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Home My WebLink About10863-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy No..~ t 0.8.6.3. $ ....... Date ..... 4U. ~.y..2.0. .................... 19~. 1. THIS CERTIFIES that the building ................................................ Location of Property .. ~.2t0. OJ..e.r~. l~p.a..d ~ ......... .8. O~l.t, ja. ql, ql,..~e~. X.q~.l~ ............ House No. Street Hamlet County Tax Map No. 1000 Section . .. ?~ ....... Block ...~ ........... Lot . .2.0 ............. Subdivision..Ifo~.t;..Cl~.e.e.l{ .~.~.a,~ee ........ Filed Map No. 3.8.~1~ .... Lot No. 80 ........... conforms substantially to the Application for Building Permit heretofore filed in this office dated · . .3. e p.~.o.nll~e. ?..1.6. .... , 19.8. Q pursuant to which Budding Permit No. 1. q~.6.3..g. ............. dated ...... ~$ p.t:.e.[~l~.e?.. 1. 9 ........ 19 .8.0., was issued, and conforms to all of the require~nents of the applicable provistons of the law. The occupancy for which this certificate is issued is ......... ............. .~.~.~. e. r.a.~.~, o..n' .a.n.d...a,d.d.~..~.~9.n...~9..~.~. e..~.~.~.n.$ .................. : ...... The certificate is issued to .... ?/.a.~r'..e.n..a.n.d...[.~.e..n.e..K.o.~..e.J. ............................. (owner, I~ er..t~r~a~... of the aforesaid building. Suffolk County Department of Health Approval ...hl ./It .................................... UNDERWRITERS CERTIFICATE NO.. ~./.B ............................................ Rev. 1/81 Building Inspector TOWN OF SOUTH0~ BUILDING DEPARTiV~t~N~ TOWN HALL SOUTHOLD, N.. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PP, E/~I$~S UNT L FULL , COMPLET ON OF THE WORK AUTHOR ZED) N°. 10863 Z Dote ...... ....; ............... ~..~. ......................... · ...... Permission is hereby gronted to: ..................... ~7~' ~ ~I ?. O. BOX 2~. .... SO~H0~, N.Y. 11971 .... 220 OL~ ROAD at premises iocQTeo OT ............... , ............ ; ................ ; ........ ~...?....~ ................. , ........................................ ~OUTHO~, ~ 1!971 : ~8~ 0~ m~a~m, ~zh~ ~ ~*~, l&~. ~. ~ ................................. . 78 ,~ 2 2o Coun~ Tox ~op No. 1000 5echon ........................ Block V...~..~ ............. ~Lot No ......................... . . Sep~embe~ 16 ~' ~ 80 pursuont to epphcehon doted ............................; ................ ~.... ~....., 19.....?., ~nd opproved by the Building Inspector, °. ........... FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Hall Southold, N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This apphcation must be filled in typewriter OR ink, and submitted in duplicate to the Building Inspec~ tot 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 dlsposal-(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 peoperW showing all property lines, streets, buildings and unusual natural or topographic featu res. 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- tmn 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 ~..~.~..~. ~,~ New Building ............. Old or Pre-existing Building .......... Vacant Land ........... Location of Property 220 ...~.r .~.~0~....~.~ ............ l~l~u~ 'N''.~ ....... \L Street ~ / Owner or Owners of Property 1. r.~..V~..-~..~..'~. · · ~ .~'..~.*. V~...~.(~ ,~.P--~.~. ................. County Tax Map No. 1000 Section 78 Block 2 Lot 20 West Creek Es-tares ..... 3848 Subdivision ................................. r~leo ]wap I~o ......... ._~.Lot No .............. Permit No..~.0.~..~.~..Z.. Date of Permit...9../..]-?/.~.~pplicant~.~ ~.~.' . .F~.~.[~. Health Dept. Approva~ ........................ Labor Dept. Approval ...................... Underwriters Approval ........................ Planning Board Approval x Request for Temporary Certificate ..................... Final Certificate Fee Submitted $.. ~...0..0 ...................... Construction on above described building and permit meets all applicable codes and regulations. Rev 10-10-78 II i FORM NO. 1 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1802 Examined ................ , 19... Approved ............... 19 ... Permit No./..~.~. ~.-~. ~.. Application No..../?. 4~.~. ~ ...... Disapproved a/c ............................ . ......... (Building Inspector) APPLICATION FOR BUILDING PERMIT l / ,(~. Date . ..~ ....... .,.., 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 locatton 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 Pem~t to the applicant. Such permit shall be kept ou the premises available for inspection throughout the work. e. No building shall be occupied or used m 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. (Sjglaature of apphcant, or name, if a corporation) (Mailing address of apphcant) \ (C.~m[ ~ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ...... 0 ;. .................... ...... ,.., ......................................... Name of owner of premises ...."~'~...\~..~:?..-~..~.'3....~ .C.D.~[. .......................................... (as on the tax roll or latest deed) If applicant ~s a corporation, signature of duly authorized officer. (Name and title of corporate officer) . Builder's License No ...... .~& .-: .-~ .~. ...... .--/.~(.~2r'& J? Plumber's License No .......................... Electrician's License No ........................ Other Trade's License No .................... Location of land on which proposed work will be done .................................................. ............. House Number ~} ;;i ................................... Hamlet County Tax Map No. 1000 Section .................. Block .................. Lot ................... Subdivision .... .~. i~"¥~'.'~....~..~ .~....~.~'~.D...'~..: ...... Filed Map No ............... Lot ............... (Name) 2. State existing use and occupancy of premises and intended use and occupancy of proposed constructmn: a Existing use and occupancy ~ ~ ~Ct . b. Intended use and occupancy ..... ~[~ ~ ~,....%.~.C, g .... ~..~ .~ ...... 3. Nature of work (check which applicable): New Building .......... Addition .......... Alteration Repair .............. Removal .............. Demolition .............. Other Work ............... , nd (Description) (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 .... 1 .................................................................... 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 ............... Height ............... Number of Stories ........................................................ Dimensions of same structure With alterations or additions: Front ................. Rear .................. Depth ................... :... Height ...................... Number of Stories ...................... 8. Dimensions of entire new consfruction: Front ............... Rear ............... Depth ............... Height ............... Number of Stories ........................................................ 9. Sizeoflot: Front .......... [ ............ Rear ...................... Depth ...................... 10. Date of Purchase .......... ~ ................... Name of Former Owner ............................. 11. Zone or use district in which premises are situated ..................................................... 12. Does proposed construction vidlate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ........ , .................... Will excess fill be removed from premises: Yes No 14. Name of Owner of premises ..: .................. Address ................... Phone No ................ Name of Architect ......... : .................. Address ................... Phone No ................ Name of Contractor ........ . .................. Address ................... Phone No ................ PLOT DIAGRAM Locate clearly and distinctly al1 buildings, whether existing or proposed, and. indicate all set-back dimensions from property lines. Give street and blocki number or description according to deed.~ grid show street names and indica~te whether interior or corner lot. STATE OF NEW YORK, ~ ~,~Ts ' ~ ~'~O" ..... t.. '7'''''""................t'O ~ be~gduly sworn, deposes and says that heis the applicant (Name of individhal signing contract) above named. He is the ............................................................. ~ ............................ (Contractor, agent, corporate officer, etc.) of said owner or ownem, ~d is dul~ authorized to perform or have perfo~ed the said work and to m~e ~d file this application; that ~1 statements contained ~ this application are true to the best of his knowledge and belief; and that the work will be perfomed in the m~ne~ set forth ~ the application filed therewith. Sworn to before me th~ ROI~Y p~BEIC, State of ~o. ~2.452477~ quaJlhed In Suffolk Coun~ ~ ~t~ ~mm[ssmon [xpmres March 30, 19~