HomeMy WebLinkAbout10960-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y,
Certificate Of Occupancy
No ....Z.! 9.3.6.7.. ....... Date ffanuazW ag s 1981
THIS CERTIFIES that the building ................................................
Location of Property .... 7.7.5..B?.o.o..1~ ~..R.9 .a.el.s ......... .~.z,.~.~..np.o.~.~. ,. ~...~.., .............
House No. Street Hamlet
County Tax Map No. 1000 Section ... O~3. ..... Block .... .0.~ ........ .Lot ....0.~ .6. ..........
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore fried in this office dated
... ~.o.v. 9~.b.o.e. 3., ...... 19B.O.. pursuant to which Building Permit No .... ).0..969..z..........
dated ... l¢.o.v..e~b.~.l~.. 7s ............ 19.8.Q, 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 .........
............ A..c1~.~.$9.n' .~.o...I)~..~.X..Xf.n.g ............................................
The certificate is issued to
(owner~
of the aforesaid building.
Suffolk County Department of Health Approval ...~.../.R ....................................
UNDERWRITERS CERTIFICATE NO .... P. 9 .n.tl.i.n.g ......................................
Rev, 1/81
Building lfi~pector
SOUTHOLD, N~ Y. i
BUILDING P,~R,~T~r
(THIS PERMIT MUST BE KEPT ON THE: , i ~
PRE~!S~S UNTIL lULL
COMPLETION OF THE WORK AUTHOR ZED) ; ·
,.,.. ............................. ~. , 19 .......
Permission is hereby granted to: : ~ 4~
...~r:.....~~.~...~.Z, ............ ~ 7~
~o ~ ~;~.~.~.....~~.~....&~.:.~; ~.x.~;z~,~.....~..~ ..........
..~.~ ~&~.~...,,.~m.:...~:..:...~.~~.~o ...........
~. .~.~,~e~ ,o~o~ ~, .~..z.~.c ...... c~zo~.~....~.~C~ ........... ~~.?~..~..~
Coun~ Tax ~op ~o. ]000 Sochon ......... Bilk ............... ~kot ~o., .............
pursbant ia application dated .. .~...'~}....;, 19.,.~, and spprov~ by the
Building I~spector.
~ee ......~ ..............
Rev.~ 6/30/80
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town
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.
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.
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
New Building ............. Old or Pre-existing Building ............ Vacant Land .............
House No, Street Ham/et
Owner or Owners of Property ............ .~. .............................
County Tax Map No. 1000 Section . .~..~.-.~-.~ ....... Block .../ ........... Lot....~../..~'. .......
Subdivision..~. ~...~. ~.q~. ~.~ .~..Filed Map No. ~ .... Lot No
Permit No/~ ~ ~ .~ Date of Permit/~'~':~ .Applicant ~. ~~:~ ~' .....
Health Dept. Approval ........................ Labor Dept. Approval ........................
'~~ gB dApp
Unde~Fiters Approva ............ Pmannin oar royal ......................
Request for Temporary Certifica~ ..................... Finam Certificate .....................
Foo Submittod $ .............................
Construction on above described building and permit meets all applicable codes and re~],u lations.
FIELD INSPECTION
FOUNDATIOM ( ~ st )
FOUNDATION (2nd)
2.
COI¥~ENTS
ROUGH FRAME&
PLUMBING
INSULATZON PER N.Y.
STATE ENERGY
CO E
FINAL
ADDITIONAL COMMENTS:
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1803
Examined ~ .~.~.....Z ..... ,19 ?
Approved ?.~..~J.~.. ~ ...... , 19 .~.~. Permit No../..6/..~(.~..~
Disapproved a/c ....................... (~ ..... ./.~ ~
................... z ..... -?. ......
{(~~'"' "' ~'l~}~;~t;;i ..........
Application No. ~ .°.~?.C). .........
APPLICATION FOR BUILDING PERMIT
Date ~ ~.~.. ~ .......... ,9~
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 pr&mises 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 inspections.
(Signature of applicant, or name, if a corporation)
3/
~4..~..~...,~.'~.....~..//. ~ p..o. ........
(Mailing t(ddress of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
.O2~.~....~.c~/. o.~.~..W.~A .... .~. ~-d.~. ~.. &.~.~p~..~.c,..-. ........................
Name of owner of premises .. C~..~.[~ .... .~.~..~7. l' ,~./'//?..O. .........................................
(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. ~ffr.C .~.~O. ~.. ........
, t/ ' ~7~-~~
Plumber s License No..(,~.dP..~..l.2.(~..p..~(cJ./~..~....
Electrician's License No. ~.~.'~P.~. :/~.~ ..........
Other Trade's License No ......................
1. Location of land on which proposed work will be done..~., .i.....t~ ...,.-- . .
A
~.~:7.% .... ~..7~t~..t~: .... ~.c~ ~o.~ .... ~..~.: .......
House Number Street Hamlet - --
County Tax Map No. 1000 Section .................. Block .................. Lot .~~ ......
Subdivision~'.~..~.~. ~. ?~. ~ .~.~. ~... Filed Map No. ~ ~ ......... Lot ...............
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy.../... ~./.~Q ~~.0. ~/~ ~..~ %' ~. ~.'.~/ ...............
b. Intended use and occupancy ~'. ~/.. l~ff~.¢.r~Z~., d~:~¢2 ~ .....
3. Nature of work (check which applicable): New Building .......... Addition.. ~'7....... Alteration ..........
Repair .............. Removal .............. Demolition .............. Other Work ...............
-4~ i (Description)
4. Estimated Cost ..... .,-~--./. · · ! ......................... Fee . .f.~-?.~.~ ..............................
~ (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 natur~ and extent of each type of use .....................
7. Dimensions of existing structures, if any: Front ...,~.dP.~. ........ Re, az_ . ~.¢9...r'. ... Depth . . ~ O../ ......
Height ..... ~.. ........ Number of Stories ....... ~.~..~....7/,,~., .... ! ..................... , .........
Dimensions of same structure With alterations or additions: Front ....~..Zf..~ ....... Rear .. ,o,~.<:D..~ ........
Depth .... . .~,21~..~ ......... ;.. Height .../..~. ........... ,~t' ' · Number o~f Stories .... ~.~..~-~.~ .f.f_~. ....
8. Dimension.s o~[ e?ire new const[uctlon: Front .. ~f. f.~.,j~ .../..~. ;-..~P.~'./ .... Depth /.~.~..~..~.~. ....
Height ../~. (:~ .......... Number of Stories ..... ~ .AX'.~'...Q. (:~) ................. ~, ...................
9. Size of lot: Front .... ]..~..O.! ........... Rear/..~.~>...~?./..~..C~.: ...... Depth . .-~...O..~. .............
10. Date of Purchase ............................ Name of Former Owner .............................
1 1. Zone or use district in which ~remises are situated .....................................................
1 2. Does proposed constructio~n vioiate any zoning law, ordinance or regulation: ... ~ ..O. .................... ,--,,.
13. Will lot be regraded .. ~.~. I ................... Will excess fill be removed from premises: Yes
14. NameofOwnerofpremises~. /~'t~/'~'J,~//~fO Address~._.~.gf.*.z'.~'./4.a~.r~ PhoneNo ~Y.'~ ,~/.,~..~.
Name of Architect ......... ; ................ Address ...... '... ~. ......... Phone No ................
Name Of Contractor~-/'[O..~,~.~.q .~....~-./.~.. ( .A,~.. Address~./.~.~.P~..~/-t4~. b( ..... Phone No~. ~.ff..,~./..~. 2<...
PLOT DIAGRAM
Locate clearly and distinctly al! 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.
STATE OF 'NE~,
COUNTJI~.OF ~.
.... -~J'~'c'~{ ..........being duly sworn, deposes and says that he is the applicant
above named.
,[ (_ (Contractor, ~gent, corporate officer, etc.)
of said owner or owners and is du~ auth~rm or have perfomed the said work and to m~e ~d file th~s'
application that all statements conthined ~ this application are true to the best ofh~s knowledge and belief; ~d that the
work will be perfomed in the manner set forth ~ the application filed therewith.
Sworn to before me this :
...... ......
......
V' ~~.2D~o~ ~' ~ ....... (Signature of applic~t) t
i ~0. 52-8125850, Sulto~ ~o~ ....... ' .......
, ~em Fxuiras ~arch 30, 1~.~,