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HomeMy WebLinkAbout9969-z FORM NO. 2 TOWN OF SOUTHOLD BUILDING DEpARtMENT TOWN CLERK'S OFFICE $OU~'HOLD, N. Y. ~ BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 9969 Z Permission is hereby granted to: ................................................... ?/.~ 0 at premises located at ..... t ..................... .............. ~---~,-~.,-,; ............ ............... ;.;~...;..,. ............................ Fee :~....~...~,,.~ ......... 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. Fina{ survey of property with accurate location of all buildings, property lines, streets, and unusuat 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, Industria~ bui{dings, 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 peoperty showing all property lines, streets, buildings and unusual 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 /¢7? , Date ~ New Building ~' Old or Pre-existing Building Vacant Land Location of Property ...~ Z.L'~. ............ /~.~.~. ~.../...'~. '~/~J .... ~ ................ ~ .... House No, Street Ham/et Owner or Owners of Property ~~. ~.. ~. ~.~ ~ ........................ County Tax Map No. 1000 Section d~/~ Block ~ ~ Lot.. ~ ~ Subdivision .~~ .~ .~: ~:~ .... Map No ............... Lot No ............... Permit No.~.~ . Date of Permit ......... Applicant ....... ~) ..... Health Dept. Approval .... ~ ............ Labor Dept. Approval ... ~Z(~ ............ .... ............. .......... Request for Temporary Certificate ..................... Final Certificate ...~ ................ Fee Submitted $ .... ~-. ..................... Construction on above described building and permit meets all applica,~c~s 7~_regulations. Applicant .~, .~~...~...; ~ .~..': .'~.~, .~. .................. Rev. 10-10-71~ TOWN OF _~OUTHrlLD OFFICE OF BUILDING INSPECTOR TOWN CLERK'S OFFICE SOUTHDLD, N. Y, 119'71 TEL. ~6S-~6GD TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N, Y. Examined ............................ ./.. :; ....... , 19.: ...... Approved ........................................ , 19..~ ..... Permit No. -~/ / ~- Disopproved a/c ............................................................................................ Application No. ;...: ............................ (Buil~l(ng Inspectbr) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by typewriter ac in ink and submitted in triplicate to the Building Inspector, with 3 sets of plans, accurate plot plan to scale Fee accord ng to schedu e. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public 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 applicant agrees to comply with all applicable laws, ordinances, build!ng 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) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder· ................................................. ~Wz~'. w :DL~.;L3,J.I~;~: .................................................................................................... Name of owner of premises ...... ~-t~,~,o~"~eG~te.~at'~o ..................................................................................................... If applicant is a corporate, signature of duty authorized officer. (Name and title of corporate officer) Builder's License No ..... OW~e~. .................................... Plumber's License No ................................................. Electrician's License No ............................................. /c~x~,-c~/~'Fo ~--.(jSz~z' Other Trade's License No. ~' 1. Location of land on which proposed work will be done· Map No.: ~ i.' · ~: , ~. · ~:~.i.:-)~'*t....~...~.~e~ ....... Lot No....~/.1 ................. Street and Number ....:,,g~,~M...:~..~......t~.~.~r~ .......... ~,~.:j:e[+j~ .................................................................................... ~'/~ '~ . ~· Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ...,~t~e~.~..i. Yt~. ......................................................................................................... b. Intended use and occupancy ......................... ~.e...~z3.[.h_..a...cl~cl~..aC/.,,].,%?c,~o&~t ........................................... 3. Nature ot' work (check which applicable): New Building'. ................. Addition .....~ ........AIterotion X.~ .......... Repair .................. Removal .................. Demolitior. .................... Ofher Work ............. : .................................... (Description) 4. Estimated Cost ..................... L~q)0..~ ........................... Fee '~5~(~t~o be paid on filing this application) 5. If dwelling, number of dwelling units ....... Ol'~.~ .............. 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: Fron~ ............................ Rear ................................ Depth .................... Height ........................ Number of Stories ................................................................................................................. Dimensions of same structure with ollerations or c~dditions: Front .................................... Rear ............................ Depth ................................ Height ............................ Number of Stories ................................ 8. Dirnensions of entire new construction: Front ........... ~20' ................... Rear ..... .~) .................. Depth .....1.3 ............... Height .................... Number of Stories ..... DI'I~I ......................................................................................................... 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 ....... ~",~?'"dJ:~ ......................................................................... 12 Does proposed construction violate any zoning law, ordinance or regulation: ................... .llt~ ............................... 13. Will lot be regroded ............................ Will excess ~ill be removed from premises: ( ) Yes ( ) No 14. Name of Owner of premises ..~.~..]3~?/~k~,t:~l~!~ ..................... Address .......... ~l~&~l'~.t ....... Phone No ....................... Name of Architect .............................................................. Address ................................ Phone No ....................... Nome of Contractor .................... samte ............................... Address ................................ Phone No ....................... PLOT DIAGRAM L.ocote 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 <,bother interior or corner lot. STATE OF NEW YORK, S.S COUNFY OF ...............o~.t~= ............... ~ ¢ Xk ........................................................ · ..................................... being duly sworn, deposes and says that he is the applicar, I above named. He is the ........................................................... ;.....~.. ............................... : ................. (Contk~¢}o?, ~$~rate officer, etc.) ............................................................ of said owner or owners, and is du{y authorized to perform or have performed the said work and to make end file this application; thai all statements contained in this applicotion are true to the best of his knowledge and belieF; that the work wilt be performed in the manner set forth in the application filed therewith. Sworn to before me this ........ ~day of ...................................... , 19 .......~_ ,~ Notary Public ....................... ~ ............... A ........... Coun~ .~. ................. ' .......... p .............................................................. FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined .................. (~....~..........~,, 19...~.....~ Approved .................... ~..~....,~.., 19.Z...,~Permit No. ~ ..~...?...~ ...... Disapproved a/c (Building Inspector) Application No..~....~....~...~.... ............. APPLICATION FOR BUILDING PERMIT Date'~' -- (-~-'~'~ '~-/ 7 ~ 19 ............ 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 andof buildings on premises relationship to adjoining premises or public streets o areas, and giving a detai ed 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 orxuse~d in whole or in part for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building i~spector. 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. (Signature of 6pplicant, or name, if a corporation) ' ..................... ..... .-. ...................... ......................... ~l~licont) ~ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. owner of premises ..~~w.~..../.,.").....'~...(~.~ .~ ................................................ Name of / If applicant is a corporate, signature of duly/authorized officer. (Name and title of corporate officer) Builder's License No ........ ..~..,.2...~......1.~...'i~. ........... Plumber's License ,o .... ...~..~....~........~...: ................ Electrician's License No ............................... ~'~z~...~--~ Other Trode's License No ............................................... Location of land on wh ch proposed wor~ w be done ~Map No .¢~- . Lot No..7../. Street:, and Number .... .~.~.....~,...D.~,~& .............................................. ~..?...t.~..., Mumcipality/ State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ....... t',L~.~ .......................................... 3. Nature of work (check which applicable): New Building.. ................. Addition ............. Alteration ............... Repair .................. Removal .................. Demolitiar. .................... Other Work .................................................... ~ ~ (Description) 4. Estimated Cost ........L...~...Y....~ ........................... Fee ................. L.~...~.....~?. .......................................................... (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 .....1..~....~ ........ Number of Stories ........ ~ ......................................................................................... Dimensions of same structure with alterations or additions: Front ............ ~...~,...~. ........... Rear ...~....i.~ ............... Depth ........ .~...~.. ................ Height ........ !...¥... ............ Number of Stories ........... ~ ......... 8. Dimensions of entire new construction: Front .......... "Z. ......... . ............... Rear ............................ Depth ........................ Height ~ Number of Stories ..................................................................................................................... 9. Size of lot: Front ...... /..2..~..~..~....6 ........................ Rear ...... l...7.~..!..~....~ ........... Depth .../(...2~..~..[ ............. 10. Date of Purchase ..........L.¢~...~..¥. ............................. Name of Former Owner ....~.~-~..~ ................. 11. Zone or use district in which premises are situated ...... i~.~ ............................................................. 12. Does proposed construction violate any zoning law, ordinance or regulation: . .. Jv~'~. .. .. .. .~ ..................................... 13. Will lot be regraded .......~.....-z.. .......Will excess fill be removed from premises: ( ) Yes (~-3 No · :7 14. Name of Owner of premises ../~~. Address ...... ! Phone No ....................... NameName afar Contractor ~ ~~Architect ..... /~ .................................... ~ .................. ................. Address "~~:~''~ I~(°neAddress ...tv ......................... Phone No.N°'~.. ~"~' ":' '~ ' ~*' ~',~' ' PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all 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. STATE OF NEW,,Y~RK~,-~ ,~ [cc cou NTY~_ - , ~ ,~O"(' ..~%.~,':t'~. m../,~..... ~~/~'~ - ' ...~ ......... ~~ ............. ~.~.[.~..~..~./ .......... being duly sworn, deposes and says that he is the applicon, ~ (Nam~ of individual signing contract) abo?e named. ~ ~s ,h~ ................................ ~.~~..~. ............................................................................................................. (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 that the work will be performed in the manner set fo~h in the application filed therewith. Sworn to before me this _ ~ r ~ ~ ~ .... ...... ........ ...................... , ( ) {) ............ ...... .....................................