HomeMy WebLinkAbout10166-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate OF Occupancy
THIS CERTIFIES that the building ................................................
Location of Property/:/~s~ ~' .l~..a.:[.rl..R.Q.a.d. ........................ ~ttt:~Lq~'Ltolc .....
· Straet Hamlet
County Tax Map No. ]000 .Section ....q.~.2. ..... Block ... (5 ........... Lot ....... 19 ........
Subdivision ............................... Filed Map Ho ......... Lot Ho ..............
conforms substantially to the Application for Building Permit heretofore fded in this office dated
..... .Alp?.~...'1.2. ...... ,197.9. pursuant to which Building Permit No .... .'1.016(5Z ..........
dated ....~l~l?[~-..!~ ............... 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 .........
............ Ad.~lon .to. a .One. F. am~l~ .Dwe.llin& ............................
The certificate is issued to ....... L.o.u.t. $.e. ~. :. ¥.t.~.s. 9.n ....................................
of the aforesaid building.
Suffolk County Department of Health Approval .. NA
UNDERWRITERS CERTIFICATE NO .....
Re~
FOP~ NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTH'OLD, N~ Y.
BUILDING P, ER/vUT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N.o 10166 Z
Permission is hereby granted to:
................................. .....
,o ...... ~..~...P.. ............. ..7....°. ........... ~ ............ ..o..~:. ............ .F.~:...d!.~.T. ..........
Building Inspector.
Fee ~ ~o.~ ,,
and approved by the
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N~Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
This application must be hlled 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 ex~sting buildings (pr~or 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,
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 ............. Old or Pre-existing Building j~,.l~f~.~.~. Vacant Land .............
Locat,on of Property ................ ~/'~tt~ . ~. ¢;.t-. ~. ......... .~./(~.'T~./'..~.~ .~ .~. .....
House No. Street Hamlet
Owner or Ownersof Property . .~.C~.,..~.O~ [.-~.~...~ .~..~.
County Tax Map No. 1000 Section ............... Block ............... Lot ................
Subdivision ................................. Map No ............... Lot No ...............
Permit No../.~./.~ ~. ~. Date of Permit ~.~,/.~..Applicant.. ,~'¢~ ,/~..~. :~..F/,.~.~...J./'. ....
Health Dept. Approval ... ~.//.~. ................. Labor Dept. Approval .... .~./.~. ................
Underwriters Approval. ~.. , .z~/~.,.~(~. ~..O .......... Planning Board Approval ../1/.~. ................
Request for Temporary Certificate ..................... Final Certificate ... ~ ................
Fee Submitted $ ..............................
Construction on above described building and permit meets all applicable codes and regulations.
Applicant.../j.~'-~. Jr..~. '...~2L.' .....................
RUland Elect. Co.
P.O~ Box '1~3
Mattitu~k%N.Y. 11952
Lic.2~2
1t
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWH~uTHOLD,CLERK'SN.OFFICEy.
~x~i~ ........................................ , ]9...~ ....
Disapproved a/c ............................ :'""'/ .......................................................
> / /
........................... !..:.....:. ....... '.....: ........ ':..:.:...~ /..j. .....................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
Date ................................................ , 19 ........... ~
a. This application must be completely filled in by typewriter ox 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 o~
areas, and giving o detailed description of layout ofproperty must be drawn on the diagram which is part of this application.
c. The work covered by this apphcation may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Budding Inspector wdl 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 Pemnit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, Ndw 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. , ~:~
.... ~.~r.d~...~-,~,...,:.<CL~J.../~,~...~. ..................................
(Signat~r~f applicant, or~e, if a~corporation)/
...............
/ ' (Address of applicant) ,
State whether ~pplicant is owner, lessee, ~gent, architect, engineer, general contractor, electncian, plumber or broider
,-)x~ // :-,_,.. ?;
.................. ~...~..~..~,~,,,zt r4.,:~v,~.~,, ....... ~:; ~:,, z,,~. 1~.:c2~.. ~ ~ .................. :- .~ . ...~ ...............................................................................
Name of owner of premises .......... C~:.~Uk.,t..L:.:.~:¢~,~, ....... ~L./L~:~z~t ................................................................
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 Trade's License No ...............................................
~/1 Location of land on whi,chpropofed worl<; yvill,,b~done. Mop No.'/; ................................... Lot No ........................
Number Wi(t.~c~.:~,~,,,~,~;6...?./..~l~/f~l~(.,'~(~ ~'(~'~'~.. ...........................................................................
Street and ..... ~"' ~ ~ , Municipality
2. State existing use and occupancy of pre?nises and in,¢ended use and occupancy of proposed construction:
a Exisiting use and occupancy ....... ~.~:~J.~4~.~/~,~Z ...........................................................................................
b. Intended use and occupancy .................... ~...). ~ ..........................................................................................
3. Nature of work (check which applicable): New Buildmg~· ................. Addition ........ Alteration ...............
Repair Removal Demolitior. .................... Other Work
(~ ~ -- /~--~O.-~---- (Description)
yOo
4. Estimated Cost ¢~., Fee .........................................................................................
......... ~ ......... ~ ....................................(to be paid on filing this application)
5. If dwelling, number of dwel lng units .......... ~ ............... Number of dwelling units on each floor ..........................
If garage, number of cars ....... .....................................................................................................................................
6. If business, commercial or mixed occupancy, spec~f~ nature and extent of each type of use ............................
7. Dimensions of existing structures, if any: Front .......~ ............... Rear ........ ~. ................. Depth ....~.~.~ ......
Height ......... ~ ..........Number of Stories ~ .......................................................................... ; ..........
D~mensiSns of same structure ~ith alterations or addihons: Front ............ ~.~ ............... Rear ....... ~ ..........
Depth ........ ~ ................. Height ............ ~ ............ ~u~ber of Stories .......
8, Dimensions of entire new construction: Front ....... ~.~ ................... Rear ...... ~ ............ Depth ...... ~ ..............
Height ...~ ........... Number ]of Stories .......... ~ ...............................................................................................
~S,ze of lot: Front ............~.~....~ ........................... Rear ............ .~.~....~ ......... ;~. Depth ..~.~.,~ ........
~ Date of Purchase ...... ~......~.~..~ ............ Name of Former Owner ...... ~ ...... ~~ ........
11. Zone or use district in which ~remises are situated ...................................................... ~ ...................................
12 Does proposed construction vi~late any zoning law. ordinance or regulation: ......... fX¢.~ ....................................
13. Will lot be regraded ...~ .......... ~W~II exces~fil~l.~e removed ~m p~em~e~:~ ) ~es (~No
14. Name of Owner of premises ..~.~.~..~ Addre~..~~Phone No. ~.~.~
Name of Architect ...............~.~ ............ .~ ........................... Address ..~ .................. ~......~ Phone No .......................
-'; ~' ' /~ ..~,.~h' ~.~.~,,~.~
: PLOT DIAGRAM Y
Locate clearly and distinctly alii buildings, whether existing or propos~ i~W ~11 set-b~ck dimensions from
property tines. G~ve street and Nook number or ~scription ac.c~to deed. and sh~ strut names and indicate
whether interior or corner lot ~ ~ ~ '/'-C~
COUNTY OF ............. ~......i r'
(Na~e of individual signing contract)
(Contractor, agent, corporate officer, etc.)
of said owner 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 canto ned in this application are true to the best of his knowledge and belief; and
that the work will be performed in the manner set foffh in the application filed therewith,
Sworn...~.~....~.to~re me__., (~~this ~ ....
Nota~ Public,~.~ .................... Coun~ ......... ~.~.~.....,¢.z;.t ...... ~ ..................
f I i , (/ (Signature or applicant)