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Home My WebLink About9995-z 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 fil~ed in typewriter OR ink, and submitted in duplicate to the Building inspec- tor with the following; for new buildings or new use: 1. Final survev 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. 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 unusua~ 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- lion 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 New Building ............. Old or Pre-existing Building ............ Vacant Land ............. Location of Property . .~./~,/~..~'~..~. · · .~, · .~..~..~. ....... ~./~..' .7~..T:..~: ,~',~?.~.~..~(.,,..: .~.'~/.: ..... House No, ~ Street i Ham/et Owner or Owners of Property .. ,//~'.~/. ~/.'/.~. ~ .... F '/' .O.../~...~. ............................ County Tax Map No. 1000 Section .. ~(..0..~7. ...... Block ..... .~ ........ Lot ..... /...~.. ..... Subdivision..~./../-../~.~.(~.<~... J?/~.~. ~ 0./.'~. .... Map No...~..~.. ,~..~.... Lot No ............... c Permit No. ~.~.,~,~:.Z'. Date of Permit ./.'0/~.¥//7~'.Applicant · .~. Z(,~'-/.'.Z:.~?~ ' Health Dept. Approval..~./z...~/~.. ~. ............ Labor Dept. Approval ........................ Underwriters Approval .... ~/...? ............. Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate ....................... Fee Submitted $., ~0 0 Construction on above described building and permit meets all applicable codes and regulations. R,v. lo-le-?a Applicant .~..0...'~...'.. ,~......~: . , . .~----~., ~.~. ~.~_~.. , , TOWN OF SOUTHOLD Building inspector's Office Town Clerk Building Southoid, N, Y. 765-2660 ~'-. z;,~,,,~,~' TOWN OF SOUTHOLD BUILDING DEPARTMI:NT TOWN CLERK'S OFFICE SOUTHOLD, N. ¥. Examined ,~ ~ ................... Approved · ~"~" ..Z i 97. L'~.... No. ... ~,,.~,./ .............. , Permit Disapproved a/c ............................................. ,.?x..,~/.....__ Inspector) - APPLICATION FOR BUILOING PERM'' Date ................... ./...'~./..(a /7 ................... , 19...2...~ ..... ~, INSTRUCTIONS a. This application must be completely filled in by typewriter or~ 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. Plat plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets m areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this application. d. shaft be kept on the premises available for inspection throughout the work. e. No building shall be occupied or used in whole or in pc~rt for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. The work covered by this application may not be commenced befgre issuance of Building Permit. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such permit APPLICATION IS HEREBY MADE to the Building Department for the issuance ora 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 ir~ buildings for necessary inspections. ........ ./.. .Az . ........ (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ......... : .................................. ................................ , ......................................................................................... Name of owner of premises .................. . .~....//../.../....7~'....~... ........ ,~.~..../...(.).../.?...~.. ............................................................................ If applicant is a corporate, signature of duly authorized officer. ............... iName and title of corpor.~e' officer) ' License No Builders ............ "'"' ................................... Plumber's License No ...... ~.?....~...;~..~...0. .................... Electrician's License No ........ .~..,,./Z,,.~,,~=,~.~,~,,(. ......... Other Trode's License No ............................................... 1. Location of land on which proposed wqrk will be done. Map No.: ,..~...(......~. .......................Lot No...../.....~::.. ............ Street and Number ....~../....~.~...~...~,~./..C..~ .......... ...,~....~...%:~...~ .................. ,,:?5.~Z./,~...~,,,,,~,,,,/,,.~,,,.~...,~,,d..%. ......... ~.~..;: ........... ~/~'O,_,~- 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 ................... ~ ................~ .........~ ................. ': ...,4~.. ....... 3. Nature of work (check which applicable): New Building,. ................. Addition .................. Alteration ............. .~,. Repair .................. Removal .................. Demolition .................... Other Work ..................................................... ~ ~:~Z- (Description) 4. Estimated Cost ................... ~.~.~. ......................... ee .................................................................................... (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 ~pe 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 ~ner ........................................................ 1 1. 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 b~ removed from premises: ( ) Yes ( ) No 14, Name of Owner of premises ..~..:..~,~.g..~.~. ..................... Address .....~.~.~ ....... Phone No ....................... Name of Architect .............................................. ~ ~ , _~ ............... Address ................................ Phone No ....................... of Co,t, to ..... Addra ...... ..... ,ho,. No. PLOT DIAGRAM Locate dearly and distinctly all buildings, whether existMg or proposed, and indicate oil set-~ck dimensions from prope~y lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner Jot, STATE OF NEW ~QI~.~ ~ ~ [ S S COUNTY OF .~.(,(J/--/-J,l-Z(,,~.(,,,-~f ' ...........~ --' ~....cl..X~'...f~.....cCr'~..~:/...._.,'~.; ........ ,~...~..../...~....~....~.. ........ being duly sworn, deposes and says that he is the applicon, (Nome 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 ~ke and file this application; that oil statements contained in this application ore true to the best of his knowledge and belief; and Swon to fore met~istha~rthe workwiHbeperforme~in--~e manner set fomh in the application filed therewith. ........ .... .................... ~ ~ ~ (Signature of applicant)/ ~oz z~O