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Home My WebLink About9762-zTOWN OF $OUTHOID BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTH'OLD, bi. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE Pi~EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 9762 Z Permission is hereby granted to: ~,.~.,,.~./>~t/~ ~o ..... ,./.:,~...Z ......... :~z..:: .......... premises located at pursuant to opplication da~ed .....................................': ....... , I~ .... ~nd opp~oved by t~ Building Inspe~or. Fee $ ........................ 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 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. 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 $5.00 Date . New Building . .~,.. Old or Pre-existing Building(X)., ....... =/Vacant Land ............. Location of Property ./~.'~(,g~). ......... Jou~ No. Street \~ Jam/'e't Owner or Owners of Property ~-~..~ ~r~. ~~~ ..... .. ....... .... ......... ot.. Subdivision. ~~...~ ...... Filed Map No. Health Dept. Approval ...... ~ ............. Labor Dept. Approval .... ~ ............. ,.. Unde~riters Approval ........................ Planning Board Approval Request for Temporary Certificate ..................... Final Certificat~ , . .~,-, ........ Fee~ubmitted$..~.,.~..~ . ~ ~'¢- ~0~ ~ ............. Construction on above described building and permifmeets all app~cabl~odes and regulations, TOWN OF $OUTHOLD OFFICE OF BUILDING INSPECTOR ' P.O. BOX 728 TOWN HALL SOUTHOLD, N.Y. 11971 TEL. 765-1802 - Applicant Dear ~- ~'~v~ : This is to advise you that the job under Building Permit~No. ~] ~ issued to on ~\~% ' for Q'.~L~,.~. ' - ~J is completed and a final inspection has~7 has no~g~7 'been do~e. In order to complete this file, it is necessary that a Certificate of Occupancy be issued. Please fill out the enclosed form(s), return same to the above office with a check for $5.00 payable to the Town of Southold. Ftease indicate to whom the Certificate of Occupancy is to be mailed, and arrange with this office for an inspection date. Thank you for your prompt attention. Very truly yours, Victor Lessard Administrator VL:ec Enclosures TEL. TOWN OF SnUTHOLD OFFICE OF BUILDINn INSPECTOR TOWN CL£RK'S OFFICE: N-'-'- ~Y:~-- "~ o~PART~NT AT 765-2660 9AM to 4PM ~OR ED INSPECTIONS: 1.BEFORE BACNFILLING FOL:~DA. TION OR START ~&,~ 3, BEFORE COV~RtN~ 4. F1MAL WH~M JO3) NOT R~PONsJ~]L~; gO~ OR CONSTRUCTia~ ERRORS 5. ALL CONSTRuCTIo, N ~U~T , ,r. STAT C FO~M NO. 1 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Approved ................ Z.~.~-/......~./, 19.~..~, Permit No ..... . .~......7....~.,.,A...~ Disapproved a/c ................................... :~ .................................... (Building Inspector) Application No. ~ 7~ ~ APPLICATION FOR BUILDING PERMIT Date ...... 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 o detailed description of layout of property must be drown on the diagram which is port 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 o 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 port for any purpose whatever until o Certificate of Occupancy shall hove been granted by the Building inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of o 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 oil applicable lows, ordinances, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. ............................ (Signature of~plic~n~t~, or~ame, if a corporation) .... (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. /'2_/ ............................... /~. .~. . f. . . ./. /. .~. .~. ~/ .................................... ~ ...................................................................................... . Name of owner o, premises-.".,:.:. ....... ................ ........................................................... if applicant is o corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ......... ~.. ............................... Plumber's License No ................................................. E~ectricion's License No ............................................. Other Trade's License No ............................................... Location of land on which proposed work will be done. Map No.: ........................................ Lot No ......................... Street and Number .................................................................................................................................................... Municipality State existing use and occupancy of premises ond/~.4~,///~, int,e~d u~)a~~roposed construction: o. Exisiting use and occupancy ......... /....../..,..~,~,~.../. .......................... ..'~..-.....*-.! ................................................. / 3. Nature of work (check which applicable): New Building'. ................. Addition .................. Alteration ................ Repair Removal Demolition .................... Other Work ................................................. "' .................................... (Description) 4. Estimated Cost ~e~f,~,~ ~. Fee ........................... : ............................................................... .... (to be paid on filing this application) 5. If dwelling, number of dwelling units ...... Z .................. Number of dwelling units on each floor ............................ If garage, number of cars ............................................................................................................................................. business, commercial or mixed occupancy, specify nature and extent of each type of use ............................ 6. I~f f e istin structures if any' Front 2/ i~, Rear · · ' ...... 7. uimensionso ~ g , , ........... ,....~ ............. ~.....( Depth ...~ Height ....~..~.. ............ Number of Stories ...... ~...~..~.. Dimensions of same structure with alterations or additions: Front ....~....(. ......................... Rear ....~.../. ................. Depth ...... g-rf7....(6~... ................ Height ../...?.. .................. Number of Stor~s ...... /("~"L~"i"~:~-';; ....... D t' 8. Dimensions of e/mire new construction: Front ......... .~ ..... ] .................. t~ear ...... 4..4. ................ ep n ........................ Height ~.. ~ Number of Star es /.. '.~'...~C. ............................................................ ........................ ~7"~ ............ ~ O ' e th 9. ' Rea ..../. ................................. D p .... .7.. ........................ Size of Jot: Front ....... / ............................................... Date of Purchase ........................................................ Nam~,p~f,,,F.°~,~er~O,-~n~r ~'"'"'~" ........................................... 10. Zone or use district in which premises are situated ........... ¢~~.~..~..~z.. .......... ~"i .................................. ll. ...~...~, Docs proposed construction vic~late any zoning Iow, ordinance or regulation: ....................................................... 12. ' /', from ramses ( ) Yes (/~) No 13. Will lot be regraded ...... ..t~....¢~. ............. Wil excess f II be removed f~/P : Address .~...?Z.~/.~ ................... Phone N~'. ..................... ,4. Name of Owner of premises ......~........~....~/~....~..~ ..... .............................. Phone No ....................... Name of Architect .................... ,~--..~..-..I ............................. Address · .~.....~./. ;r- ~ Name of Contractor .......... ~....cJ.:...~.....~....~'~....~.. ............ Address¢, ................... Phone No ...................... PLOT DIAGRAM Locate c early and d st nctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block number or description accord ng to deed, and shew street names and indicate whether interior or corner lot, ~TA'I'E OF NEW~'~O~If-J ~ J) ~ ~S.S COUNTY OF'. .......... . ~.~~ ...................... being duly sworn, deposes and says that he is the applicam .... (Na~e 'ot~ndivi(~tu~l signing contract) above named. He is the ~~~-'- ......................................................... '~'r'"~"C .............................................................. ................. (Contractor, agent, corporate offic , of said owner or owners, and is duly authorized to perform or have performed the said work and to make and fil~ this application; that all statements contained in this application are true to 'the best of his knowledge and belief; one that the work will be performed in the manner set 'forth in the application filed therewith. Sworn~to before-me this ' ,.~ ,¢/,~/~//~ ...... ....................... ....... ....... .............................. ..........................