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Home My WebLink About9710-z1~01~,~ NO. · TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte Of Occupancy No ............. Date .......... 19... ' THIS CERTIFIES that the building located at ............................ Street Map No ............. Block No ........... Lot No .................................. conforms substantially to the Application for Building Permit heretofore filed in this office ., 19 .... pursuant to which Building Permit No ......... dated ...; .......... ~'~'~/" ~::> 7S dated ....................... , 19 ...., was issued, and conforms to an of the require- ments of the appli~ble provisions of the law. The occupancy for which this certificate is issued is ......................................... ~/~-~ I ~n' ';~'i'i'i'~J .................... The certificate is issued to .................................. _~ .... , ,, _ ............ ( owner, ~t ) of the aforesaid building. Suffolk County Department of Health Approval .................................... ~. 7~. UNDER~RITERS CER'I'i'FICATE No ............................................. HOUSE NUMBER .............. Street ............ - .............................. Building Inspector FOI~M NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N.. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 9710 Z Date ..~5.~> ........ 8 ..................................... , 78 Permission is hereby granted to: ............ ~%' · · !'2- e~:3::'t?/" - ~" ~'on'~ ............................. ............ ~.c. ..~r~z...o~ ~l~n ............. to .- ...)~c]..5. · · ~¥~ ·. ~n,> --t~-~m-i-7~:~. --i{~¥ ~-Z(t ~[-n ~ ................................................................................... at premises located <3t 'l~O.~..:P.9.i&&.e.. x-',-o amh._ ~[O'r~ .................... ...................................................... ~5~-lTbz-L*ct~ ~'~r TU~k pursuant to application doted ...... ~a~r. ....... L~ ................................. , 19-~...., and approved by the Building Inspector. Fee $'"t ~';'C~! .......... Building Inspector TOWN OF SOUTHOLD , Building Depmtment Town Clerks Office 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 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.of 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 in- 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 $5.00 3. Copy of certificate of occupancy $1.00 Date New B~ilding ................ Addition ...... ~. Old or Pre-existing Building ................ Vacant Land .............. Location Of Owner Or Owners Of Property ........ ~.~.~J~.l~i~./.~.D$~.. ,~...~....~....~....~.. .................................................. Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No ..................... ' .................. pp' ,,~,,../,/~'~;, ~.,, ,. :,~,,, .~,., _~,,,, ,~, ,~1, ,,,.,, ,_/,/~,,C~.' / Health Dept. Approval ......... .~,.'.~,: ........................ Lobar Dept. AppraYal ................................................ Underwriters Approval ........ ~..~.~,: .......................... Planning Boord Approval ........................................ Request For Temporary Certificate ........................................ Finel Certificate / Fee Submitted $ ..... .~...:.~...0,. ................. Construction on above described building and permit meets all applicable codes end regulations. Applicant ,.C./../..r.~..."Z.:.,... ~.~,~ ......... .c~,.~: ............ ~:..../.~'.. / Sworn to before me this ................ day of ............................................ Notary Public .................................... County (stamp or seal) 7c/ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE ~UTHOLD, N. Y. Exomined ....... ~ ....... .~ ................. ~ 9.~.. ~ppiicotion No Disopproved o/c ....................................................................... : ................... ........................................................................... ........ ....................... ............ {Buildin~ Inspoctor) Date ......... - ............... I~STRU~I ~. This ~pp[ie~tion must be completely {illed in by typowritor o~ in ink ond submittod in tripllc~to to th~ ~uHdin~ Inspector, with 3 sot~ of plan*, occur~to plot plan to ~alo. F~o accordino to schedule. b. Plot plon showin~ Iocotion of lot ond of buildings on premises, relofionship to ~djoinin~ premises or public streets o~ oreos, ond ~ivin~ o dotoil~ description of I,your ofpropor~ must be drown on tho dioorom which c. Tho work coverod by this opplicotion moy not be commonced before issuonce of Buildin~ Permit. d. ~pon ~pprovol of this opplic~tlon, the Buildln~ Inspoctor will issue ~ Buildin~ Permit to tho opplicont. Such permit sholl be kept on tho promisos ~voil~blo {or inspoction throughout the work. e~ ~o buildin~ shah be ~cupied or used in whole or in p~rt {or ony purpose wBotever sholl hovo been omnted by the Buildin~ Inspector. APP[ICATIO~ IS HER[BY MADE to tho Buildino Deportmont {or tho issuonce ~uildino Zone Ordinance o~ tho Town o{ Sou~hold, Suffolk County, ~ew York~ ~nd othor opplicoble kows, Ordinances or Re~ulot~ons, for the constru~on o{ buHdinos, *dditions or olterotions, or {or removol or domolition, os herein described. The opplkont o~rees to comply with oll opplicoble laws~ ordin~ncos, bu[Idln~ odmit ~uthorized inspectors on premises and in, bulldln~ {or n~ess~ in~ections. (Signature ~ ~ppli~nt,-- or (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises H ,q t~-/~. I 5 0 ~-J applicant is a corporate, signature of duly authorized officer. ............... ......... Builder's License No ......... L...-?. ..................................... Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............................................... Location of land on which proposed work will be done. Mop No.: ........................................ Lot No ......................... Street and Number .. / .... .: ............. :~...: .......... , ............................ : ............................. ;. .......... ~....;.......: ............ 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 ........ ~...~...~.......~ .................................................................................................... 3. Nature of work (check which applicable): New Building,. ................. Addition .................. Alteration ...~?...,.'~.,, ,~'~, Repair .................. Removal .................. Demolitior ..................... 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 oc,cupancy, 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 ................................ ]0. Dote 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 premises ~ 1~ ~"k~ ~ Address /~11~ ~ ~ ~Tu~,~ Phone No, Name of Architect .............................................................. Address ................................ Phone No ....................... Nome of Contractor ..... ~.]~.~..I ~ .~. ' .~ ~.~ ...~..~CAddress ........ ::.~.~...?...~,'~.~hone No ....................... PLOT DIAGRAM Locate dearly and distinctly all buildings, whether existing or proposed, and indicate all set-~ck 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, COUNTY OF ................................ .............. ..~....O...~..~.....~.~..:.~.....~.. ...... :.~.,.:.....~....~.../..~....~..-.,/. ............ being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above nqmed. , 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 performed in the manner set fo~h in the application filed therewith. Swo 'n to before me th s