HomeMy WebLinkAbout12189-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No..g.. ] ! .7.8.6. ........ Date ...... 3.?.3_?.. ! ,5 ................... 19~.3.,
THIS CERTIFIES that the building ................................................
Location of Property ....2.~6:5 ................. Xe. p.n.e.q .0.~.~..D.v..Sy.e. ......... .S.o.u..~.h.o.~.O...
House tva. Street Ham/et
County Tax Map No. 1000 Section ...0.5.5 ....... Block 03 .... Lot 01 1
Subdivision... 7.eP.n.e. c. 9.~.~...ly .a.v.k. ........... Filed Map No. 5. ~..~ .7 .... Lot No...5.5. .........
conforms substantially to the Application for Building Permit heretofore filed in this office dated
.... ~e..bF.u.a.v. ¥..2.3. ..... 19.8.3. pursuant to which Building Permit No... J .2.1. 8. .9 . .Z ...........
dated ...... ~. ~r.c.~..~ 3 ............. 19.8.3., 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..p.r. $ .v.a.t.e...o.n.e.-~ f..a,m.i.l.¥, dwelling.
The certificate is issued to ....S.0.~H..~.g..B.~. ~.H~.E.~..&..E.L~ .E.N.~..~$?J.S.S..I.C.It .................. (owner,qe~ee. oc-tef~rrt~'
of the aforesaid building.
Suffolk County Department of Health Approval .. ~. .3 .-- .S. 0. -. .2 .2 . , . ?/J 5/83 ,. Robt... /i. .g. il3_a
UNDERWRITERS CERTIFICATE NO .......... P. ? .n.d.~. n. g ................................
Building Inspector
Rev, 1/81
SOuTH¢
(THIS, pERMIT MUST 'BE KE~ ~N
COMPLETION OF THE
1 18B Z
af ~remises located at~...:
~U~ty TAx Map No. 1000 :Sedtion
p~Ji~ant ~o application .... ..........
and approved by the
InspectOr
FORM NO, 6
TOWN OF SOUTHOL~D
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 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 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 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.
of occupancy on pre-existing dwelling/r land use $/~/$5.00
Certificate of occupancy $5.00
2.
Certificate
3. Copy of certificate of occupancy $1.00
/
~/ Date .......
New Building ...... ' ....... Old or Pre-existing Building(X) ......... =/Vacant Land .......
ocat on of Property... . ' ..........
........................... 0.¢, ._
Hou~ No. Street Hamlet
Owner or Owners of Property
· ~" ~ ~:~.~-~- .' · t~ ..........
County Tax Map No. 1000 Section . .~.~ ........ Block ~ Lot.
Subdivision Y~0¢.~0~ ~.K ........... Filed Map No..~¢~...Lot No. :...~C ....
Permit No. ./g/ ~.. Date of Permit .......... Applicant ~'Jl
Health Dept Approval Labor Dept Approval '
Unde~riters Approval Planning Board Approval -
Request for Temporary Certificate .................... Final Certificate ........
Fee Submitted $ .............................
Construction on above described building anO~m~s all ap~cab~des and ~gulations.
FIELD INSPECTION
FOUNDATION (1st)
FOUNDATION
2.
(2nd)
ROUGH FRAME &
PLUMBING
INSULATION PER N. Y.
STATE ENERGY
qODE
FINAL
looo25B THE NEW YORK BOARD OF FiRE UNDERWRITERS
BUREAU OF ELECTRI¢IT~
THIS CERTIFIES THAT
only the electrical equipment as ~scribed below and i~r~duce~b~ th~ applica~ ~a~ed ~ the ab~v~ ap~i~etlon ~umber in the pren~ises of
in the following Iocatlot~; [] Basement ~ 1st FI.
wasex..~.odo. ~aly 7 ~
[] 2nd FI.
and found to be in corn
- Section Block
)lia~ce with the require~nents of this Board.
Lot
FIXTURE FIXTURES RANGES OVENS EXHAUST FANS
OUTLETS SWITCHES FLUORESCENT
DRYERS
SYSTEMS
NO. OF FEET
OTHER APPARATUS:
~-6.F.!.
E R { V
I C
NO, OF HI-LEG A W. G NO OF NEUTRALS A, W G
OF HI-LEG OF NEUTRAL
Electrical Ventures
P. O. Bc~
Ostler Moriohe~ N.Y., 11934
LIc. #847
/' GENERA1~
MANAGER
~ I Th,s cert,fmate must not be qltered ,n any manner; return to the off,ce of the Board f"nc rrect nspect~s may b~'ide~tif ed b~, the r credentials. ~
FORM NO, 1
TOWN OF SOuTHO~D
BUILDING DEPARTM~N
TOWN HALL
SOUTHOLD, N.Y. 11~71
TEL.: 765-1802
Examined .~./..~.../~..., 19 ? Application
Approved .. ,~.~.. ('.~..., l~Pe=it No ....
..... ...... ........
Disapproved
... ;T'~ (Budding Inspector)
~PPkI~TIO~ FOB BHIkDI~G P~IT
Date .... ~ ........
INSTRUCTIONS
a. This application must be completely filled in by typewriter or inink and submitted in triplicate to the Building
Inspector, with 3 sets of plans, accurate plot plan to scale. Fee according tQ 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 wilt 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)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises .... L~2x.~q,w~x . . ? .... .~..~ .... ~ .~44d~ ................. (as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
.... ......
(Name and title of corporate o~'ficer)
Builder's License No... ].O~. &-..7 ./4. 55 ..........
Plumber's License No .... .g'.~. ?..Z . .~. ...........
Electrician's License No...~ ./-/?..7 .~. .......... ~
Other Trade's License No ...................... :
Location of land on which proposed work will be done. ·..A//?....ff~..O.~ .~.G .o..~...../.~. C. ~/.¢.3~./d../..~o.../3. o.,.5~.
House Number Street Hamlet
County Tax Map No. 1000 Section ..... 0.57.~.~. ....... Block .; .}:~ ............. Lot...2~'Y...I. [ ........
Subdivision..xJ.e':.~. O.e.q°..J~....(9.°,, .¢'.g-. ............... Filed Ma~ I~o...':~./..~.7 ....... Lot. :~..~. ..........
(Name)
State existing use and occupancy of premises and intended use and o~cu. bancy of proposed construction:
a. Existing use and occupancy ....x/c4.ca-. ~4..~. ................... ......... ............................
b. intended use and occupancy ./.~J...~....~.. '
3. Nature of work (check which apphcable): New Building ........ Addition .......... Alteration ..........
Repair .............. RemOval .............. Demolition .............. Other Work .............
.~. ~. ~_~ (Description)
4. Estimated Cost . .~¢~.q.~O... i ......................... Fee .............................
~ (to be paid on filing this application)
5. If dwe!ling, number of dwellinglunits ..... .J ......... Number of dwelling units on each floor.../ ............
If garage, number of cars .../i ...................................................................
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 ................... i · · Height ...................... Number of Stories
8. Dimensions of entire new construction: Front..~.~ .......... Rear...'~. ~. ........ i ~e'p't&".~-~.)~ i i~-~i iii
..................................
Height ............... Number of Stories ..... Depth .~ .~.~: .qL~ ..........
9. Sizeoflot: Front ...t/.6/.'~q ...... Rear
10. Date of Purchase .......... ; .................. Name of Former Owner .............................
11. Zone or use district in which pr~mises are situated .....................................................
.12. Does proposed construction violate any zoning law, ordinance or regulation: ................................
13. Will lot be regraded ........ I .................... Will excess fill be removed from premises: Yes No
14. Name of Owner of premises /.¥~c?.,~.~.~./~,.h...~.F~.~,~.tl~c Address ~oo-~ ~7~r sn ~ Phone No(~4~) .a.t,.-~: ~q.45?
............. · /~y/~ ....
Name of Architect ./:.~.~1¢. ?~o//#~.~r~/.~. .......... Address .~q~ ./~w,~[,o ~ Az,fi.. Phone No ................
Name of Contractor ~..~.~.fi~.'/t. ~on~,T; .5 ~ .c~ ...... Address ~.Fq-/~'e~ ./H.e~-a.~... Phone No. 7.-*Z rJ.q ?~. ....
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and, indicate all set-back dimensions from
property lines. Give street and bloc~
interior or ~orner lot. ._q-~e.
number or description according to deed, and show street names and indicate whether
Nolarv Public, ............. ~
~ NON~RY PUBLIC,
STATE OF NE~'~RK, .~ //
COUNTY ~F~z~?~5~.i .~': ~ ·
....... ~.~.. ~_.~...!. · .'~~... being duly sworn, deposes and says that he is the applicant
(Name of individual sig~ing contract)
above named.
He is the .............. ....... . ./'/f~. ·.. .... .....~."~. · ·.... ..............................................
5on .a tor corporate officer, etc.)
of said owner or owners, and is duly-"",mt~-'~z~d~ or have performed the said work and to make and file this
~ ' h all e nt 'trane
applicat'on, t at stat me s con ' d 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
I SUFFOLK CO. HEALTH DEPT. APPt~OVAL
H.S. NO.
~-'~ '~' STATEMENT OF INTENT
SYSTEMS FOR THIS REsIDENcE WILL
CONFORM TO THE ~AN~AR~
~ ~ ~ SUEFOLK CO. DEPT. OF HEALTH ~V~CE~.
~ ~ (si
~ D~ SUFFOLK CO. TAX MAP DE~G~T~:
~:~o~'g~.~:~ T ~o,,~ ~,,~ ~
LAND ~U~YOa5
6~EE~RT NE~ YORK
L
GREENPORT
NEW YORK
SUFFOLK CO. HEALTH DEPT. APPROVAL
H.S. NO
Medford, L. L, N. ~/- 11765
STATE:I~ENT OF INTENT 7 ~ ~ //
THE WATER SUPPLY AND SEWAGE DISPOSAL
SYSTEMS FOR THiS RESIDENCE WILL
CONFORM TO TH:[ STANDARDS OF THE
SUFFOLK CO. DEPT. O~ HEALTH SERVICES.
APPLICANT
SUFFOLK COUNTY DEPT. OF HEALTH
SERVICES -- FOR APPROVAL OF
COJ~STIAUCTION ONLY / /
SUFFOLK CO. TAX MAP DESIGNATION:
DIST. SECT, J~..OCK PCL.
DEED: ~-. ,~A : - p.
SEAk,
765 1802 9 f,&~ T~O 4 PM FOR THE
'3
!~ cc~Fper tubing is usec~
|'or 'wa~er dis[ributing
system; p]!;]ng shc¢l be
of types K or L only
If copper fubing is used
for water distributing
system; piping shaJl be
of types K or L only
CROSS