HomeMy WebLinkAbout9765-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
.......... Date auZy zz, 197.
THIS CERTIFIES that the building ................................................
Location of Property . .101D.5..So~u'~dvi~.~ AV~-~,. ~.Q~ko.]~l ....................
House No. ~treet Hem/et
County Tax Map No. 1000 Section .... 5 ~ ...... Block ..... 8 ......... Lot ...... .5 ..........
Subdivision .......... XXX .................. Filed Map No.. ~:~g...Lot No... g~.~ .......
conforms substantially to the Application for Building Permit heretofore filed in this office dated
·.. J~r~. 5.t .......... , 19 .7.9. pursuant to which Building Permit No...9..7.6.5.Z. .............
dated ......... J~ty~e.. fi.~ ........... 19 7.9., was issued, and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is .........
D]~CK ADDITION TO PRIVATE¢ ONE FAMILY DWELLING
The certificate is issued to . A$i~.e..G,. Kr~qlgJ-.o. qt~ ..................
' (owner, '~f~,~'~' ......
of the aforesaid building.
Suffolk County Department of Health Approval ..... I~../.~. .................................
UNDERWRITERS CERTIFICATE NO ............. .N[.~. .................................
Rev 4/79
Building Inspector
FORIYI NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
$OUTHOLD, N.. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 9765 Z
Date ........ ~T~-'~e ....... ~ ............................ , 19.?.8..
Permission is hereby granted to:
........... AI&C e ..O.....K~ab].och ...........................
to ......... ackL.o~t~..a.P.r, lva~..O~a..ra~L%y...l~e3.llng...(nee.~) .......................................
at premises located at ..... .'J.O.'l.O~i...c~D.l,l,"3.~.VJ, f~. ~.~.~ .................................................
.......................................... ioutBold, .. ~Ie~..~.ork ...........................................................................
pursuant to opplicotion doted ....... ~TLI~.~, .........~. ........................... , 19...7.~.., and opproved by the
Building Inspector.
Fee $"'q5;'(~) .........
Building Inspector
1000-54-8.-5
TOWN OF SOUTHOLD
, Building Department
Town Clerks Office
$outhold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
]fist'ructions
A. This application rnusl 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 oil 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 o 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 ............. V....../.4 ......... .~...~. ......
New BLiilding ................ Addition ................ aid or Pre-existing Building ................ Vacant Land ..............
Location Of Property .............~...~....I...~....~........6~...~...~.~..~.).:¢..~.....~.1~..¢.., ............ S,~I-~..~n./.~... ................
Owner Or Owners Of Property ....X~./t~.'~ ...... ~.~.....~..~..~.~..~.. ...............................................................
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No..~..7...~.~..,~,,. Date Of Permit ...~.J~./.Z~,Applicant ..~./~.~.....~...,..~./~.~.]er~..JZ. ..............
Health Dept. Approval ............................................ Labor ~pt. Approval ................................................
Unde~riters Approval ...................... ~. .................. Planning B~rd Approval ~ ~
Request For Tempora~ Ce~ifi(:ate ....................................... Fin~ Certificate ~
Fee Submitted $ ........... ~ ......................
Construction on above described building and permit meets all applicable codes and regulations.
Applicant ................ ~.....~,....~ ...................... : ......
Sworn to before me this (~ ~. ~:, '/.~r~ ~,,
(stamp or seal)
................ day of ............................................
Notary Public ................................... County
Examined .......... t.TLIt&e......~ ............. , 19....~.~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
/~oproved .......... ~TMI~I~....~ ............. , 19....78 Permit No ....... ~?6...~..Z.. .................
Disapproved a/c ............................................................................................
(Building Ins~ctor)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
Applicat--~on No .......
I
Dote ..... ...?...u.....~....E. ..... ~. ., 19
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. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets az
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, building 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.
.... ¢.~.~ ................... ;~....L~h..~..o ...............................................................................................................................................
Name of owner of pC//e/mises..~.~..o.-.....~4..~...../~..~..~.L/~...~...~. ........................................................................................................
If applicant is a corporate, signature of duly authorized officer.
(Nome and title of corporate officer)
Builder's License No .....................................................
Plumber's License No .................................................
Electrician's License No .............................................
Other Trade's License No ............................................... / ~ b D · -- Z ~ ~ C~_~ ~
Location of land on which proposed work will be done. Map No.: ...................... ~ .......... ; ...... Lot No .........................
Street and Number ..c~.,~,,/.~.....~.(g,~,.,.,~,,.~,?,:<~.~,~;~,...,~.,~.g: .................................................................. .~,~,..%~,/,.~',. .......
Municipality
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Exisiting use and occupancy ~......;~..~ ................ ?...~/.,....~, ..............................................................................
b Intended use ond occupancy .~.~....~..~.......~.~.......~.d..z.~. ......... .~...c. ............................................................................
3. Nature of work (check which applicable): New BuiJd~ng~. ................. Addition .................. Alteration
Repair .................. Removo~ .................. Demolition .................... Other Work .../~,.~-~.....~'..~..~.~...?/.~-.~ ............. .
(Description)
4. Estimated Cost ~"~f~.]..~.~..Q. ................................ 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 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 .................... Number of Stories .............................................................................................. :""'z' ..............
9. Size of lot Front ~0' /~/~'/- Rea' ~0'./...~..../~... Depth ./.' ?~..~....?...~...~..
10. Date of Purchase ....~...u,~.;..3.4..../...~...,~ ....................... Name ,of Former Owner ..~...?....Z~......../~.....~.ff~.~./. .....................
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.... ....../~O. ............... .. Will excess fill be removed from premises: ( ) Yes ( ~'No
14. Name of Owner of premises Z~.~'..c.~..~i.'......~..~.~./~..q.~' ............ Address ...~..~?..z.~..~.~..'i~....~.,,~,~,% Phone No.
Name of Architect ............................................................. Address ................................ Phone No .......................
Nome of Contractor ............................................................ 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 descrip~on according to deed, and show street names and indicate
whether interior or corner Io~ D"/gJ6/~l' ~ ,
duly sworn, deposes and says thet
STATE OF NEW YORK,
COUNTY OF ....5.~./~..,.!/~ ............
........ . .T. ?..~. ~...~...~..?~.-.~-...z¥..,~.~. ~./.~..¢..~. ........................................... being
(Nome of individual signing contracf)
above named.
He is the .~"-~.~z.~...~..~. ...............................................................................................................................................................
(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
thor the work will be performed in the manner set forth in the application filed therewith.
Sworn ~,~ ~ore me this
ce~. day of ..~:/~-¢~J~-~..- , 19 ~..~-~,~
........ .... .............................