The URL can be used to link to this page

Home My WebLink About12675-z FOEM NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N! 12675 Z hereby grante~Lto~ ~ at pren'jises located, at ...... L..~..I~. ...... ~.¢,e.,..~P~, ........ ~i~.~..j~./~........: ..... County Tax Map No. 1000 Section ..... I~..~..~.. ...... Block ........ ..~..C ....... Lot No...,~.. .................. pursuant to application dated ...C~...~.....~ .................... , 19.~..~1, and approved by the Building Inspector. Fee $ / '~' / Building Inspector Rev. 6/30/80 TOWN OF SOUTHOLD , Building Department Town Clerks Office 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 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 19,57), Non~conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey~of property 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 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 Dote ....... x ......... x ............................. New Building ................ Addition ................ Old or Pre-existing Building ................ ¥oeant Land .............. Owner Or Owners Of Property .......... · .~/~..~,'~.-..~~'....~. r-- ~ ~ ......... Subdivision ................................................................// Lot No ..... x~ ,~ .-..~... Block No...~.~.....~j/ N o~.?...~....7....~.. Date Of Permit ./.~.~..?....Applicant x~.~.'....z~..4~..~L~..~..~..;..~....,~ ~ Permit ..z... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ FinaJ Certificate Fee S ......... -- Construction on above described building and ~ermit me ts all app~ ................ o, ............................................ I1~',/I I111 Notary Public .................................... County ~l-~ ' 0~ I~ ~ BLDG. DEPT TOWN OF SOUT~OLO FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 Approved .~..~. !.O.., 19~.3. Permit No)..~.~..~.g..~. Disapproved a/c ..................................... Received.../.O./2.. (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted 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 issued 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 tl~e 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 regulation_s, and to admit authorized inspectors on premises and in building for necessary inspe.,qtion>., ~ .~-~ ,~ ...... .ff,.v.A. ?~.. ~.~,! r. >: ?~,~...62..~: ....... (Signature of applicant, or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ..... >./.. ........................................................ Name of owner of preulises..~..~.~.~/. >~.')~ .~..~.~..~....~. ............................................. ~ (as on the tax roll or latest deed) If appl?ant is a corporal;ion, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No...--~.o?..~.~..o./'.4...~.~..~??..~. Plumber's License No. : Electrician's License No ....................... Other Trade's License No ...................... 1. Location of land on which proposed work will be done....~.~.~..~.~..~: ?...~.>g~ .kO...~. .... ..-:., ........... .o. ....... ............. .......... ttouse NumberStreet Hamlet. County Tax Map No. 1000 Section ..... .~..~..~. ...... Block ........ .~. ........ Lot ..... ~ .......... Subdivision ..................................... Filed Map No....~..~..[ ....... Lot .... .~ .......... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: & a. Existing use and occupancy .... ~. ~ 7> ..... .~..c:. ,.~.~ ............................................... b. Intended use and occupancy ...'Y..~..~ .t .~...~.~.c.q .~ ............ .................. 3. Nature of work (check which a plicable): New Building .......... Addition .......... Alteration .......... Repair .............. Removal .............. Demolition .............. Other Work .~/~.~,~',e._ ~e.}~.q~ . (DesS'ription) 4. ]Estimated Cost .... d...~..~.°. ..................... 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 mixeld occupancy, specffy 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 ............... I?ight ............... Number of Stories .................................................... Size of lot: Front .... ~/.~/ ............. Rear ..... ~/.~. ............. Depth .../..'~..g~. .............. Date of Purchase .......... ~ ................. .,~ame o~ Forn~er O~w]ner ............................. Zone or use district in which pr~mises are situa, ted.../.[ ,~t. ~.~.~L't~ 1.......t ........................... Does proposed construction viq!a, te any zoning law, ordinance or regulation: .. Will lot be regraded ..........~V,~. ......... ~ .... ,.. Will excess fillbe removed from ........................ premises: Yes Name of Owner of premises .~'~ I~./../J~. ~.~.~.e.~.~[Address C.~.a?~t././.~. ~.P~. ~ .~t.~,l~one No ................ Name of Architect ......... ; ................ Address ................... Phone No ................ Name of Contractor. ~.~r-/~.Y:.q~, .~:*.~tt,.~'~. ~.~.. Address ................... Phone No ............... 10. 11. 12. 13. 14. PLOT DIAGRAM Locate clearly and distinctly ali buildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. Give street and blocklnumber or description according to deed, and show street names and indicate whether D interior or corner lot. STATE OF NE~QY. xO~K,// ..... (-~-m~-~;.~.~.d.,~.s]~~ ~ ~ .,~--- ~-~-- --~ -~~ .... being duly sworn, deposes and says that he is the applicant above named. e ~s the ......................... .~.. ~ ................................................... ~ ~t[act~ent, corporate officer, etc.) of said owner or owners, ~d is d~7 author~m or have performed the said work and to m~e and file this application; that all statements co~tained ~ this application are true to the best of his ~owledge and belief; and that the work will be perfo~ed in the m~ner set forth in the application filed therewith. Sworn to before me this .................. si n ..... : .... ~ ~2.~125850, Suffolk ~o~/ ( g ature ofapphcant)