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Home My WebLink About10021-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N.Y. Certificate Of Occupancy No, .. %10.123. ....... Date ........ ~..ep.~.e.m..~??..~. ........... ,19. THIS CERTIFIES that the building ................................................ Location of Property .... 5¢9.7.0 Main Road, . $outhold House No. ' ................... '$~/ebt ....................... County Tax Map No. 1000 Section .... 6/~ ...... Block ..... 'l ......... Lot .......... 17 ..... Subdivision ............................... Filed Map No ......... Lot No .............. conforms substantially to the Application for Building Permit heretofore filed in this office dated ·.. Oc/colaer..6 ....... , 19..7.t~ursuant to which Building Permit No...!0Q.2.i..Z. ........... dated .... No.v. enlb~. ~. 7. .......... 19.7.~ was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for which this certificate is issued is ......... .......................... Banl~ ................................................. The certificate is issued to ...... The .blonth. Fo. rk. B.sxlk, &..T~.~..gO.rap..agy ........... (owner, of the aforesaid building. Suffolk County Department of Health Approval .......................................... UNDERWRITERS CERTIFICATE NO ....... .N../4.2.8. ~../4.2. ................................. Building Inspector Rev 4/79 l~OE~ NO. ~ 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) No. 10021 Z Permission is hereby granted to: ./.../..r:.,::::./Z ...... .:~::~./.~.t.V..........TJA.~.~.....4.:..~:7 r~ ..... ........ ......... ......... c.,~.~.~.., ........................... at premises located at .............. ..~...~..~.'....7...0. ....... ../~....~.../..~./. .......... ..~.c~.~...~.../..~. ........................................... pursuant to application doted .............................. tO....~....7.. ....... .(~...., 19.7..~...., and approved by the Building Inspector. Fee $...~....~:.i... FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions 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 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 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. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of peoperty 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 or land use 3. Copy of certificate of occupancy $1.00 $5.00 Date .......................... New Building ............. Old or Pre-existing Building ............ Vacant Land ............. House No. Street Hamlet County Tax Map No. 1000 Section ~'.. ,~.' ........ Block , . . ./ ........... Lot../?. ............ Subdivision ................................. Filed Map No ........... Lot No .............. Permit No, ./, .O~,~. ,/,, , Date of Permit /.~, ./.~.Z,/, ,~'~, .Applicant ~r~,, ,~",~ ¢, ,~?,~ ,.~,',7-~:~*,~,, ~. ........ Health Dept. Approval ........................ Labor Dept. Approval ........................ Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate ....................... Fee Submitted $ ..... ~5,, p,O, ,. ' Construction on above described building and permit meets afl al~plicable c,~es and regulations. PP .d_ · · '~'-' · ,L':~; .................................. ,.,,. 3. Nature of work (check which applicable): New Building~· ................. Addition .................. Alteration ................. Repair .................. Removal .................. Demolition .................... Other Work ..................................................... 4. Estimated Cost I 4 DT)"'~ ................................ Fee c~,~ (Description) (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 ..,J~..~/.,~,.,,~ .......... 7. Dimensions of existing structures, if any' Front ..........~.....L.~I ........... Rear ........ ..~....~. ...... Depth ....~...~. ......... Height ...... !..~.. ............ Number of Stories ........ l ........................................................................................................ ,~.. Dimensions of same structure with alterations or additions: Front ........... ..~....~. ................. Rear ......... .~.....~. ........... Depth ........ .~....O.. ................. Height ....... .k~...~ .............. Number of Stories ...........L ................... 8. Dimensions of entire new construction: Front ........... ~'.. ..................... Rear ......... ~....~... ......... Depth ........ ~. ~ Height ....].~...! ........ Number of Stories ..... [ ................................................................................. 9. Size of lot: Front ...............,~.~ ................................ Rear ................. ~...7......-. ............. Depth ....... }..~,....~... ............ v~ ,.K. 10. Date of Purchase ...........~..~..~ ................................. Name of Formej; Owner ................................................ 11. Zone or use district in which premises are situated ...... ~...O...~..~....~.~..~...q. ..................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: .......... ?~J....~. .................................... 13. Will lot be regraded . .......~......O. ............ Will excess fill be removed fram premises: ( . ) Yes (~) No ~,:!.~. ~....?.~ 14. Name of Owner of premises ........ /~.....~.'...:J~..Z.~ ..................... Address Phone No. Name af Architect ~.i~.?..-...~,",,?.'..,~,.,,,,-,,.~,,.~,~..~ ...... Address ..... ~....~ .................. Phone No ....................... Name of Contractor ....... .~.... ,~......,~..~'.'. .............................. Address .,l~.b/:..Z..r.!.~..~.....~...... Phone No....o(. ............... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions frorn praperty 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 COUi~I~Y' OF ......... ?.~.~.,,:.~~/...x?Z.,/./..~..../..T.M,.~.~being d,~y swo~n, deposes and says that he ~s the epp~can, - (Name of individuaJ/s~'gning 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 th s application; that all 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,gp~cation filed therewith. Sworn to b_efere me this .[/ / ,r-'---"~-- ~ [/' ] .........,,,, , of ....... 2~.L..../........(~..'.~...Z.'....~ Noto~ Pub,ic,I~.U,/r.,:'.~..~.,,....:..,:,,.:.,...U.Z./.4..4.:.:.., Co,n~ ................ ............................... N~TA~Mp~B~t~iS$,~Ci~JOy~eE~¥O(k, (Signature of applicant) Ou~fled m Suffolk County APPROV~ED A~ NOT_ED 765-2660 9AM to 4PM FOR REQUIR- ED INSPECTIONS: 1. BEFORE BACKFILLING FOUNDA- TION OR START FRAMING 3. BEFORE COVERING PIPES OF ANY KIND 4, FINAL WHEN JO~ COMPLETED NOT RESPONSIBLE FOR DESIGN 5. ALL CONSTRUCTION MUST MEET ¸, , [ (=U.l ov~ ?,"co;,, ~'r',"'~--- SLCTIONI s; CT~o~l -kIOKT¢ FOP, K bAkJR 4- T~,UST co- .,~o UTt. I oL1) ~R,k~ c+-I · S]T~. pL.A~!