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HomeMy WebLinkAbout10306-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupency
No... ~9~'. ........ Date .... J'allttlLt~.
THIS CERTIFIES that the building ................................................
Location of Property ~j~ ~jo~80. !.m2tOn .l~oir~t
County Tax Map No. 1000 Section ..... 1.'15...Block ....... .1.% ..... Lot ..... 020, ........
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore fried in this office dated
.... ,l'Ltl.~r..1.1 ......... ,1979. pursuant to which Buildin~ Permit No .... 10~O~Z ...........
dated ..... ~l'Lt.l.~r..1.1 ............... 19.79, 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 .........
..................... Ons .FaedJ.y. Iheellln& .w/Addition .......................
The certificate is issued to ............. OOOV~I. ~o 1~1~,.~ .....................
of the aforesaid building.
Suffolk County Dep~utment of Health Approval ........... I~/R ...........................
UNDERWRITERS CERTIFICATE NO ................... ~l..~.'~Z.O~ .....................
Building Inspector
FOI~I NO. 2
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, FI. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
CQMPLETION OF THE WORK AUTHORIZED)
N9 10306 Z
Permission is hereby granted to:
............ ~..,..~.~.~ ...... ~.~-.-.~.~. ................
.../U,~.~...~....=.C. Lzc~z~.9..~...~....-..~,
... -- ,~.....,.&~./.¢~./~ ........................
~o ..:'Z~......E~.~ ~.... ~.~./~.~..../~c~.~ ~ ...... ~...~2/2....~.~.....
...~s~.....~~.~ ................................................ ~ ....................................
at premises Iocat[d at ..~/~Z~.....[~..~.....~gQ..~/M~.~. ...........
pursuant to application dated ........... .~.~......(.~ ................... , 19.7...~.., and approved by the
Building Inspector. ~
Fee $.. ./. ~....~ .....
..... ~ ........... .. ......... :~,,~ ........
F
}
S° FORM NO.6
TOWN OF SOUTHOLD
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 surrey 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 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 .�oyember. 29; , 197,9. , , , ,
i
New Building . . . . . . . . . . . . . Old or Pre-existing Building . ... . . . . . . . . . Vacant Land . . . . ... . . . . . . .
Location of Property op. . . . . . . . . . . . . . . . . Luptgr Point ,Road , , , , , . . .M tituck,
House No. Street Hamlet.
Owner or Owners of Property, „ George, Bird. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
County Tax Map No. 1.000 Section . .115. . . . . . . . . . Block . . . . . .11. . . . . . . Lot . . . . . . . . . . .
Subdivision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filed Map No. . . . . . . . . . .Lot No. . . . . . . . . . . . . .
Permit No.103Q6Z . . , Date of Permit . . .7./11/Upplicant . . . .Sidney, Beebe , , , , , , , , , ,
Health Dept. Approval . . . . . . . . . . . . . . . . . . . . . . . .Labor Dept. Approval . . . . . . . . . . . . . . . . . . . . . . . . .
Underwriters Approval N. L�.`7 .7U.7. . . . . . .Planning Board.Approval . ... . . . . . . . . . . . . . . . . . . .
Request for Temporary Certificate . . . . . . . . . . . . . . . . . . . . .Final Certificate . ... . . . . . . . . . .. . . . . . . . . . .
Fee Submitted $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Construction on above described building and permit meets all awlicable codes and regulations.
Applicant . r . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . .
Rev.10-10-78 �� jig
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41
' � 1
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1802 //
Examined . . . �.C. . . ., 197/ ApplicationNolos��?. . . . . . . .
Approved . . . .l l. . . ., 1.97?. Permit No. lases?.
Disapprove a/c . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
v
( ilding Inspector)
APPLICATION FOR BUILDING PERMIT
Date `�. . . . . .. 19 .7y
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 drawn on the diagram which is part of this appli-
cation.
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 necessary 'nspections.
. 1-0,4 41:12V( . . . . . . . . . . . . . . . . . . . . .
(Signatu f applicant, or name, if a corporation)
(Mailing address of applic nt)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
(iu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name of owner of premises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(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. . . .' � . . . . . . . . . . . . . . . . . .
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 Street Hamlet
County Tax Map No. 1000 Section . . . . . . . . . . . Block . . . . . . Lot . . . . . . . . . . . . . . . . . . .
Subdivision . . . . . . . . . . . Filed Map No. : . . . . . . . . . . . . Lot . . . . . . ... . . . . .
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Intended use and occupancy.. ': . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
r+
3. Nature of work (check which applicable): New Building . . . . . . . . . . Addition . . . . . . Alteration . . . . . . . . . .
Repair . . . . . . . . . . . . . ..Removal . . . . . .. . . . . . . . . Demolition . . . . . . . . . . . . . . Other Work . . . . . . . . . . . . . . .
�I (Description)
4. Estimated Cost . . . . . . .v. . . . . . . . . . . . . . . . . . . . . . . . . . Fee . lam` . . . . . . . . . . . . . . . . . . . . . . . . . . .
(to be paid on filing this application)
5. If dwelling,number of dwelling units . . . . . . . . . . . . . . . Number of dwelling units on each floor . . . . . . . . . . . . . . . .
If garage,number of cars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use . . . . . . . . . . . . . . . . . .
7. Dimensions of existing structures,if any: Front . . . :�. . . Rear �. �?�? . . Depth . . . o2rr... . . . .
Height . /:`� `. . . . . . . . . . Number of Stories . . . . ./ . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . .
Dimensions of same structure with alterations or additions: Front ®� . . . . . . . . . . Rear d. . . . . . . . . . . . .
Depth . . . . . . . . . . . . . . . . . . Height .f. �i� . . . . . . . . . . . . . . . . . Number of Stories . . . . . . . . . . . . . . . . . . . .
8. Dimensions of entire new construction: Front . . . . . . . . . . . . . Rear . . . . . . . . . . . . . . . Depth . . . . . . . . . . . . .
Height . . . . . . . . . . . . . . . Number of Stories
9. Size of lot: Front . . . . . . . . . . . . . . . . Rear . . . Depth � �. .. .ay. .
10. Date of Purchase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of Former Owner . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11. Zone or use district in which premises are situated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. Does proposed construction violate any zoning law, ordinance or regulation: . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . .
-13. Will lot be regraded . . . . . . . . . . . . . . . Will excess fil e renpved from premises: Yes No
14. Name of Owner of premises-AR-0,4F
. . . Address 1. . . . . . . . . . . . .Phone No. . . . . . . . . . . . . . . .
Name of Architect — — . . . Address . . . . . Phone No. . . . . . . . . . .
Name of Contractor 1W Address . . Phone No. .�,3`�^:sZ( .
PLOT DIAGRAM
Locate clearly 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.
Nv'(ni�'yP`l"
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Olys �lo02 Berm s I- �z P
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'70 R,&L000d
NPP
STATE OF NEW PORK S.S OIL
COUNTY F . . . . . 8x IG�c�c.
. . . . . . . . . being duly sworn, deposes and says that he is the applit�ant
(Na e of ndividual signing contract)
above named.
Heisthe .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly 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 that the
work will be performed in the manner set forth in the application filed therewith.
Sworn to before me this c�
. . . . . . . .117 . . . . . .day of. . . . . , 19 r�/
Notary Public, . . . . . . . . . . . . . . . . . . . . . . . . . . County
BA�1YtrE C. c0nnoy. . . . . . .
- NOTAIRYT11hirc,Stt►!8 ei New yorh (Signature of applicant)
"In. 52-5792000
C� � •�'ii 30, ll��
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