name of Architect ................ ¢ .................... ~ ........................ Address ..;> ............................ Phone No.y...; ................ ............................................................ Name of Contractor A'~ J ~"~'~-'~ [ ~'~" > Address ................................ Phone PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-~ck dimensions from prope~y lines. Give street and Nock number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK,- .~ - OO't~r~ I~ COUN YY [DF. ...........~. ................... ................. ..~.....m..~..~....~....~..t..~..~k ............................................... being duly sworn, deposes and says that he is the applicam (Name of individual signing contracf) above named. 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 all statements contained in this application are true to the best of his knowledge and belief; and tha~ the work will be p,~[kormed in the manner set forth in the application filed Sworn to before me thrs '~// ,ex day 5./ ......... .......... . \/ ........... ............... ........ .................................... ._ \ (Signature of applicant) NOTARY PUBLIC, State of New Yo~k No, ~2-4612739 Qualified in Suffolk County Commission Expires March $0, 19/.~/7 ,,,NOTIFY BUILDING DEPARTMENT AT 1. BEFORE BACKFILLING FOUNDA- TION OR START FRAMING NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS -.~, ALL CONSTRUCTION MUST MEET REQUIREMENTS OF N.Y. STATE CODE AND TOWN HOUSING CODE & ZONING