HomeMy WebLinkAbout12762-zFOR~ NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. Zq2475 Date Hay 21 1984.
dwe. lling
THIS CERTIFIES that the building N..e.w.. 0..n.e..f.a..m.i.l.y. ..............................
Location of Property .~..].7:05. Village Lane, ....... Mattituck
House/vo. Street Ham/et
County Tax Map No. 1000 Section 1 07 .Block 11 .Lot 2.
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore fried in this office dated
·...N.qv.....q.0. ......... , 198..3. pursuant to wtfich Building Permit No..~.2.7.~ ~ g ..............
· dated .N.qv.,..2.~ .................... 198..3., 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 .........
A private one family dwell.i.ng.
Raymond & Theresa Van Etten
The certificate is issued to .................... /o~n'o'r,'l~se'o'gr't~'n't) ......................
of the aforesaid building.
Suffolk County Department of Health Approval...............13-S0-20.2 ......................... .
UNDERWRITERS CERTIFICATE NO .............. 1~ ~ 3.7.~/~ 5 ............................
Building Inspector
Rev. 1/81
FOEM NO. 2
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
12762 Z
Date
Permission is hereby granted to: /
.W....~ ........... .~..~.~ ............................. ; .....
...~~...~.........~.:~:.....!..!.~..~.~C.
..........
at premises located at ....!.:.~....~....~.. ........ ..~..~.~..,..~.~ ........
County Tax Mop No. 1000 Section ...... .)....Q..~. ....... Block ......... .~.k ........ Lot No ..... ~ ............
pursuant to application dated ....~..~~.....[...~. ................ , 19..~..~., and approved by the
Building Inspector.
ui ding Inspector
Rev. 6/30/80
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
~outhold, N.Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
I~structJons
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 applicatJle.
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 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 dweJling J
land
3. Copy of certificate of occupancy $1.0
10
use --t~re-Exist:Lng C.O. $15.00
Vacant land C.O. $ 5.00
Date ..... d...
New Building ... · .~'. · ...... Old or Pre-existing Building ............ Vacant Land .............
Location of Property .........................................................
Street HarnJet
.7;4r.,,. u. /. ./. : '. Y. ........
.... /.( ....... Lot ..... ~..~ ......
Hou.~ No.
Owner or Owners of Property ........ /. ...........
County Tax Map No. 1000 Section .... (~ .'~ ...... Block
Subdivision ................................. Filed Map No ........... Lot No ..............
Permit No/~.. ~'~.~..~.. Date of Permit .......... Applicant ..................................
Health Dept. Approval . ! .~...'~..-~..q .% '~).~', ..... Labor Dept. Approval ..... .~' .................
.~..~. '~. ~. ~, .~.,.~. Planning Board Approval
Underwriters Approval ..................................
Request for Temporary Certificate .................... Final Certificate ...... v/ .....
Fee Submitted $...~'. .............. ,4. .........
Construction on above described building and permit meets all applicable codes and regulations.
C /App''cant · ........................
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION
FRAMING
2ND [ ] INSULATION
765-1802
BUILDING DEPT.
INSPECTION
FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION ZND [ ] INSULATION
REMARKS:/,
FRAMING /~ FINAL
INSPECTOR
FIELD INSPECTION COMMENTS
FOUNDATION (~st)
FOUNDATION (2nd)
ROUGH FRAME &
PLUMBING
3.
INSULATION
FERN. Y.
STATE ENERGY
CODE
FINAL
ADDITIONAL COMMENTS:
,[TH SERVICES
N ONLY
lO0. 0°'
I P Oj~' CHIC. AGO TFTI~ INSU~ANC~ CO. .-
~O~-Ol~Y
~ G~ MA~O~' RAYMOND VAN ~TT~N
FORM NO, 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1803
E×amined 19
Approved ~. ~..3:. 1.., 19 ~ ~. ee~it No. ~ q ?. &.;. ~
Received ......... ~,19...
Disapproved a/c .....................................
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 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 regulation% and to
admit authorized inspectors on premises and in building for necessary inspections.
(Signature of applicant, or name, if a corporation)
. Z., /., . . /. . .o 2. . ,?..//.. . &',.
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
........ . .............................................................................
Name of owner of premises . ~(~/i)/A~..o~.~.. r.. ,~?( ett ~.5 .~)....~.~..n/. ~..~?.~/.~. ..............................
(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 ..........................
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
1. Location of land on which proposed work ~vill be done.. '.~/~'. k ~ ff~ ~. ~....~./~ .~..~.). ~../5.'r.7..t'.-i' [J.~ ~.C ........
..... .................................................................................
House Number Street Hamlet
County Tax Map No. 1000 Section . 1.0.~ ............ Block ...... 1./ .......... Lot .... r~ .............
Subdivision....~.~'.(.[.~ .~..{~1.O~'3~. ............ FiledMapNo..~...~..~..~. ..... Lot ..... l.~. .......
(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 ... ~ ..... ./.D?/.~. .... .c~. ?. I! .2. .r?.~ ...............................
3. Nature of work (check which applicable): New Building ...t/5...... Addition .......... Alteration ..........
Repair .............. Removal .............. Demolition .............. Other Work ...............
~ (Description)
4. Estimated Cost ... ~../~.O(~,. ~.O.. ..................... Fee . .I..~. ~ :.~...O. ..........................
(to be paid on filing this application)
5. If dwelling, number of dwelling units ............... 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. 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 ........................ j ...............................
9. Sizeoflot: Front ...................... Rear ...................... Depth ......................
10. Date of Purchase . .~.~.)(... .~. ~..O' ....... Name of Former Owner . J(./.'4~.c. .e~...,(.e..J. ~/~/o
11. 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 ....~/...V.---~. ....... ._2. ......... t~t~l~e~xcess fill be removed from premises: ~ No
14. Name of Owner of premises ~.)(.~.4~. z/~.~.3.~.P/~d]e~..~ I.,~.~.~..?~.ff.~..~,qt. Phone No...~.~ff. 5 ~..~.~?...
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.
STATE OF NEWt/fl'O~a W~' S S
COUNTY OF ~... '
....... · ~..~~ ~ ........... being duly
(Name of individual signing contract)
above named.
sworn, deposes and says that he is the applicant
Notary Public, State of New ¥orl~
No. 52-0344963 Suf,'olk Count~
Commission Expires March 30, In .~..9~~
He 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 all 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 application filed therewith.
Sworn to before me this
Notary Public, . ~)¢5q441~....c_~/.: ,.~~ County
C'/ ' JUDITH T. TERRY \
...... ...................
(Signature of applicant)
C
~ A
~ ..e'~ge '~U.l~pos~l and ~a~e~ supp~
facili~ie~ for thi~. loqation have bee~ ~ ~'~
~ef of Gen.eral ~ln~erl~
M~iN ROAO
LOT I$
MA P OF
"VI L l A GE MA
FLIED OCT 24, 1962; N~- $GG9 {
A T MA TTITUCK
TOWN OF SOUTHOLD
SUFFOLK CO
T
I00' 00'
CERTIFIED TO;
SOUFttOID SAVINGS BANK
CHICAGO TITLE INSURANCE CO.
# 8~08- 0196 7
RAYMOND VAN ETTEN
THERESA VAN ETTEN
II ~,~ . ,con. sult!ng engineer,
II
313west main street
II .rive .rhead ,.new york 11901