HomeMy WebLinkAbout9764-z FOI~M NO. ~
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN GLERK'S OFFICE
SOUTH'OLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
CQMPLETION OF THE WORK AUTHORIZED)
N? 9764 Z
Permission is hereby granted to:
............ ~.0 s,eph .. Fas ~- e~m]fJ. ,. J~ ~ ....................
to ..... bu;Lla...a..,~w, Lmm;l.r~..pool .. ar~ ...~enee ............................................................................
c~t premises located at .............. ~.O.O.,~i......~l~.~
.................................................. Southold,.. Rew...Yo~.k ...........................
pursuant to application dated A'v~]/: ....... .1.~. ................... , 19.7..8...., and approved by the
Building Inspector.
Fee $'"'"J~rO0 ........
IOOO- 7o ~ 5-/
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.
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 ............ Vacant Land .............
Location of Property ................ /~¢¢.,~'..~?...~.~.,,~3¢~. .......... ~.~.. ¢,~ .~..~.~.-/~. ....
House No, Street Ham/et
Owner or Owners of Property ...... .~J~..C~1¢-~.~¢~. .... <~?¢..~¢.%~.,,C~.'? ............
County Tax Map No. 1000 Section ............... Block ............... Lot ................
Subdivision ................................. Filed Map No ........... Lot No ..............
Health Dept. Approval ........................ Labor Dept. Approval ........................
Request for Temporary Certificate ..................... Final Certificate .......................
Fee Submitted $ ...... ~.~,~ ....................
Construction on above described building and perrr~it meets al~ applicable codes and regulations.
o- a-Te C. // I
'FOB, b~ NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined .... ~T.~3.~. ............ ~. ............. 19...7.~
Approved .... ~.~3.~ ............ 5 ............. 19...~.~ Permit No....¢.?.6.~ .....................
Application No .........~).~. ,~, ~. ..............
Disapproved a/c ................................... "'~'~';';7'~ ...................
(Building Inspector)
APPLICATION FOR BUILDING ~PERMIT
INSTRUCTIONS
a. This application must be completely filled in by typewriter ot~ in ink and submitted in triplicate to the Building
Inspector, with 3 ,sets of plans,, accurate p at plan to sca,le. Fee according to schedule.
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or publlc streets o~
areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this ~pp[ication.
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 c~ 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, building code, housing code, and regulations, and to
admit authorized inspectors on premises and in buildings for necess<3ry inspections.,
........ .......
(Address of applicant)
State whether applicant i lessee, qgent, architect; engineer, general contractor, el~ctr c an, plumber or builder.
Name of owner of premises .....~..~...~..~Z~.~......~.~..S~.~.~..~.~.~..) ....... ~....~..Z .............................................
If applicant is a corporate, signature of duly authorized officer:
(Name and title of corporate officer)
Builder's License No ................. .~.......~......! ....................
Plumber's License No .................................................
Electrician's License No .............................................
Other Trade's License No ............................................... ~
Location of land on which proposed work will be done.~ ~Mop N,o.':,,..:...~..,~.'..~.,:~.:..~..~.~...~..~.~...,. LOt No....~ ....................
Street and Number .......... Ij'Z[)~.)...~.. ........ .~...~ ....... ...L~......~...~.:[.......~....~.l~.....~.~.'~.. ............. ..~.....~...~..~.,~..(~..~....0.. ...........
Municipality
State existing use and occupancy of premises and' intended use ~and occup6hcy o~ proposed construction:
a. Exisiting use and occupancy ............ .~.....~....~.... ............ ......................................................................................
b. Intended use and occupancy ............. :.~....~..~.....~....~..~..,t~.....~....~....o.~.?....~ .........................................................
3. Nature of work (check which applicable): New Building' ....~..~...O....~.. Addition .................. Alteration .-: ........
Repair .................. Removal .................. Demolition .................... Other~rk ......................................... ~ ..........
4. Estimated Cost ..... ..~.~.-.~.~ .................................. Fee ~ ~2 (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 ............................
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
..,D...:..-~....~,~.I Number of Stories ~ ......................................................................... Rear ................... ..~....~.~. .............. Depth ................................ ~'~ ...............
10. Date of Purchase ........................................................ 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: ........... . .~......~.. ..................................
13. Will lot be regraded. ...... .~).....'.O. ............ Will excess fill be removed f, ro_m premises: (~4~' Yes ( ) No
14. Nome of Owner of prem,ses ~.~...~..~..~....~...~"-~...~.~...~..~.~...-~....2....~.~d~e'ss~..~::~`:L'~.~!~
· ' '- ?:'? ....... Phone No .......................
Name of Architect .............................................................. Address ................................ Phone No .......................
Name of Contractor .~2.~....~....1~....[I..~....~.. ........ )~.,~....~..~--.~,~... Address ................................ Phone No .......................
PLOT DIAGRAM
Locate 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
whether interior or corner Iol,
L
STATE OF NEW ,YOI~IC [ c c
COUNTY OF ...~..~.ki.D..~.t..C. .......~'~
................ ~..~.~:.~...~.-~..~') ........ ~...~.~.~..~....~...~..2=.~,..~'.~.~..~....tt...~..~being duly sworn, deposes and says that he is the applicanl
(Name of individual signing contracf)
above named.
........ .......................................................................
He is the ........ (Contractor,~ 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 gr,,true tg~theJzes~ of his knowledge and belief; and
ti,ar the work will be performed in th~ manner set forth in the appl~atio~n fil~'81 tl~rew~h.
Sworn to b~fore me this
.......................... ........... :: ................
Notary Pubhc, . ......... .~ ..................................... ~. ~-'~ty ~..~..~.....~:.... ...............................
~fl,~.~:..~_ (Signature of applicant)
NOTARY FUILIC, State of New~'Y~'
Qualified In Su, ffolk Ceu~ly
No. S2-411~ f a