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Home My WebLink About10018-z FOR~ NO. ~ 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? 10018 Z Building Inspector. FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall 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 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- t[ons, 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 peopert¥ showing all property lines, streets, buildings and unusua~ natural or topographic featu res. 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. 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 $5.00 Date ...... .... New Building ............. Old or Pre-existing Building ............ Vacant Land ............. · ..... Location of Property ; ....... ~:'..' ...... ( .............. '. · · ' House No, ~/ Street Hamlet Owner or Owners of Property . ................ ............................ bubdw~s~on. / ( ~.~.~ ........ ' ............ ii...'.. ~.w~ap I~O ....... , ........ LO~ ~o ............... Permit No. ~:.~ .~ ~.~. Dato o, ,ermit ~(~.~.Appl,c,nt... ~':~ ~. ~..~~ .... 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 applic,.able codes and regulations. Applicant ....~ ....... J ............. ~ .......... f,. ............. Rev. 10-10-78 APPLICATION FOR BUILDING PERMIT 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 public streets or 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 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. (S gnature of al~plicant, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Nome of owner of p em ses ........... ".d.t..J ....... t. ...... ..... .................. ,.~ ................................................................................. If applicant is a corporate, signature of duly authorized officer. tmame and title or corporate ofticeo Builder's License No. / ' ~ ~' ' ~ / / .~5..~;. 'z.' ~ ~' Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No .................................................. , 1. Location of land on. wh,ch proposed work w,ll be done. Map No../br.~.~,.~-~.~ ....... 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 ' ' ~ b. Intended use and occupancy ....................... ~...,~..~ .......... ~'¢~>~;~.. .,t~:~.2wT~.~.~f.y~.~;.....~ ............. 3. Nature of work (check w~ich applicable): New Building'. ................. Addition .................. Alteration .... Repair .................. Removal .................. Demolition .................... Other Work .................................................... ~..~. (Description) ...... ..................................... Fee ...... . ..................................................................... Estimated Cost 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 ................................ 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: ........................................................ 13. Will lot be regraded . ........................... Will excess fill be removed from premises: (~) Yes ( ) No 14. Name of Owner of premlses~J~..~./~.~2..~,..~/'~.~,~... Address~.~..~..,_~.~.~.~,~.~..~ ,~,-~.' Phone No ....................... Name of Architect .............................................................. Address ................................ Phone No ....................... Name of Contractor .. L ........ Address ~.~..C~.~...~.~.~...... Phone No. 4~..~..~...~'..~f.~ u PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, ~ c S COUNTY OF ................................ ................................................................................................. being duly sworn, deposes and says that he is the applicom (Name of individual signing contract) 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 alt statements contained in this application are true to the'best of his knowledge and belief; and thor the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this Notary Public .~.V,Z/'/.I~'~/G~.' ..~p.:..~z..~r~.~.~.~;.~¢¢.- ~,ounty ........... ................... :._. ................ ;. .............................................. ,// (Signature at applicant) PAM[t^ J, SCHIN£LLER