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HomeMy WebLinkAbout9821-zTOWN OF SOUTHOLD BUILDING DEPARTMENT 'TOWN GLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE Pr~EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Ne 9821 Z Date .......................... ~;.../. ............ , 19 ........ Permission is hereby granted to: at premises located at .............................................. ,.:.......r:.~. ........................................................... .............................................................................................. .~.~.E.Z.~!.L.~:~. ................................ pursuont to opplic~tion doted ~ ~ ~ ~/~ ~ 19.~.~.., and opproved by the Building Inspector, Fee ............. Building Inspector ~'01~,1~ 1~0. 6 TOWN OF SOUTHOLO 0 Bu;lding Depa~menl, Town Clerks Office $outhoid, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY 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 disposol--(S-9 form or.equal). :3. Approval of electrical insto{lation from ]3oard 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: I. Accurate survey.of property showing all property lines, streets, buildings and unusual natural or topogrophic features. 2. Sworn statement of owner or previous owner os 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 New Building ................ Addition ~ Old ar Pre-existing Building ................ Vacant Land Location Of Property ........................... .~,..,~.~-.~.,...~,,~, ........... .~...E~.~ .............~..~,..:rT"L..~....L.;...~,. ................ Owner Or Owners Of Property d ~) H-/~' 5/~- ~ ' Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No ..................... ate Of Permit ,4~..L. ............. icant ..~(.., ,,.~,, L ............................................................ Health Dept. Approval ................. /.¥..:.L. ................ Lobar Dept. Approval ................... /..:......:.L. ............. Underwriters Approval .................... .,/~,,,T,.,/',~ .............. Planning Board Approval ............. ~,..~..:(,~. ........... Request For Temporary Certificate ........................................ FinaJ Certificate .......................................... Fee .Submitted $ ................................. Construction on above described building and p~rmit me.ets all applicable codes and regulations. Applicant .......................... : ...................................................................... ................ day of ............................................ Notary Public .................................... County (stamp or seal) __ C, Oz. qto'7' TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Exam ned . ..~ (P, 197~'/ Zi'i ............. .................... ...................... ermit No....,.?.. ,~,,..~.../..Z ....... Application No....~....~...~.../ ........... Disapproved a/c ...~~ ............................................... ............ · ........ ........ (Building Insl~ctor) APPLICATION FOR BUILDING PERMIT 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 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. (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ...... ............................................................................... Name of owner of premises ..~....~......~...:.....~ ................ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 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. Map No.: ........................................ Lot No ......................... Street and Number ~Z Municipality 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 /_,)cf ¢~'~ ~ ~/~ ~/~//~ (,,//~4'~_, , . 3. Nature of work (check which applicable): New Building.. ................. Addition .................. Alteration ................. Repair .................. Removal Demolition .................... Other Work ~.~.~../~d (Description) 4. Estimated Cost ....... ..~...7.....~....:......6~.. ............................ 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 d 7 / Rear J 7 ' Depth ~..(./. .............. Height ........................ Number of Stories ;L .................................... 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 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 ....... .~. ....... ~..~..~.. ....................... Address ................................ Phone ina ....................... Name of Architect .............................................................. Address ................................ Phone No ....................... Name of Contractor .......... ..~.,.~./~.~. ............................... Address~,~.~.~...?.....h~.....~...-~...... 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 lot. COUNTY OF . .(J .~..~dd .~i.~.. ............................ bemg duly sworn, ~f".~.'.iiiiiiiiiiiil) i( il. deposes and says that he is the applicam (Name of individual signing contract) above named. He is the ................... ..O....(~....!..V...~.~. ........................................................................................................................................ ~ ffi ' (Contractor, agent, corporate o 'cer, 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 fo~h in the application filed therewith. Sworn to before me this ~L~~ ~ ................... of ....................... = .................. , ........ Nota~ Pubhc, . ................................................... ~ ~ ~ ............................ ~ (S~onot~phc~nt~~" .............................. ' : ..............................