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Home My WebLink About10781-zFORM NO, 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N.Y. Certificate Of Occupancy No. Z10134 Date September 5 19 80 THIS CERTIFIES that the building ............................................. Location of Property 28475 No~'th Road Peconic~ N.Y. County Tax Map No. 1000 Section 74 .Block 1 .... Lot .4.1. . Subdivision .............................. Filed Map No ......... Lot No .............. conforms substantially to the Apphcat~on for Building Permit heretofore filed in this office dated ...... J.u..1.y. fi..6 ....... , 19 80 pursuant to which Building Permit No. 1 0781 Z dated .... .J.u. 1 .y..~.6. ............. 19 .8.0. ,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 ......... .................... p.o.o.k...~.d.4~.~..~.o.n. ~.9 ~x..~.~.t.~.n.g...~.e..~.~.~.n.g ................... Elizabeth Simon The certificate is issued to .................... [o~n'o'r, ;~,$:r~'t~ ..................... of the aforesaid building. Suffolk County Department of Health Approval ............ .1)I./.R. ......................... UNDERWRITERS CERTIFICATE NO .... N/R · ./ /~/.~(c~ c--- ,.__......._~....... Building Inspector Rev 4/79 FOI~,M NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 1O781 Z Date ......................................... 19. Permission is hereby granted to: pursuant to application dated ..... .~.~ .......................... , 19. .:, and approve the Building Inspector. Fee $../..~.'~....'~. ......... Building Inspector FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Half 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 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 3. Copy of certificate of occupancy $1.00 New Building ............. Old or Pre-existing ti~ing .... Location of Property ....................... I~,~.~¥.~. House No, Owner or Owners of Property $§.00 Date ................... Vacant L ........ ~,. · ..... .... .............. County Tax Map No. 1000 Section ............... Block ............... Lot ................ Subdivision ................................. Filed Map No.~. ......... Lot No. Permit No ........... Date of Permit .......... Health Dept. Approval .... ~ ........... Labor Dept. Approval ~ ............... Unde~riters Approval ...... ~ ....... Planning Board Approval . ~ .......... Request for Temporary Certificate... ~ ........ Final Certificate ~ Fee Submitted $....~ Construction on above described build~~t ~et~app~lecode~d ~ulations. Applicant ~~.~. ~ .~ ................... FIELD~NS~ECTION __COMMENT5 .--- ~ ~ FOUNDATION FOUNDATION 2. ROUGH FRAME & PLUMBING (Znd) INSULATION P~R N.Y. STATE ENERGY CO~E FINAL ADDITIONAL COMMENT . FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N,Y. 11971 TEL.: 765-1803 Approved Disapproved' "[ a/c ................................ ~~ . /~ (Buildi~ig Inspector) APPLICATION FOR BUILDING PERMIT Application No./~.t .~./. ......... INSTRUCTIONS a. This apphcation 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 Bmld~ng 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 den}olition, as herein described. The applicant agrees to comply w~th all applicable laws, ordinances, building coda, hot!sing ~ode, and regFt~ions, and to admit authorized ~nspectors on premises and in buildings for n~ssa~lpection~. Ii [ ,/ .... ~ (Sight're ~f applicant, or namehif~a (~p,o ~at' (Mailing address of applicant) ] State whe/~/pplicant i~ owner(t~see, ag~n~t, ar~chitec~, en~neer, general contractor, electrician, plumber or builder. .... k._Sk ....x,_..(2: ......................................... ''' ~.~ . Il I ~ Name of owner of premises... C..[s .-C.C;~.~9~ ...... ~-~..k..k~...~: · . .'-D~'~-~ .......................... (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of cor.p,~[orate officer) Builder's License No... J~'pi/~...:. Plumber's License No ......................... Electrician's License No ..................... Other Trade's License No .................... 1. Locatim,~.. of land,tin, which proposed wprk, witl bell)ne. House Number Street Hamlet County Tax Map No. 1000 Section ..... .~.ff..~.. .......Block .... ./. ............ Lot....~.../. ........... Subdivision ................................... Filed Map No ............... Lot ............... (Name) State existing use and occupancy of premises and int~n~ted usq arid occupancy of proposed construction: a. Existing use and occupancy ff,~.'x.k:'k ~ ....... .~.~.~£.~.~..~..~. ..... ..X~,.~r\~.~ .... b. Intended use and occupancy ...~.c:~.tA,{....~..?~_~.~.~.~../.'./~'.~-- .................... 3. Nature of ~vork (check which applicable): New Building .......... Addition .......... Alter~.t~ Repair .......... ~,.. Removai .............. Demolition .............. Other Work~acc~. ~ ,. ~ ~ ,--~ (Description) 4. Est ateaCost ..... .......................... Fee./ ................................. , (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 mixe~ occupancy, speedy nature and extent of each type of use ..................... 7. D~ensions of existing stmcture~, if any: Front ............... Rear .............. Depth ............... Height ............... Number of Stories ........................................................ D~ensions of same structure wiih alterations or additions: Front ................. Rear .................. Depth ...................... Height ...................... Number of Stories ...................... 8. Dimensions of entire new constrUction: Front ............... Rear ...... ~ ........ Depth ............... HeiSt ............... Number of Sto~es ........................................................ 9. Size of lot: Front ...........~ ........... Rear ...................... Depth ...................... 10. Date of Purchase .......... ~..: ............... Nam~ of Fomer Owner .................. 11. Zone or us~ &smc/in w~ch presses are s~tuated ...... /~ .............. ~ ~... ~ ...................... 12. Does proposed constructio~v~ate any zoning law, ordinance or re~lation: .~.~ .......................... 13. Will lot be regraded .... ~ .~' ................... Will excess fill b~ r~moved from premises: Yes No 14. Nme of Owner of premises ...: ................. Address ................... Phone No ................ N~e of Architect .......... ~ ................. Address ................... Phone No ................ N~e of Contractor ......... . ................. Address ................... Phone No ................ PLOT DIAGRAM Locate c'leariy'~and distinctly all ibuildings, whether existing or proposed, and, indicate all set-back dimensions from property lines. ~ive street and block numb, error de, s~copfion..&ccorlt~ig to deed, and show street names and indicate whether interior or cgrneNot. ,. .,~.,,/<f,--u~/ ' COUNTY OF .~~~.~.,.~.~... ~ ' above named. ....... being duly sworn, deposes and says that he is the applicant He is the .................. ~ ........................................................... on ent, corporate officer, etc.) of said owner or owners, an~ 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 manne~ set forth in the application filed therewith. Swom to before me this,'i 1 " ' J .......... ~ ~.~ .... day of; ........ )~ .. ~..].,~, .....9~,~ ~ I NOTARY PUBLiC,State of New York , ilo, 52-8125850, Suffolk County ~ ~ ,, ! Term Ex~.~arch 30, 19~