HomeMy WebLinkAbout10316-zTOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 10316 Z
Permission is hereby granted to: ~
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pursuant to application dated .................. .7......'~...d.2....-~.. ............. 19...?,~/ond approved by the
Building Inspector.
FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
THIS CERTIFIES that the building ................................................
~ h/~.~ ·~· .... ~ .......... ~ ...., ........................ ~ ~..~ ~.¢~...
Location of Property ~s . Street Hamlet
County Tax Map No. 1000 Section .. J,/."'. ....... Block ...... 1. ........ Lot ...... ~ (~ .........
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
..... /(4.'?.:..1;?. ....... , 19V.). pursuant to which Building Permit No ..... 10;].1.&/.~ ..........
dated ..... ~'~.~75. · ~ '? ................ 195' .q., 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 .........
The certificate is issued to ~, u~...?c ~ ~ ~ ¥ j,,Q}/¢~ b x,~l>.a.t~.¢~d: ....
(owner,
of the aforesaid building.
Suffolk County Department of Health Approval ................. ;. '~I ......................
UNDERWRITERS CERTIFICATE NO ..................................................
/ A- /~, ,~'~,'/', . '.~,( ....
Building Inspector
Rev 4/'79
FORM NO, 6
TOWN OF SOUTHOLD
Building Department
Town Hall
$outhold, N.Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
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:
I, 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.
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.
Co
Fees:
1. Certificate of occupancy $5.00
2. Certificate of occupancy on pre-existing dwelling or land use
3. Copy of certificate of occupancy $ 1.00
$5.00
,... ......
Date
New Building t/" Old or Pre-existing Building Vacant Land
Location of Property ....... .~i~ !%./J...~'., ./~.b.:..~., ,~..E:~. '/.--...~. ,,~.~.~.'-.~....~.~)., .... (?.~.U. ~?.~,Z. '.~.
House No. Street Hamlet
Owner or Owners of Property . . ¥- ~/~1 -~' ~/-/? ,~, , ........
County Tax Map No. 1000 Sect.on .7~. ........... Block .../ ............ Lot ./..'~, ............
Subdivision ................................. Fded Map No ........... Lot No ..............
Permit No./~..3,/..~, . .. Date of Permit ?~'./7.~ ,7~..Applicant .)~.¢,~,~..~.'/,--....~/-J.~ .~. ,h/./. ~ .~. ......
Health Dept. Approval ........................ Labor Dept. Approval ........................
Underwriters Approval ........................ Planning Board Approval ......................
Request for Temporary Certificate ......... .~ ....... Final Certificate .......................
Fee Submitted $...~'., .~. ,? ....... . .~.f. , . .).
Construction on above described building/~n~per~t~~licable/~des and regulations.
..... ....................
. . .
~ A Y V ! E w
FORM NO. 1
TOWN ,OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1802
Approved..~-~.'7. [ -? , 19~/~Permit --, ~
..........
Disapproved a/c -iL'¥.~-.. ~ i..' .............. ~ ........
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date .~.
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 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 drown on the diagram which is part of this appli-
cation.
c. The x~ork 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.
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, N~k, and other applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or alterati9~, or fo~ removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinance, bu. ildin~/cgde, hojUsifi~ode, and regulations, and to
admit authorized inspectors on premises and in buildings for nece~a~p~iTs. ~/~)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Nme of owner of premises .... ! ......... 0 ......................
(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 ..... .~?...-~(: .~.'....-7.: ......
Plumber's License No .......................
Electrician's License No ......................
Other Trade's License No ....................
1. Location of land on which proposed work will be done ..................................................
House Number ~/~ ~. ~O · Street Hamlet
County Tax Map No. 1000 Section . ~3 .............. Block ./...~ ........... Lot .g~ ...............
Subdivision .......... ~ ..................... Fried Map No .... ~ ....... Lot ...............
(Name)
2. State exist~g use and occup~cy of premises and intended use and occupancy of proposed construction:
b. Intended use and occupancy ~o~ ~p~ ~
· i. -
3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration ..........
Repair .............. Removal .............. Demolition .............. Other Work ...............
~.~ ~ /~. {~. ~ (Description)
4. Estimated Cost t~. Fee
(to be paid on filing this application)
5. If dwelling, number of dwellingl units ............... Number of dwelling units on each floor ................
If garage, number of cars ........................................................................
6. If buslness, 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 ~ith altarations or additions: Front ................. Rear ..................
Depth ................... '... HeiSt ...................... Number of Stories ................... ~..
8. Dimensions ofontire new construction: Front .. } .c/. .......... Rear .. q ............ Depth 14 .............
Heigh~ '/~- ~w" Number of Stories
9. Sizeoflot: Front .......... . ............ Rear ...................... Depth ................... .~..
10. Date of Purchase .......... . ................... Name of Former Owner .............................
1 1. Zone or use district in which p~emises are situated .....................................................
12. Does proposed construction vio. l~te any zoning law, ordinance or regulation: ................................
13. Will lot be regraded ........ p/.d .................. Will excess fill be removed from premises: Yes No
14. Name of Owner of premises . .. .................. Address ................... Phone No ................
Name of Architect ........................... Address ................... Phone No ................
Name of Contractor ........ .................. Address ................... Phone No ................
PLOT DIAGRAM
Locate clearly and distinctly ali 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 NEW ;g'~RK
above named.
·. being duly sworn, deposes and says that he is the applicant
He is the ........ ~ ....... ~ ..............................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is d~ly authorized to perform or have performed the said work and to make and file this
application; that all statements conlained in this application are true to the best of his knowledge and beliefl and that the
work will be performed in the man~er set forth in the application flied therewith.
Sworu to before me this
......... //..7 .~ ...... day~f .... ~...~1. .... ,19.~
Notary Public, ................ i ._..,~; County/
. V..... .......
o' ag~'m a_~7-Nwn.m ' ~' ' '~' (Sigla~fl~ of applicant)
NOTaRy PUBUC? ~tate of Hew Yo~
fro. 52-8125850. Suffolk