HomeMy WebLinkAbout9637-zFORlVl NO. 4
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
$outhold, N. Y.
Certificnle Of Occupnncy
THIS CERTIFIES that the building located at ...~. ~27.-5....N.o.k. qm..i.s..R.o..a.d....
Map No ............. Block No ........... Lot No ..................................
conforms substantially to the Application for Building Permit heretofore filed in this office
dated .. Marck..20 ......... , 19.. 7.8 pursuant to which Building Fermit No.. ~. ?.6.~.7. Z
dated .. Marck. ,2.~ .......... , 19..7.8, was issued, and conforms to all of the require-
ments of the applicable provisions of the law. The occUpancy for which this certificate is
issued is ........ .Private. On.e -Family. Dwellin~ ...............................
The certificate is issued to .............. .D.o?...~..L.~.n..d~...L.u.b.o.¥ ......................
(owner, 1~
of the aforesaid building.
Suffolk County Department of Health Approval January 3, 1979 6-S0-16/4
UNDERWRITERS CERTIFICATE No ....... P..e.n.d.i.n.g ..............................
HOUSE NUMBER .,..~2.7.5. ...... Street ............ .N.o.l.co..mis Road
~Jottthold, N.Y.
Building Inspector
County Tax Map Number
BUILDING
TOWN CL~.~t'S OmC£
SOUTHOLD, N.. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N°.
9637 Z Date .........................................................
Permission is hereby granted to: ~//Z k ~/~OZ~ /-I~)/~/£_5 t L T ~
% ...........
at premises located at ........................................................................................................................ .. . .
pursuant to oppBcotion doted J~/' 'q j-~ ~.O 19..~,.~.. and approved by ~he
Building Inspector.
Fee $..,...~.....~. ............
Building~' n~ect.6r,::: , :
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 featu res.
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 featu res.
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
.~...~ .~.~. ,.~...~...z~. r ·
Date -~ ~- .~. ~.'~.~.
New Building V ............ Old or Pre-existing Building ............ Vacant Land .............
Location of Property .............. ~.l.~l[~.~.t .~1.~.~.'..' .~,, .o~.'~,,, .. S'o ~-~ ~-~o.~ .....
House No, Street ..... / ................ Hamlet
Owner or Owners of Property . .~ ~..~.~.~..,. ~'T~.. ~.. ~ .~ ............
County Tax Map No. 1000 Section ............... Block ............... Lot ................
Subd~wsmn ............... ~.. ,~..~ . ~ ..... ..~p No ............... Lot No ...............
Permit No. ~.7.~, Date of Permit ~/~¢~Applicant~ ..................................
U nde~riters Approval . ,~ ~ ............ Planning Board Approval ......................
Request for Temporary Certificate ..................... Final Certificate
Fee Submitted $ .~.:. ~.. '~9 .............
Construction on above described building and permit m~le codes and regulations.
............ ...........
THE NEW YORK BOARD OF FIRE UNDERWRITERS
pm BUREAU OF EI. ECTRICITY
I'--- 8E JOHN STREET, NEW YORK. NEW YORK 10038
THIS CERTIFIES THAT
iflthe/ol~ing ~tion; ~ ~ment ~ lst FI. ~ 2~ ~. ~t~n fl~k ~t
~ exami~ on ~ ~ ~ ~ ~ ~ ~ a~ ~ound ~ be in ~mpliance witA t~ r~uiremen~ oy thh ~.
RX~ ~X~ ~ ~ ~ O~ ~ W~ ~HA~T FA~
21 3~ 22 21
~o~/~
2-3~e ~teo~o~
1-~.5~ Rot Water Heater
· FOltNI NO. 1
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Disapproved a/c
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
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 o;
areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this opphcotion.
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 o 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 nome, if a corporation)
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, genera[ contractor, electrician, plumber or buiider.
..C.. L
Name of owner of premises ) .~...~.lq', i..~i?>~'
If applicant is~a corporate, signature of dul~ authorized officer.
(Name and title of .........
Builder's License No .....................................................
Plumber's License No .................................................
Electrician's License No .............................................
Other Trade's License No ...............................................
1. Location of land on which, proposed work will be done. Mop No.:~...i,~..~..W.t~.k~. ................. Lot No .........................
Street and Number ~....~.~.~.~.~...~ .......... .~..~.~.~..~:.m..~M:~ .
Municipality
2. 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 ~ r~t%~ ~GC~ ~~ ..
3. Nature of work (check which applicable): New Building ........... Addition .................. Alteration .................
Repair .................. Removal .................. Demolition .................... Other Work ....................................................
(Description)
4. ~timated Cost . ../....~...c.:.:~:;.~... .............
(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 ; z' '. '~- ".i ·
Rear ............................ Depth ...::..:: ...............
Height ..)..;'...~.: ........ Number of Stories .../..?...~.. .........................................................................................................
9. Size of lot: Front ..... /.L: .............................................. Rear / /-' -' 4 ....
........ -~ ................................. Depth ................................
10. Date of Purchase ....... · ....... :: ........................................ Name of Former Owner ...'."(..: ..... ':...~....~ .............................
1 1. Zone or use district in which premises are situated ....... ~ ......... : ....................................................................................
]2, Does proposed construction violate any zoning Iow, 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 No.
Nome of Architect ' ~ ' ~ "' , Address ...... Phone~ No.
Name of Contractor !.~.!....'...;; ......... ;.!.....: ....... :..._r..: ............ Address ~. ............................. Phone No.'/.(....~....?..f..i.~.
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 end indicate
whether interior or corner lot.
STATE OF NEW ,YORK, I. ¢ ~
COUNTY OF .... .~;:;..~..~..~. :~;'.:. [ .......... ~ '~"~
........... ;....:..z.'. ...... ;%....';..;.;.; ...... ;~ .................. being duly sworn, deposes and soys that he is the applicant
(Name of individual signing contract)
above named.
He is the (~.,~ ~,. x, ~ .....
(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 end file
this application; that all statements contained in this application are true to the best of his knowledge and belief; and
tha~ the work will be performed in the manner set forth in the application filed therewith.
Sworn to before me this
........... ..c:.~: ....... day of ..~.x'..J.~..~.......M.+. ........................ , 19Zk'5.. ~' "-,, r ./ / //
Notar~ Pubhc, [LIZ^RETH ANN 'NEVILLJ] ~' ~';~/ ~ ,County ' '~'~'~lgnature of apphcant)
NOTARY PUBLIC, St,~te of New York
]~rm expires M~rch 30. 19~;~
SUFF' CO. DF. PT. OF HF.A~.TH ~IGI;~ ~t'&1~l~Nl' Of' ~
FOR APPROVAL ~ ~U~ ~LY
, ~E WA~ ~U~Y ~ ~A~
DATE: D~ ~ ~'~ R~I*
H. S. REF. NO.: ~A~ ~ IU~ ~ ~.
t I
OI.A.G
APPROVED AS NOTED
ED INSPECTIONS:
REQUIREMENTS CF N.Y. STATE CODE
A~chltect and E~¢ee~r's Seal
c CTiO
"Alteration of this Document
by an 4Jchitect or Licensed Prol~s
/~LBEI:,LT A. SACCO ~,~g GORDON K AH/LER. S
ARCHITECTS & ENGINEERS
54655 MAIN ROAD SOUTHOID, N. Y, 1197':