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Home My WebLink About11571-zTOWN OF SOUTHOLD Building Department Town Hall $outhold, 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 Buitding Inspec- tot 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 disposat-(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buitdings, 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 sunzey 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 . . ..~.. ~. ~..El... Old or Pre-existing Building(X) ......... =/Vacant Land ~ ............ · ocat,on of ..... ......... Hou~ No, Street Hem/et Owner or Owners of Property .~C~. ~:~ . .~ ..................... '. ..... County Tax Map No, 1000 Section ~, ~.~ [,. Block . .': ............ Lot..~ .......... Subdivision ................................. Filed Map No ........... Lot No .............. Permit No..I.I. ~ .~. ~ate of Permit.~.~/¢~Applican,...~.. ~ ~ :.( ...... ............ Health Dept. Approval ........................ Labor Dept. Approval ...................... ,.. Unde~riters Approval ........................ Planning Board Approval .................. Request for Temporary Certificate ..................... Final Certificat~ ...... Construction on above described building and permi~meets all app~ab~odes and regulations. ~1.~ ~00 7S-- Applicant .~~, ~ ............................. FIELD INS?ECTION COMMENTS FOUNDATION (1st) FOUNDATION {2nd) 2. ROUGH FRAME & PLUMBING INSULATION PER N. Y. STATE ENERGY ~ODE FINAL ADDITIONAL COMMENTS: filE... ;to~z~,o'~ ~ /4,,~;oe,£~.n~.,) , t~ FORM NO. 1 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N,Y. 11971 TEL.: 765-1802 Examined "J 19 Approved ......... .~..~'~ .... , I . . .~Pe~it No.. ([.~'.~ .I.. ~ Disapproved a/c ..................................... hSV0 - Avpncation No...O..-5..7. .... (Building Inspector) APPLICATION FOR BUILDING PERIVIIT 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 or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- cation. 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) .... ......... ...... ., (Maitihg address of app/l~m ) ~ ~_ State whether applic.ant is owner, lessee, agent, architect, engineer, general contradtor, electrician, ptumoer or ounner. Name of owner of premises ~.c.b..~. ........... .~.. :~..~.~ ......; .................................. (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ....... Y~.- .............. Plumber's License No ......................... Electrician's License No ....................... Other Trade's License NO ...................... 1. Location of land on which proposed work will be done .... ~. · ./~.. · :~.~.~. ~~ ........ House Nmnber Street Hamlet (,/ (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a Ex~shng' ' use and occupancy .... ~ff?/A-C? .~ .................................................. ....... 3. Nature of work (check which ap licable): New Building .......... Addition .......... Altera~joj~,~ ...... Repair .............. Rem, ,al ......... ..... Demolition . ~ ........... Other Work ~g(/-/f.t, at,. ~ 7 o o..' (~get~ ~- o~ (Description) 4, Estimated Cos dy. ~..~. St. / ~_S ~tr_ .', /_5 ~'--~,dgt~,, .~itO 5. If dwel!ing, number of dwelling )nits ............... Number o f 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. D~ensions of existing stmcture~, if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ........................................................ D~ensions of same structure wi~h 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 Fomer Owner ............................. 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 ....... ,~ L' '. '; ' ' ~ 'itl ' ' ' Will excel_fill bg rem¢~e~ from premises: _Yes ~, No 14. Name ~f Owner of premises .~. ~. Address .~. ~4~ ..... Phone No. ~. ~.~. ~ff.~.. Name df Architect .......... [ ................. Address ..... ~ ............. Phone No ................ Nme 6f Contractor ......... ' ................. Address ................... Phone No ................ PLOT DIAGRAM Locate clearly and distinctly all ibuildings, property lines. Give street and block interior or corner lot. whether existing or proposed, and. indicate all set-back dimensions from lumber or description according to deed, and show street names and indicate whether being duly sworn, deposes and says that he is the applicant STATE 0 F NEW,,Y'O RK '~ '° S COUNTY O,F~... ~fName of ff~dividua sign!ng contr/dt) above named. He is the ................... ./. :~.'. ........... .:.~. ................................................ (Contractor,,,affent, corporate officer, etc.) of said, owner or owners, ~[[~o,,r~m or have performed the said work and to make and file this application ;i that all statements cent, ined in this application are true to the best of his knowledge and belief; and that the work will b6 performed in the manner set forth in the application filed therewith. Sworn to before me this Nota_ry Public ..... ... >_,, ......... ~ ~County., , No. 52-8125850, Suffolk Term ~plies March 30, 19.tCv