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Home My WebLink About10396-z FOI~M NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PP. EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 10396 Z Permission is hereby granted, to: ~ at premises located at ........................................... :r"~'v~7*~'~"~.' .......... '~'Z'''~' ................................ .... '£i5':t'"'"'~"~ ................. rj":"~:'""-rc,"r",'n'"czz ....... :L .............. ,/q4..P.. ............. D.-¢-t ....... .................................................................................. ............. ..................................... pursuant to application doted ........................................................ , 19 ........ , and approved by the Fee $ ........................ Building Inspector [ · I I FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions This apphcat~on 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. For existing buddings (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. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use $5.00 3, Copy of certificate of occupancy $1.00 Date .......................... New Building ......... Old or Pre-existing Building ............ Vacant Land ............. Hoalth Dept. Approval ........................ kabor Dopt. Approval ........................ !~0~ NO. TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE ~UTHOLD, N. Y. Examined ............... ....~. ~proved Disapproved a/c ........ {Buildin~ Insp~tor) Application No..Z..~....?....~....~.. .......... APPLICATION FOR BUILDING PERMIT ........,...../. ?.:92. ..... INSTRUCTIONS a. This application must be completely filled in by typewriter o~ 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 drawn on the diagram which is part of this application. 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. 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 ,'/L ~ ,/~/~, State whether applicant i(owner,")lessee, agent, orchitect, e. gi.~er, ge.~rol contractor, ~lectricion, plumber or builder. ............. ~: ~C~ ............................................................................................................................................................... ~-J N~, of ow o p ~ ....... ~ . "~ ........ t ............. d~.-...~ ............................. d ........................... ,,~ ~ / If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ......................... , ........................... Plumber's License No ................................................. Electrician's License No .................: ........................... Other Trode's License No ............................................... 1 Location of land on which proposed work will be done. Map No.: .~..I. .................. Lot No ...... ~..~ .......... Street and Number ................................................................................................................................................... Municipali~ 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: o Exisiting use and occupancy .............................................................................................................................. b. Intended use ond occupancy ................................................. ,¥ ....................................................................... 11. 12. 13. Nature of work (check which applicable) ew Buildi ................. Addition .................. ,Alteration Repair .................. Removal'. ................. Demolition .................... Other Work ................................................... (Description) (to be paid on filing this application) If dwelling, number of dwelling units ............................ Number of dwelling units on each floor ........................... If garage, number of cars ....] ......... ..~... ......................................................................................................................... If business, commercial or mixed occupancy, specify nature and extent of each type of use ............................ Dimensions of existing structures, if any: Front ............................ Rear ................................ Depth .................... J I Height ........................ Number of Stories ................................................................................................................. Dimensions of same structure with alterations or additions: Front ....................................Rear ............................ Depth ................................ Height ............................ Number of Stories ................................ Dimensions of entire new construction: Front ........... ?. ....................... Rear ............................ Depth ........................ Height .....~...~ .......... Numbelr of Stories ................. ( ........................................................................................ Size of lot: Front .............. ..~.~..~ ................................. Rear ............. ~.~ ...................... ,D.e~oth ./.?' ......................... Dote of Purchase ....... .?..7..~::...7....R ........................... Name of Former OwnerRe./(.~.~..~.)F~/.'4~..~.~..'CZ(/.d/. ................. Do~s proposed construction ?iolote any zoning Iow, ordinance or regulation: ........................................................ Will lot be regraded ........... .A('...~ .......... Will excess fill be removed from premises: ( ) Yes (%) No Nome of Owner of premises . .~¢.~..4{/A ddres~..~X?.(C/..~.r/T/. Phone No. Name of Architect .............~ ................................................ Address ................................ Phone No ....................... Name af Controctor ........... ~ .............................................. Address ................................ Phone No ....................... ~ PLOT DIAGRAM 'Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-bock dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether iHterior or corner lot. /-~c,~ /-v T, ,~ '-~- STATE OF NEW YORK, I S S COUNTY, OF ....... ~t~f.:£o],k .......... f ' .0]..a..~.onoe ~ ~ .... bein~ duly sworn, deposes and says that he is the applicam '(Name of individual signing contracf) above named. He is the .............. gon~o~ ................................................................................................................. (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 contained in this application are true to the'best of his knowledge and belief; and tha~ the work will be performed in ~he manner set fo~h in the application filed therewith.x , Sworn to be fo re me this i ~ ),~~ ~ ~.. ~ , i (SignOre of applicant) / ~ LYNNE CARLSON ~ / i ~alifled I~ Suffolk Ceunty 'on Expir~ March 30, 198~