HomeMy WebLinkAbout12710-z FORM NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, Iq. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
1271O Z
County Tox Mop No lO00 Secton ~ ..~ Block Lo o '%~
pursuant '0 application dated ....~..~....~...~. ................... , 19~..~., and approved by the
Building Inspector.
Fee $.~.;.~ .....
Rev. 6/30/80
FORM NO. 6
TOWN OF SOUTHOLD
Building Dopartmont
Town HaH
$outhold, N.Y. 11971
765- 1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
! /tl FiB I 3 1987
DLOG
TOWN Or': SOUFHOLD
Instructions
A. This application must be filled in typewriter OR ink, and submitted ~a mammas= 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 unu~al
natural or topographic features.
2.Final approval of Health Dept. of water supply and sewerage disposal-IS-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 inmalla-
lions, 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)o Non.conforming uses, or buildings and "pre-existing"
land uses: .
1. Accurate survey of property showing all property hne% streets, build ngs and unusua~ 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.
C. Fees:
1. Certificate of occupancy New Dwe).lJ. ng.$25.00, Acco,sar? ,.$10.00 BuuLne~n ~S0.00
2. Certificate of occupancy on pre-existing dwelling ~ 50.00
3. Copy of certiflcate of occupancy $ 5.'00, over 5 years ~10.00
4.wc t n na c,o. $ 20.00
5.Uudated c.g. $ 50.00 Dale .~ 1./. ,/. ,/. ,/,. ~. ·
6, ~lteration $25.00 / '~ / --
New C on s b r u c ~ t on... ~. Old ~r Pre-exi~ting Building ..
County Tax Map No. 1000 Section .././~') ....... Block .... /. ........ Lot ..... / ~. ~...
Subdivision ............................... .~.Flled Map No ........... Lot No ..............
Health Dept. Approval ........................ Labor Dept. Approval ........................
Underwriters Approval Planning Board Approval · ·.
Request for Temporary Certificate ..................... Final Certificate .......................
Fee Submitted $. '~..,~.,. ~). ...............
Construction on above described building an~mtt me~s alr~?l~)bl~ codes and regulations.
_.. ....... ":-','"'"m'"' ..........................
_,
FIELD IN~EC~ION
FOUNDATION
(1st)
FOUNDATION
2.
(2nd)
ROUGH FRAME &
PLUMBING
COMMENTS
INSULATION PER N.
STATE ENERGY
ODE
FINAL
ADDITIONAL COMMENTS:
TOWN OF SOUTHOLD
OFFICE OF BUILDING INSPECTOR
P,O, BOX 728
TOWN tIALL
SOUTHOLD, N,Y. ! 1971
TEL. 765-1802
Thls is to advise you that the job under building
permit no. 12710Z issued to Andre~...Gal~ano :
on ~1~_~8/83 __ for Foundation iS complete4 and
;] final inspection {]as ( ) has. not ( x )' been done.
in order to complete this file, it ia necessary that
a Certificate of Oecupaucy be issued. Please fill out the
enclosed form, return same to the above office with a check
for $25.00 payable to the Town of Southold. Please indicate
to Whom the Certificate of Occupancy ia to be mailed, and
strange with tills office for an inspection date
Occupancy or ese is unla~fu! without a Certificate of
Occupancy. Please. help us to clear up thi~ matter es that
legal action dote not have to be taken.
Thank you for your prompt attention.
Very truly
Victor Lesaard
Executive Administrator
Memorandum from...
BUILDING INSPECTORS OFFICE
TOWN OFSOUTHOLD
TOWN HALL, BOX 728, SOUTHOLD, N.Y. I1971
765-1802
/,~ 5'0
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-180:~
Examined O.~..~.~., 19'~.~.
Approved ~..--~....~...~.~.., , 9~$. Permit No.J..~."} .J.0 ..~.
Disapproved a/c .....................................
APPLICATION FOR BUILDING PERI~/IlT
Date .................. , 19...
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 the construction of buildings, additions or alterations, or for removal or demolition, as heroin 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 building for necessary inspections.
:: ..............
(Signatu~ of applicant, or, amc, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Nameofownerofpremises .:~..~...~.7~Pi$~.'ii~.'.~.i ~.' .~.'~31 iii i ii i i iiiii ii
(as on the tax r631 or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No ....... ~. x. 511 .............
Plumber's LicenseNo .........................
Electrician's License No .......................
Other Trade's License No ......................
Location of land on which proposed work will be done ..................................................
........ · '. . .0. .......... .W. . .7. :: . . .D. . .................
House Number Street Hamlet
County Tax Map No. 1000 Section ....... /.[ 3 ....... 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 ..........................................................
b. Intended use and occupancy ...... ~. ¢.~.~gL4t ....~...~Lqn. ace~, . ~9 .k~g~.. ,...0~4~ .........
3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration ..........
Repair .............. RemO, val .............. D~nolition ............. Other Work ...............
~,Ft-~/~,g,-~...j~ ~w.~-o~ ~.t~,~/.~'&c~q~ .l~ C/~./ (Description)
4. Lstimated Cost ~. t/>.~-- ....................... 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 ..... i ...................................................................
61 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 .................... i · · Height ...................... Number of Stories ......................
8. Dimensions of entire new construction: Front ............... Rear ............. '.. Depth ...............
Height ............... Number of Stories ........................................................
9. Size of lot: Front ........... i ........... Rear ...................... Depth ......................
10. Date of Purchase ........... i .................. Name of Former Owner .............................
11. Zone or use district in which promises 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
14. Name of Owner of pre~hises ...i...' .............. Address ................... PhoneNo ................
Name of Architect ........................... Address .................. ..Phone No.; ..............
Name of Contractor .,~-g~.~./..'-~.~/~ ..... Address ~[~ O~/. ;22.d~). ,/~d~P, hone No.~. ~.~../-d..~PO'"~. · ·
PLOT DIAGRAM
Locate clearly and distinctly all! buildings, whether existing or proposed, and, indicate all set-back dimensions from
property lifies. Give street and block number or description according to deed, and show street names and indicate whether
interior or corner lot.
copper tu[~ing ~s u,~ed
Jor water d stnbuh ~g
system; pipiffg shall be
~t~ types K 9r L 0n!y
rF, r~r-~' '~ "~ NOTED
765-1802 9 AM 'FO 4 PM FOR THE
FOL, LOW)NG {N~DEC'TIONS:
1. FOIJNOATION - 'I"WO REQUIRED
FOR POU2n'D cONCRETE
2, ROUGH" FRAMING & PLUMBING
3. tNSLH, ,"rm J ..... ,-,,-..
4. Flb1AL" ( ~" J: ..... ~,ON MuST
BE ('.--~,~m '"'i[ FOR C. O.
ALL CF?''%r'RrICTjON S':IAdJ. MEET
THE RF'-'''tpFMENTS OF Tile N.Y.
STNi.r Cf~MqTRUCTION & ENERGY
COD[q. NOT RESPONSIBLE FOR
D~g~GN Og CONSTRUCTION ERRORS.
STATE OF NEw(Y(Y(Y(~RK,., /,/~ ~ S
above n~amc °JrmclwidrraI stgning c°nt~ct)
being duly sworn, deposes and says th~he is the applicant
e is the ~(C
ontractor, 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 all statements contained in this application are true to the best of-hi,s-knowledge and belief; and that the
work will be performed in the manner set forth in the application filed therewith.
Sworn to before me this
........... /.'-~ ....
~ubJic, j .,,.~. ~//~, .,,>~ ...... ~founty
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