HomeMy WebLinkAbout10843-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y. ,
Certificate Of Occupancy
No ..... Z.10.1./745 ...... Date ...... 0.91;O.b.e. 17.7., ............... ,19..60
THIS CERTIFIES that the building ................................................
Location of Pro ert 2.0.00...P.e. qu..~sh .~.¥.0.~.14. e., .......... ~.~.~9.h.o.g¢..o.,. N,Y.
P Y h3~,~'e'~'o. ' .... Street ........
County Tax Map No. 1000 Sectmn .... .].0~. .... Block ...... ~1.. ......Lot ....... .0.3~ ......
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
...... JBJ~llllg..J 9.~ .... , 19. J~(~ursuant to which Building Permit No...1,0.~.~.~...Z ...........
dated .... AllgllS.~..2.'1 · ............ 19 ~. , 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 .........
................ ~.t.t.~.o..n..t.q..~..~.~.t..&rig...~..e.z.z.t.n. ~ .............................
The certihcate is issued to .... ~.e.~.8.~..ti..H.,..E. g/~.~. .....................................
(owner, le.~,~.~
of the aforesaid buildiilg.
Suffolk County Department of Health Approval ...... .~I/.R. ................................
UNDERWRITERS CERTIFICATE NO .........
Building Inspector
Rev 4/79
TO~N ~OF
BUILDING
TOWN ~HALL.
SOUTH'OLD, N.'Y.
BUILDIH~ PERMiTi:
(THIS PERMIT MUST BI KE~T eN ~H[ PA~IS~S~UNTIL I JLL
COMPLETION OF THE WORK AUTRORIZEb)
Permission is hereby graqted to:
County Tax Map No, 1000 Section ..... ;,,,;;, Bloc ,~,~. ............ ~Lot No ..............
pursuant to appllcation~ dated ..1~...~ ...... ~ ....... ....,,..~......, 19.~., and approved by the
Buildln~ Inspector. ~ ~ ~
Inspector
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southoid, N.Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
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 certihcate.
C. Fees:
1. Certificate of occupancy $5.00
2. Certificate of occupancy on pre-exist~ng dwelling or land use $5.00
3. Copy of certificate of occupancy $1.00 Date .... /f~.f2~~./~...
New Building ............. Old or Pre-existing Building ............ VaCant Lan
Location of Property ~ ........ .~ ............. ~ ................. ~ ...................
House No. Street Ham/et
Owner or Owners of Property ,.. ~..V~..~..Z?.~.. ~ ...... .~.... ~ ~ .G'~'..~-.~::~ .......................
County Tax Map No. 1000 Section .. ~..~. ~ ....... Block .../../, ......... Lot...,C'3.. ?..~* .......
Subdivision .............................. Filed Map No ........... Lot No ..............
Permit No. Z4~,~..//fJ.. Date of Permit . .~?./~. ,~.App licant....G?~ ~/j'~ ~.../~.~.._~.--_..~.'~ .(-../~...
Health Dept, Approval ..... . ,~....~-~.~ ......... Labor Dept. Approval ..... ~-, ~, ,~,z, ~..~ ........
Underwriters Approval ..... .~4¢.~.'.~¢¢.~¢,. ~4'.~;-. ..... Planning Board Approval ......................
Request for Temporary Certificate ..................... Final Certificate .......................
Fee Submitted $ .~.. ~.~, ......................
Construction on above described building and permit mee~ all applicable code, s and regulations.
Applicant ...... ~..~?~...~'., ./~.¢~'~'.... ?~ ...........
Rev, 10-10-78
FIELD IN~PECTION
COMMENTS
FOUNDATION
(~st)
FOUNDATION
2o
ROUGH FRAME &
PLUMBING
(2nd)
INSULATION PER N.Y.
STATE ENERGY
CODE
FINAL
ADDITIONAL COMMENTS:
JSO.O .... ~
.<I:
0
6 CAL.[;: 40'--- I"
El = d..Oid&. MOLIUM~'I,4~'
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-180:3
Examine~, .7....,~,./. ...... 19 .t~>?.
Approved xe e.. ....... 1
Disapproved a/c ......... ~ ..... ..~ ........ .~
........ ........
APPLICATION FOR BUILDING PERMIT
Application NO. ,/-(~.,~..~. g ........
Date ............... 19...
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 drown 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 prermses and in buildings for necessary inspections.
/-¢~X ~"d~ff(Malhng address °f apphcant) ~'
state whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
........ .... · ..........................................
Name of owner of premises ~
(as on tt~e (/aax'r011 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....,e. ..................
Other Trade's License No ......................
L Location of land on which proposed work will be done ..................................................
House' ~' '°~e~'~ Number ............................. S~ '~'~reet ~~~'~---- .......................
County Tax Map No. 1000 Section ..... ./~..~. ........ Block ...... .// .......... Lot ..... /.dp. ...........
Subdivision... ~.~t.~.~.~rC~,e-~ .................. Filed Map No ............... Lot ...............
/fl (Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy .~fq fd. 3-.~./~/.F~ .x/.~../.4/ .... ~.~./.~/5C..'{. ~.~../.~fl.~.~..~/~)....~.'d.(~.dd..6.~: .......
b. Intended use and occupancy
3. Nature of work (check which applicable): New Building .......... Ad&tmn .......... Alteration ...' ..... ~..
Repair .............. Removal .............. Demolition .............. Other Work ...............
.~.~.~...f'?. ~ ;~/~_~ (Description)
4. Estimated Cost ............ ¢ ............. Fee ......................................
(to be paid on filing this application)
5. If dwelling, number of dwelling dnits ........... Number of dwelling units on each floor. ~--- ' ~
6. If business, commercial or mixedl occupancy, specify natu,r.e, and extent of each type of use ..... ~ .~::-.: .~ ..... -..-'A-7.. '~
7. Dimensions of existing stmcturesl, if any Front .~. ~. ~c~ .~.. Rear . .g.~ ~..Y Depth ....~.q..~.~.. ..
Dimensions of same structure with alterations or additions: Front .... .~. ~..,(..7. .....Rear .... ~.~> .,(-y7. .......
8. Dimensions of entire new construction: Front ... ~.~ r, ,,._. ~ ~ ....
· ~ ....... Rear ... ~. ........ Depth .~.~..Y- .....
~ 1. Zone or use district in ~hich premises are situated .... /~, ~..xD.~./.,~. g ..............................
12. Does proposed construction violite any zoning law, ordinance or regulation: ..... /f~X~.. ~. ............ /..,,~.....
13. Will lot be regraded .... .~;. ~i -~ ................ Will excess fill be removed from premises: Yg'~ No
Name of Architect ....... ~ ?..-'~'7...cT ......... Address ................... Phone No ................
i Name of Contractor .... ~./44~/~?.,~ ............ Address .. ~.'4~/. ~ ....... Phone No .... ~.. ,4...:'Z~.. ~..
PLOT DIAGRAM
Locate clearly and distinctly all~ ' '
:buildings, whether existing or proposed, and, indicate all set-back dimensions from
.roperty lines. Give street and block number or description according to deed, and show street names and indicate whether
interior or corner lot.
STATL OF NEV~ YORK,/,, ~-
COUNTY OF ?. ~ ..,~..,~-?....-'~. ....
J
,rporate officer, etc.)
ave performed the said work and to make and file this
rue to the best of his knowledge and belief; and that the
iled therewith.
· XOWA y/
Suffolk County [
ires Uarch 30, 198~.~ ~
(Contractor, agent, c,
of said owner or owners, and is duly authorized to perform or
application;.that ail statements contained in this application are
work will be performed in the manne} set forth in the application
Sworn to before me this,,~_,
/
/q
,
II~I~ARy PUSLI
No,'f
~alifisd n
Commll~ IExl
....... ~..ffrZ¢..f~.....~.:....A~'.~.~ f,.' .~. .............. b, ing duly sworn, deposes and says that he is the applicant
(Name of individual sign!ng contract)
above named.
He is the ...................... . ..................................................................