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Home My WebLink About10276-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 5570 Main Bayview Road, Southold County Tax Map bio. 1000 Section ...... 7.8....Block ...~. ........... Lot .... /~0 ........... Subdivision ............................... Filed Map bio ......... Lot No .............. conforms substantially to the Application for Building Permit heretofore filed in thi~ office dated · . .J.l~yl..~. ~.~ .........., 19 79. pursuant to which Building Permit No..~.qaT~..~. ............ dated .... .~.u~...e.. ~.~., ............... 197~. , was issued, and conforms to all of the requiremants of the applicable provisions of the law. The occupancy for which this certificate is issued is ......... ....... ~..c.z?.s.~.9~..~.u..~.~.dAn. g .................................................... The certificate is issued to ....... ~.o..hrS...B.u.~.I~..h.~?.d.~. ................................... (owner, le;;se or tenant) of the aforesaid building. Suffolk County Department of Health Approvak ....... I~]./.R. ............................... UNDERWRITERS CERTIFICATE NO ............... lg/~L ............................... Building Inspector BUIt,Dlt~ WIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) No.·; J,0276 Z Pen~i,~ion i~ ~ granted to.' ...... .~...~.~.......~.~.~.~.~.£.~ .................. ~..o....~.!.~....,...~.:.:'..L,...~..~/~......~? ,~ ......... ~..~-I.~.~..~...,....~L.:..~ ........... ~..~...? ~ / to ......... ~:.~.~.~. ............ ~ ........... ~.~...~...~.~.Z .......... .~/..~.~.L~...~ ......................... pursuant to appllcatlan dated .............................. ..v...~...LL2......~.L*., 19......{., and Building Inlpector~ approved by the FORM NO. 6 TOWN OF $OUTHOLD Building Department Town Hall Southold, 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 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. B. 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 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, 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 ) / · .~' r Pre ex~stl~ Budding Date ..................... L a" no~'Pr;'i~v]'~.'~j'~ J',~) ' 'h~ ' ' ""~'~,~/-~/;/~ ..... ',,~J~ ..... oc ,,o P ....................................................... , Street ' h- .... Owner or Owners of Property .............. ~. ....... ~. ........................... J CountyTax Map No. 1000Section...'7.~. ........ Block .... .~. ......... Lot .... ~..l~. ....... Subdivision ........................... ---- ~ '/"'~ ...... Map No ............... L~No ............... Permit No. /~. ,~,. ,J~,~, Date of Permit ?~, ,~"/~,~)pplicant~. ~,.~,,, .~ , , ,~, Health Dept. Approval ........................ Labor Dept. Approval ........................ Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ..................... Final Certificate...y '~'~ ............. Fee Submitted $....~./.~ ................... Construction on above described building ar~permitj'neets all al;~licable codes and regulations, Applicant.. ~..~.~~~~./.;~.. ,~. ?_~ ~/~ '/ Examined ................. ,19... Approve~. ............. 19 .~¢~rmit No ....... .~ Disapproved a/c ..................................... BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL: 765-1803 ~Xi~ding Inspector) x__ ~. ~P~I~C~TIOI~:OR BUILDING ER '~ ~h% ~STRUCTION~~ a. ~s' apphcat~on' ' must b~Cc~p~~ by typewriter .°r in ink, Inspector, with 3 sets of plans, ~&ura~e plot ~ldn to sere. Fee according to scneddle. b. Plot plan show~g location of lot and of bufld~gs on premises, relationship to adjoining premises or public streets )r a~eas, ~d ~ving a detailed description of layout of prope~y must be drawn on the dia~m which is part of this appli- :ation: c. ~e work covered by this application may not be commenced before issuance 6~ Bmld~ng Pe~t. d. Upon approvM of ~is application, ~e Bulldog Inspector will issue a Building Pem~it.to the applicant. Such pe~it ;h~l be kept on the premises available for4nspection throughout the work. e. No building shah be occupied or used in whole or in pa~ for any pu~ose whateier until a Ce~ificate of Occupancy ;h~l have been granted~y the Building Inspector. ~PLICATION IS HEREBY M~E to the Budding Depa~ment~or~~f a Building Pe~it pursuant to the Building Zone Ordnance of ~e Town of Southold, Suffolk County, New York~ ~ ~her applicable Laws Ordinances or Re~lations, for ~e constmcfion of buildings, additions or for or demolition, as herein described. Fhe applicant agrees to comply with all applicable laws, ordinances, code, ~dmit authorized inspectors on premises and in building pections. 3rate whether applicant is owner, lessee, agent, architect, engineer, · .................. ~ame of owner of premises f~ /'/~t (as O11 If applicant is a corporation, signature of duly authorized officer. code, and regulations, and to or name, if a corporation) . electrician, plumber or builder. )r latest (Name and title of corporate officer) Builder's License No..ff'.~(..A":4/.~ . . . .-~. ~(~ .d. ~.-.-.' .~.~. Plumber's LicenseNo ......................... Electrician's License No ....................... Other Trade's License No ...................... Location of land on which proposed work will be done .... d.~.,Z..P/,/. ~.~.- .~. · /'~).< ...................... ..................... ................ House Number Street Hamlet County Tax Map No. 1000 Section ...O..~0~. ........... Block ...... ~....~. ....... Lot... ~....~..~. ........ Subdivision ..................................... Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premises and intended use and occupancy of proposed construction: ia. Existing use and occupancy ........... .~. .................................................. I, I:tended use and occupancy, ........ '~.' 1 5~J..~TJ.~..~. ~t ~ ..... '~' ?L'~' 'L~ ............................... 3. Nature of work (check which applicable): New Building . w/ Addition Alteration Repair .............. Removal .............. Demolition .............. Other Work ............... (Description) 4. Estimated Cost ............................... Fee ...................................... (to be paid on ~ing this application) 5. If dwelling, number of dwelling units ............... Number o f dwelling units on each floor ................ If garage, number of cars ........................................................................ 6. If business, commercial or mixed occupancy, specify nat~ and extent of eachct~e of use .......... .~ ...... 7. Dimensions.,~f~xisting structures, if any: Front .... ~ ....... Rear .. ~.. ........ Depth ...~.~ ........ Height . ~ ........... Number of Stories ........................................................ Dimensions of same structure with alterations or additions: Front ................. Rear .................. Depth ...................... Height ........... ~ .......... Number_o~,Stories .......... .~, / ........ 8. Dimensions of enJ~r~ new construction: Front ..... ~../. ...... Rear .... ~. ......... Depth .. ~.. .......... Height ...... ~.i ...... _Nulnber of Stories ......... /. ...... ~r ......................... / ............ 9. Size of lot: Front ...... ~.~. ............. Rear ...... /..dZ~ ........... Depth ...-e?,,d.4.-- ............ ~_. 10. Date of Purchase ......... /..~. o/..~. ............. Name ?f Former Owner/?~ ~ .//.-=.. · ·.l~. .~. .f~. .~./'}'.t~..' · ~ .'~. 1 1. Zone or use district in which premises are situated ........ ~ .... ~.~A/. ~ ............................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ...... d,('..0 ...................... 13. Will lot be regraded .......... 477..~ .............. Will excess fill be removed from premises: Yes s/No 14. Name of Owner of premises ~ tO.~..~]~//-~/~ .,b..77-. .... Address .~.,4-./y'...~./.~-.L~'.. ff.,~..: . .. Phone No..'%~-.. ............ Name of Architect ........................... Address .,..t)...-~-...,.,./. Phone No ................ Name of Contractor ~., ..~A .~. ~-../4.. ............. Address~'..O .F'ff~9 '/./q¢ ............... Phone No. PLOT DIAGRAM Locate dearly and distinctly all 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. '~ ' i STATE OF NEW YORK. o o COUNTY, OF. ~/6~-~2~'~2. ·: · ............... being duly swor , deposes and says that he is the a plicant (Name of individual signing contract) above named. iHe is the ......................................................................................... (Contractor, agent, corporate officer, etc.) iof said owner or owners, and is duly authorized to perform or have performed the said work and to make and Erie this iapplication; that all statements contained 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 :~ c:~& .... day of...~. · .~ ........ , 19 ..~.Y ~NotaryPublic, . ................................ County (~ 14. ". .................................... : /t2::~ ....... .~ lqo'r.~¥s,mo~l~'~.¢~.~ .,.,,o. ~.~;~'<~'~r'._~. ,, ~ (Signature of apphcant)'