HomeMy WebLinkAbout9833-zFORM NO, 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold~ N.Y.
Certificate Of Occupancy
THIS CERTIFIES that tho building ................................................
Location of Property2605.. G ~' and. ~.v.~n u e.~ ........... ~ ~ ~ ;t .b.~l ~lg ~..~, ¥, ..............
House No. Street Hamlet
County Tax Map No. 1000 Section . . .1.Q7. ...... Block . ...6 ........... Lot ...... ! .3 .........
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
· ~.uJ.¥..1.2 ............ 19.7Bpursuant to which Building Permit No. 9.8.3..3..Z ..............
dated ...... .J.u.~.,¥..1 .~.~ .............197...8. , 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 .........
(owner, ~¢~._or ~
of the aforesaid building.
Suffolk County Department of Health Approval ...... ~ ./.R .................................
UNDERWRITERS CERTIFICATE NO. N/R
Building Inspector
Rev. 1/81
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTH'OLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 9833 Z
Date ,J'~y 12 19 78
Permission is hereby granted to:
............. ~.by.~.~,~......~ ~._r~...~v~ ~,x~ ...................
~o ....... ~¢t.~.. on.. ~...a..~..~.~...~....a......r~...t...v..a.~ ?....~ .e....~.~.t...z.~......z~....e..Z...z. ~ ......................................
at premises located at ................ -2-~0~-.GI;'~,.-,~..~ ..........................................................................
.................................................... .~.a.~..x...~....o..k..~...~.,.~?. ........................................................................
pursuant to application dated ....~.~......?..2. .................................. , 19...~..~., end approved by the
Building Inspector,
Building Inspector
TOWN OF $OUTHOLD
Building Deportment
Town Clerks Office
$outhold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructiuns
__~2.. Certificate of ?ccupancy on pre-g~[s_tLng_d~w~elling or land use
A. This application must be filled in typewriter OR ink, and submitted in triplicate 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 installation from Board of Fire Underwriters.
4. Commercial buildings, ~ndustriol 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 a certificate.
C. Fees:
1. Certificate of occupancy $5.00
, .00
Date ................................................
New Building .................... Old or Pre-existing Building ............................ Vacant Land ............................
Locat,on Of ................
Owner Or Owners Of Property ,.~1 .... )..~. .....~...C)~X~V~...~'2~...~.~/..~.-v~. ..~. .............................................
Subdivision ................................................................ Lot No .......... x. Block No ............. House No .............
Permit No..9.~...~...~..... Date Of Permit ..Apphcant
· 2.. ?c~.t~ ..9~..I.~0..~...
,~'~-~.."7 / ,,~ ('~'~'/7/ Labor Dept Approva
Health Dept. ^pprovm .............................................................................................
Underwriters Approval .............................................. Planning Board Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate ..........................................
Fee Submitted $ ....................................
Construction on above described building an~pe~pit r~ee~s all apDlicable codes~ and regulations.
~ppiicant · ~¢~. · .~.~..~.~ ~. ,.~..~. · - ·: ..; ...... ;~.~.. ~ ...... ~ ...........................
(stamp or seal) ~'"~
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 ........................................
House No. Street Hamlet
Owner or Owners of Property ........ ). ,o?p~;~. ~-~ .q_\-.~,v3.O' .......................
County Tax Map No. 1000 Section ............... Block ............... Lot ................
Subdivision ................................. Filed Map No ........... Lot No ..............
Permit No. 9~.G~. ,~.. ·~, Date of Permit ' . .Applicant . .).9~.~,(:~'.UO.~ .........
Health Dept. Approval ........................ Labor Dept. Approval ........................
Underwriters Approval ........................ Planning Board Approval ......................
Request for Temporary Certificate ..................... Final Certificate . .~ .....................
Fee Submitted $ .............................
Construction on above described building and I~rmit meets all app, Jicable codes and regulations.
Applicant . . .~. ~v'[4-~. .............
FO~M NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined ............ J..V,~,~...,..~ ~. ........ , 19....'7...8,
Approved ............ ~.u;L~.....fJ2. ........ , 19..~.. Permit No ..... 9~.33. ......................
Disapproved a/c ........ ~'~i~'~ ...... ~:. ......................
Application No. 9833
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS Date .-~.../..~..~... ................... , 10..~...~..,.
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.
...... ......... ..............
(Si~[ature of applie~t, or name, if o corporation)
Y ~ ~J~ 7 ( tess o app icon1:) ............
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner ~--~" "~ ' ' ~ '
of premises ..t-.~..'...:'/..t.~,.)...'~ ........ L.~..~.'~C~.L."(~...~L~..~...~.x...~ .......................... : .......................................................
If applicant is o corporate, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No ...... O[,L~.~/~3_...<~.~... .......................
Plumber's License No .................................................
Electrician's License No .............................................
Other Trade's License No ...............................................
Location of land on which pr°p°se~d~d w°[k~-~ ~ t, ~ ,~ t ~will be done. Map No.: ........................................ Lot No .........................
Number. ~ .~....~....~3 ...... .~...I'T: .~.~>.~....~...V.....~?~..... ~.~...c~'~j~ .~..'l[.~..g~ ~.. .................................................
Street
and
Municipality
State existing use and occupancy of premises and intended use and occul~ancy of proposed construction:
a. Exi~iting use and occupancy ...~....~.~..~C~,..~. ............................................................................................................
b. Intended use and occupancy .~.1~. ~......u4).Y...~.....~., .......~...~..0~.~/~ ...................................................................
3. Nature of work (check which applicable): New Building,. ................. Addition .................. Alteration ................
Repair .................. Removal .................. Demolition .................... 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 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 .....................................................................................................................
9. Size of lot: Front ,~.~ ................................................. Rear .J...~.' ................................. Depth ...~... ........................
10. Date of Purchase ..... ../.~...~..~. ................................. ,,,..Name of Former Owner ........................................................
11. ;~Z~oU~e~iis~inCj;~iihichpremisesaresituated',~.~'..~l'~C,-tf~"('~ '.'~..~ '.i ;iii
12. p p t c'on violate any zoning law,'~;'~'i'~c; or regt~i;~i~i"'il ..i....iiiiiiiiiiiiiii'.iiiiiiiiiiiiiiiiiiii iiii
13. Will lot be regraded ...~.~; .............. Will excess fill be removed from premises:.( ) Yes ~,~ ) No
14. Name of Owner of Address Phone No.~-~..(~.%~.~.f-,)
Name of Architect .............................................................. Address ................................ Phone No .......................
Name 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 description according to deed, and show street names and indicate
whether interior or corner lot.
OdELL /'4
ODLk~TY OF ,...~Z.~.~- _ .
' /// (Name of individual signinglcontracf)
above(/named.
rm~[te 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 ali statements contained in this application/are true to the'best of his knowledge and belief; and
that the work will be performed in the manner set forth in the ap¢ication filed therewith.
Sworn to__his
Noto, Public, ......~
~ ~ ~/~ , ~ ~ ~, ~nature of applicant)