HomeMy WebLinkAbout10791-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
No .... Z.~..0.0.9~, ....... Date ........ -,-,. ....................... 19 .~q
THIS CERTIFIES that the buildmg ...............................................
Location of Property . .~0.~..Y~ns.~.9.n..Ro.~.a. .................. 0.~..~9?.g.'.u?.,..~.:~.....
Ho~s'e No. ' .... Street Hamlet
County Tax Map No. 1000 Section . ..~. '! .1 ...... Block.. ?.4 .......... Lot ..... 5: .~ .........
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
...... ,~)?.~y..1.5.' ....... ,19 .~.0. pursuant to which Building Permit No ......... ~.979.t~ ......
dated .... p~.'l:.~.. ~g ............... 19 09., was issued, and conforms to all of the requirements
of~aplipl~.h~rprovisions of the law. The occupancy for which this certificate is issued is .... ~. ....
·..~.e. ~Ar.~;..~.~.~.~. .... .~.o.~,.~..~ .a..~.' ~ .o.~p.,~. ?.~..~.o.. ¥.x.~.~..t.~.~.~..~.~.o~ ...................
Thomas A. Gilber~
The certificate is issued to ..................... [dv~n'e'r,$~iP~ ......................
of the aforesaid building.
Suffolk County Department of Health Approval .... .N./.R ........................
UNDERWRITERS CERTIFICATE NO ....... .N../~. ....................
Building Inspector
Rev 4/79
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
'TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PER/rUT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 10791 Z
Dote ................................ , 19.
Permission is hereby granted to:-.Z-
....... c/~.~..../.~/~.~..~.~.-zoc.
....... ~o~.&.....~..: .........................
...... ~-I~.~.~ ..... /l~7t
to ..... ~T~.....~2,~..~~~...~r~ z~Z ~....l.~. ....
~,~.,~:.....~.~_~,~ ~ _ ,~¢~ ......... .~,~..~...~..~: ..................
....................................................................................................... ~z~.~-:.=~.~ ........
pursuont to opplicotion doted .............. ~ ................., 19~., ond opproved by the
~uildin~ Inspector.
Buildinfi In~ector
INS~-ECTI~N COMMENTS
FIELD
1.
FOUNDATION
FOUNDATION
2.
ROUGHFRAME &
PLUMBING
(2 d)
INSULATION PER N.Y.
STATE ENERGY
CODE
FINAL
ADDITIONAL COMMENTS:
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 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. Su bm it P lann lng Board approval of comp leted site p lan requ[rements 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
$5.00 f
Date..~/..~. / .o~.. .............
New Building ... ~ ........ Old or Pre-existing Building ............ Vacant Land .............
Location of Property ...~..~'.~2.~ .'~. .... ?.~..~/~../~..." .~ .............. .(~f-~
House No. - Street
Owner or Owners of Property .. ,~...~ .... ~/-....~. ~,~/'~ ~(--~. · · ...........................
County Tax Map No. 1000 Section , :.../.(~'. ..... Block ....... Z',~,, .... Lot
Subdivision ................................. Filed Map No ........... Lot No ..............
Permit No. ,/~.~.//... Date of Permit ~?.~,~..?-~. licant...~P.../~/...../~r~'..~....
Health Dept. Approval... lw/~ ................. Labor Dept. Approval ...
Undervvriters Approval .... ~/./~. ............... Planning Board Approval
Request for Temporary Certificate ..................... Final Certificate ..../~ .................
Fee Submitted $...~.~..0~.. ....................
Construction on above described building and permj~meets all applicable codes and regulations.
FORM NO. 1
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1802
Examined . ~. ~,(.~5 . m2~ .., 19 o~.O
Approved .~'..~./.ctt'.....~d .... 19&. Permit No../..~...~..?/.~
Disapproved a/c ....................................
/
f (Building Inspector)
APPLICATION FOR BUILDING PERMIT
Application No../.~..~.~./. ..........
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in mk 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 applb
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 budding 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.
Tile 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 necessaw inspections.
......
(Signature of applicant, or name, if a corporation)
dz.?Z/
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
............ ...................................................... ..................
Name of owner of premises . .~.~. ~./f4{//~ ....... . .<~.(../~..~:~-..t.'-5 .... E.7-./Y'.cT..d~'..'~..~....~.: ) .................. (as on the tax roll or latest deed)
If applicant is a eorporanon, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No.....~../. ..................
Plumber's License No ..... .A~./,4. ..............
, //.ifa
Electrician s License No ....... /.' ..............
f
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...".~'.d ...........
Subdivision .................................... Filed Map No .............. Lot ............... (Name)
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy . ~. ,~.z.~. ......... .~/ ..............................
b. Intended use and occupancy . ~.x~....~..~'.. it..~... ~/. ~,~./~../.. >~,~--_g~.. ~ .,~...,~..~.~d'..d~.~..o./~.~.~."].
3. Nature of work (check which applicable): New Building .......... Addition .. 2~ ...... Alteration ..........
Repair .............. Removal .............. Demolition .............. Other Work ...............
, ~/ <" (Description)
4. Estimated Cost . ~. Fee . [
i (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 loceupancy, specify nature and extent of each type of use .....................
7. Dimensions of existing structuresi if any: Front ............... Rear .............. Depth ...............
Height ............... Number of Stories ........................................................
Dimensions of same structure with alterations or additions: Front ................. Rear ..................
Depth ...................... Height ...................... Number of Stories ......................
8. Dimensions of entire new construction: Front.../.~..'. ~ ..... Rear ... ~.~'..t~. ..... Depth . .~-{~. ~- ........
Height ~' ' Number of Stories ./..
Size of lot: Front ...................... Rear ...................... Depth ......................
Date of Purchase ............................. Name of Former Owner .............................
Zone o~ use district in which premises are situated .....................................................
Does proposed construction violate any zoning law, ordinance or regulation: ....... ~.t~) .....................
Will lot be regraded ........ ~-~.~. ................ Will excess fill be removed from premises: Yes >~. No
Name of Owner of premises .................... Address ................... Phone No ................
Name of Architect .......... i ................ Address ................... Phone No ................
Name of Contractor .~'~.. 1~..~i~/.~... Address ~~ .... Phone No. ~'~O.~.--./-W~'.~...
10.
11.
12.
13.
14.
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 9umber or description according to deed, and show street names and indicate whether
interior or corner lot. ~
STATE OF NEW YORK.
COUNTY OF.. ,5~,:/n~. b~ .... S.S
...... ...~d.o./~... ~t~F?"~/. ......................... being duly sworn, deposes and says that he is the applicant
(Name of individual sign!ng contract)
above named.
(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 :
................ ?..~...)~....day o~ ....... .~.~.~. ........ 19 ~O
Notary_.~blic,c~~ ~, ~ ._. ~ .., ~._ County' /~
FOR THE
I/ ,I
APPROVED BY
DRAWN BY