HomeMy WebLinkAbout10500-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. Z-1.32. 9 q .......... Date ....... A PR.I.b · I .................. 1985 ·
THIS CERTIFIES that the building .... AD D t.T.I. 0 Iq ...................................
Location of Property 25335 MAIN ROAD ORIENT
House No. Street Hamlet
County Tax Map No. 1000 Section . .0fi. 8. ....... Block ...q3. .......... Lot 013
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
NOVEMBER 15 19.79 gp 10500Z
........................ pursuant to which Buildin ermit No ......................
dated .D.E. ? .E.N.B.E.R...5 ................ 19 .7.9., 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 .........
· .. ~..F. OR · .g.~ · AD~>~?I ON..?~..A'~ · EK.I. STtNG -DWE.DB ING ............................
The certificate is issued to JOHN F. Mc CLELLAND
(owner, levee or tenant)
of the aforesaid building.
N/A
Suffolk County Department of Health Approval ...... ....................................
UNDERWRITERS CERTIFICATE NO... N 5 0 1 1 6 1 .......
Building Inspector
Rev, 1/81
t
FORI~ NO. 2
TOW~ 0F $0O?H01.V
BUILDING DEPARTM£NT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
CQMPLETION OF THE WORK AUTHORIZED)
N? 10500 Z
Permission is hereby granted to:
~,,~ , ~<.~./.~.:.::........C....~.:..:(?.:~././..,,...,~..~.~.,
,<;',?:' zz
t.o .~..c~ ~Z. 54/.',/..~.~. ~."~xz~...(~.'4/"<..~.c?.~..'..~-.....~.....~}~../..',.~.(,.(...'.'~<~...~ ...
.../..
at premises located at 2,~..~.~.~..~.....'~..(...~.....~..~.'L'.~...;~.-.~."~' '~'~"-"/~-~'-"~'~""~"~:'y't ......
pursuant to application dated /~.~....O .b~:......../...~. ............ , 1~... ., and approved by the
Building Inspector.
Fee :f_,...v~.. .............
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FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N.Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
This application must be filled in Wpewriter 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 topographm 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.
For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing"
land uses:
1. Accurate survey of p~-operty showing all property lines, streets, buildings and unusual natural or
topographic featu res.
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
3. Copy of certificate of occupancy $1.00
4.Vacant Land C.O. $5.00
$15.00
Date ...... -? .........
New Building ... ~ ........ Old or Pre-existing Building ............ Vacant Land .............
Location of Property
House No. Street Hamlet
Owner or Owners of Property ~.....~:. ?....:.%~.~ ?.q....~...~.~...~. ~'7.~...f~..a~...~. .......
County Tax Map No. 1000 Section ............... Block ............... Lot ................
Subdiwsion ................................. Filed Map No ........... Lot No ..............
Permit No. ~.0.~..0.Q~.. Date of Permit (.~;tO .q,...AppHcant/~.~ .~..%'~0-~ .~, .~:~,..'...
Health Dept, Approval ........................ Labor Dept. Approval ........................
Underwriters Approval ........................ Planning Board Approval ......................
Request for Temporary Certificate ..................... Final Certificate .......................
Fee Submitted $ .............................
Construction on above described building and/~Ti~ meets all applicable codes and regulations.
Applicant ~ .~ vv~....~.: ~P~....~..~ ...............
Rev, 10-10-78
THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
J~ pl~, 85 JOHN STREET, NEW YORK, NE~/ ~iORK 10038
only the electrical equipment o~ described below and introduced by the applicant r~am~d on tke above application number in the premises of
Jo~ ~Cell~ld~ Maiu Rd,, ~, ~r:L~'~t~, N.Y.
in the following location; [] Basement [] 1st FI. [] 2nd FI. Section Block Lot
w,s exa,nined on Jffl%~ ~ ~ ~0 and found to be in comphance w,th the r~quirements of ~his Board.
FIXTURE FIXTURES RANGES OVENS
DRYERS
SYSTEMS
NO OF FEET
E
EXHAUST
OTHER APPARATUS
S E
R V ~ c
AWG'
OF CC COND
NO OF Hi-LEG
AWG
OF HI LEG
NO OF NEUTRALS
AWG
OF NEUTRAL
Make S~l~is
P.O, ~x~ 64
Easc ~,~ion, ~.Y, 11939
Thts cerbfJcate must not be altered in any return to the
IN ANY
FIELp IN~ECTION
FOUNDATION (qsP)
FOUNDATION (2nd)
e
ROUGH FRAME &
PLUMBING
INSULATION PER N.Y.
STATE ENERGY
COn E
FINAL
FORM NO. 1
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
.~.~..~ TEL.: 765-1803
Examine .......... .~ ...., . 7
Approved ......... ~ ...... 1 ~. · . Permit No./..~..~.7.~.~ ~
Disapproved a/c ................ ~
(Build'fig Inspector)
APPLICATION FOR BUILDING PERM IT
Application No./(~...~..-'.~. · .~. ......
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 tot and of buildings on premises, relationship to adjmning 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.
· ,~ 4~I~LIgA,TION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the
~l~m'l~ gbne~'Ordinance of the Town of Southold, Suffolk County, Ne~; 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)
iMaihng address~of applilSant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises...(~.... · · .Og~. · · ~ ................................................
(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./t. 't'~<..~7......~?~./~.' ./.'~.. ·
Other Trade's License No ......................
1. Location of land on which proposed work will be done ..................................................
House Number Street Hamlet
County Tax Map No. t000 Section ..... 4.~. .......... Block ....'~.. ............. Lot.../.'~. ..............
Subdivision ..................................... Filed Map No ............... Lot ...............
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed c°nstructi°n:
a. Existing use and occupancy ............... O~ ~, d. ~..~,~' ..... ,Pa t'C/~J,~_ ........... J ~-~ .....................
b. Intended use and occupancy ~Y.'¥. ..... .~7~..¥T7.":~
3. Nature of work (check which applicable): New Building .......... Addition ...~. ...... Alteration ..........
Repair I .............. Remo,Vai .............. Demolition .............. Other Work ...............
' ,8' · i ~ ~ ~ (Description)
4. Estima~edCost ...... '..~.'.~ ........................ Fee/'.~7../.~...~77.. ..........................
: (to be paid on filing this application)
5. If dwelling, number of dwelling Cnits .... [ .......... Number of dwelling units on each floor ................
If' garage number of cars '"' '
6. If business, commercial or mixe4 occupancy, specify figure/and extent of each Lw_e r~f use .... .-'. ...............
7. Dimensions of existing structure~, if any: Front .... ..,~-~..~. ...... Rear .... ~ ...... Depth ... ,~ ~ .........
Height' . . . Number of Stones . . .].~.~ ...............................................
Dimensions of same structure with alterations or additions: Front .. ~ ............ Rear ,.,...~.~ ...........
Depth .... ~.' .............. i' · Height ...................... Number of Stones.. J/~'.~,, ...............
8. Dimensions of entire new construction: Front ............... Rear ............... Depth ...............
Height ................ Nu, m~er of Stories .......................................................
9. Size of lot: Front .../.d.Y...,........... Rear .... ....... D.e th .............
10. Date of Purchase .......................... Name of Former Owner ~.~.~ ..........
11. Zone or use d~stnct ~n winch premises are s~tuated... ~ ........... ~. ........................
12. Does proposed construction violhte any zoning law, ordinance or regulation: ... Oo¢~ .............. .~.~, ......
13. Will lot be regraded .... ~ .................... Will excess fill .be removed from premises: _ _ _(Yes)__ _l>lo
14. Name ;f Owner of premises ~..O~¢¢ ~... Address .. 0 ~ ....... Phone No. ~.~.~1~..."~ .~.~..
Name 6f Architect .... , ...................... Address i i ~..: . -.. :.~.. i i i i Phone No ...............
Name of Contractor..~./~. ~).~ ......... Address~'. ~ Phone No. ~..YT. · O. ~'. ~.O.~.
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 humber or description according to deed, and show street names and indicate whether
interior or corner lot.
COUNzyS ATa OFoF'N W R r , , SA
...[.. ~. being duly sworn, deposes and says that he is the applicant
(Name of individual sigding contract)
above named.
(Contractor, agent, corp6rate officer, etc.)
of said owner or owners, and is du y authorized to perform or have p,efformed the said work and to make and file this
application;that all statements contoined 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
~/ ~LIZABETFI ANN NEVILL~ { i .................
';OT^RY PUBLIC, Sfsle of N~w Yo~k (SiBnatu;e of applicant)
No. §2-8]25850, Suffolk
; Term £xl),res March 30,
Q
NOT~Y B~'MG D.:, ~,RTMENT AT
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