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Home My WebLink About10449-z ~OP~M NO, 6 TOWN OF $OUTHOLD , Building Department Town Clerks Office 5outhold, 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 Inspector 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 installations, a certificate o{ 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: ]. Accurate survey of property 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 formation required to prepare a certificate. C. Fees: ]. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use $5.00 3. Copy of certificate of occupancy $!.00 .......... ...................... New B~ilding ................ Addition ...,...~....,... Old or Pre-existing Building ................ Vacant Land .............. Location Of Property %0 .... Owner Or Owners Of Property C~x.r'~ ..~.', ~t ~)~ ~, ................................................................ Lot No ............. Block No ............. House No.,,2.~.~,,. Permit No...I.D.~.~...~ Date Of Permit Heolth Dept. Approval ......... ,~%.~;; .................. Labor ~pt. Approval ....... % UnSe~riters Approval ...~ ...................... Planning B~rd Approwl Request For Temporow Cedificate¢ / ...............L:,.: ................... Fin~ Ce~ificote Fee Submitted $ ~.;.~ ......................... Notary Public .................................... County Construction on above described building and permit meets all applicable codes and regulations. App fica nt ... b.//~..~..~../. ...... ~.....~...z....~'..<~....~. ~ .,,~ ...../ ........................................... Sworn to before me this ................ dayof ............................................ (stamp °; s::')' ! ~ d~ b ' 1'1¢ ~' ~ ., ? rll, THE NEW YORK BOARD OF FI!RE UNDERWRITERS BUREAU OF ELECTRIOITY ' 85 JOHN STREET, NEW YORK, NE~,N YORK 10038 THIS CERTIFIES THAT only the electrical equlpmen t as described below and introduced by the applicant named on the above application number in the premises of Ou~tis Norklm, ~ St'., Village Ler~, Orient, N.Y. in thefollowing location; [] Basement [] 1st FI. [] 2nd FI. Section Block Lot was exa,nined on ,'[~t~l~PPA. 1980 and found to be ln compl,ance wtth tlie requirements of this Board. FIXTURE FIXTURES OVENS EXHAUST FANS OUTLETS DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS TIME C[OCKS UNIT HEATERS MULTI-OUTLET SYSTEMS NO OF FEET DIMMERS SERVICE DISCONNECT OTHER APPARATUS. Pm%elboard/~ ~ L~-14cir. S E R NO OF CC COND A W G, pER ,~ O~ CC COND ,V I C E NO OF H~ LEG A W G OF HI NO OF NEUTRALS J A W G OF NEUTRAL 1 5 P.O. Ee~t 11939 Tbs cerhhcate must not be altered in any manner, return to the office of the Board COPY FOR FOI~M NO. 1 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Approved .................. .~.~..¢,~....~....~.., 19...~.~/. Permit No. J Disapproved a/c ....................... ~ .................................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. Th~s application must be completely filled m by typewriter o~ in ink and submitted ~n 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 Jot and of buddings on premises, relationship to adjoining premises or public streets or areas, and giving a detailed description of layout ofproperty 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 wdl ~ssue a Budding 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 pa rt 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 o 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 w~th ail 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) .............. ........ .............. ,~ (Address of applicant) State whether applicant is o~lessee, agent~ ~ntr~ct~ electrician,~ o~ If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ............................ .~../~.. ..... Plumber's License No. Electricion's License No ............................................. Other Trade's License No ............................................... Location of land on which proposed work will be done Mop No.: ....................................... Lot No ......................... Street and Number ........ .../~'.,..~:.~..~¢~......~..~...:. ................................................................................ Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ............ /~ .~.~. ~ b Intended use and occupancy ........... L~..~...~..~ .................................... ::..,.z ..: ...................................................... 3. Nature of work (check wh ch apphcable): New Building .................. Addition .................. Alteration ............... Repair .................. Removal .................. Demolition .................... Other Work ................................................... ,~ C) CO~ //_..~...---- (Description) 4. Estimated Cost ..................... ~ ...................................... Fee ................................................................................... ] (to be paid on filing this application) 5. If dwelling, num e[ ng u .......................... Number of dwelling units on each flo~?/I/ If gbrage, numb~f ~ ~...]......~ ......................... ~[7..[~.~Z~..Z....~ ............................................................. 6. If business commercial'mr ~ixe~occupancy, sp~c,mfy ~ature and exteDt,~f~qqh type of use ............. 7. D~mens~o~s-~mg structures, ~t~ny: Front ...... ~...4 ................. Rear ................................ Depth .................... Height ........................ Nu~er of ~ories ...... ~T......~..~..~ ............. ~ ............................................................... Dimensions of same structure with alteratio~dditibn~: ~c..~ ...................... Rear ........................... 8. Dimensions of entire new construction: Front ............ ; ....................... Reor,,,,~ ....................... Depth ..................... / , Height ,,,:,Z:, ............ Numbe~ of Stories ......... ,(, ....................................... ~..,,~ ............................... ~ ........ 10, ~ Date of Pur hase ................... ~. ....... A.....L ................ Name o mer Owne ...................................................... 1:1. ~ Zone or use d~stnct in whmh premmes are s~tuated ................... ~.M,,,,: .......................... ~ ................................... 12:L~ Da~ propose~ construction violate any zoning aw, ordinance or regu at'on .... ]St- ~l~,fet be r~graded ..................~..,~,Wdl exc~ f~ll~e removed from premises: ~. Yes ( ]4. '~ of Owner of premises .....~ ............................................... Address ................................ Pkona No ............... :,,ma~e of Architect ..........,....~' ...... ~ .................... ~ .................. Address ..................... ,~ Phone No ....................... -. ~a~' pf Contractor .............~ ............................................... Address ' Phone No, ~ PLOT DIAG~M Izoc~tW~l~Hy and distinctly afl buildings, whether ex~stmg or proposed and indicate all set-~ck dimensions from property I 6es, ~G ye street and bl~c¢ number or descriphon according to deed, and show street names and indicate ~hether interior~ or corner lot. (~¢~ ~ STA-r E OF, NEW YORK, ~.S COUNTY OF ................................ ........... - ............................................... , ....................................... being duly-sworn, deposes and soys that he is the oppl/com · '(Nome of individual s~gning controcf) above named, i He ~s the ......................................... , ................................................................................................................................... (Contractor, agent, corporate officer, etc.) of said owher or owners, and is du y authorized to perform or have performed the said work and to make and file this application; that all statements conta ned n th s appl cat on are true to the best of his knowledge and belief; and that the work will be performed i~ flhe manner set forth in the application filed therewith. Sworn to before me this (. ~, : , ,~ ; " ~.., (Signature of applicant) C~lllinisslon Expires iMm'ch 30~