HomeMy WebLinkAbout10650-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
No....Z.1 0011-8 Date ,Tuly 25 .................. 19 80
THIS CERTIFIES that the building ........................................
46~ P~ivate Road #3 Southold, N.Y.
Location of Property/:/~t~s~
County Tax Map No. 1000 Sectmn . . .0.7..0. ...... Block 06 .Lot
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
....~p?.t. 1...21 .......... 19 .~.0. pursuant to which Building Permit No ....... ?.0.6..~.O.Z. .......
dated .... .~l.a.~..~. .................. 190.0. ,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 .........
........ a..a.a.~.~.~. 9.n..to...~..~..~t.~.n.~ .~.?. ?..m..~.~.~., p~.~..~.~.n.~. .....................
Ola~a Px'oul~
The certificate ~s issued to ..................... [o'~0~), ~ ......................
of the aforesaid building.
Suffolk County Department of Health Approval ........... H...~. ...........................
UNDERWRITERS CERTIFICATE NO ................. p. ? .ll.c~..~..~ ...................
Building Inspector
Rev 4/79
FO1/~ NO. ~
TOWN O~ $O~THOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTH'OLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 10650 Z
Permission is hereby granted to:
.. ' .7... .~.~. .~.....C,,...... ./. .C~ .......
., oe
~o ........................................................................................................................... 7 ............
Building Inspector,
Fee $ ........................ ~ /
Building Inspector
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, 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 ~nstallation 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 requ irements 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
3. Copy of certificate of occupancy $1.00
$5.00
New Building ...~.. :. ...... Old or Pre-existing Building ............ Vacant Land .............
Location of Property
House No. Street Ham/et
Owner or Owners of Property,. q~.,t ,~L ~. .... .~..J~'~.. ~..... . ...................................
County Tax No. BOB Section . ...... B oek .... O. ...... Lot...O..I. G ........
Subdivision ............................... Fded Map No ........... Lot No ..............
Permit No../~.~.~'. ~.. Date of Permit ~¢~..~t.'.~.'..~.Applicant i-~..~..)~ ,-~...~,?~-~.~. ........
Health Dept. Approval ........................ Labor Dept. Approval .: ......................
Underwriters Approval ........................ Planning Board Approval ......................
Request for Temporary Certifica~ ........ , ........... Final Certificate ...... !~ ................
Construction on above described bu ,,ding//~/~m~ll ~:~gu 'ations.
Applicant .~. K./~j.t.~..u'..c,.~.~....~_~. - - ~...
1.
FOUNDATION
FOUNDATION
2.
ROUGH FRAME &
PLUMBING
INSULATION PER N.Y.
STATE ENERGY
CO~E
FINAL
ADDITIONAL CoMMENT ,S.:
FORM NO. 1
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1803
Examined/~....~. .... ,19
Approved ~.,~..~f..~. ..... 19 .~..65)Permit No../. ~ .~...~. O ~
Disapproved a/c ...... 7-.. ~ ............. ~ ........ ?.. /
(Bdildiffg Inspector)
Application No.../'~. ~...~.~..~. ....
APPLICATION FOR BUILDING PERMIT
Date....~.
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 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 apphcable laws, ordinances, building code, housing code, and regulations, and to
admit authorized inspectors on premises and m buildings for necessary inspections.
(Signature of applicant, or name, if a corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
.... .................................................................
Name of owner of premises . .~.f.~. {C.~....r~...[~..tt.~. .......................................................
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
L/
Builder's License No..J'~. t'~//~?':-~.. 7. :' .. ?
Plumber's License No .... KO. Cd. 1.~ ~.. ............
Electrician's License No. t:'~...~.. ~ L,~'E;>,
Other Trade s License No ......................
Location of land on which proposed work will be done.' .~.~ 0.a.. ~.J.e..c:~.. i .~.c[..- ..............................
.............................. .!.d. .......................
House Number Street Hamlet
County Tax Map No. 1000 Section ...(~. ?..(? .......... Block ...~...~. .......... Lot..(~../.~. ...........
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 ...... .~..VI..~....~)fO!. q.,.l: [qq ......................................
b. Intended use and occupancy ..... .~..~.. ['~qm, .~...6y. o~[ ~
3. Nature of work (check which a~plicable): New Building .......... Addition . . . .t-'f~...... Alteration ..........
Repair .............. Removal .............. Demolition .............. Other Work ...............
i 5 (Description)
4. Estimated Cost .... ? ...... : ........................ Fee
(to be paid 6n filing this application)
5. If dwelling, number of dwelling knits ... Cf?...~xP~ ...... Number of dwelling units on each floor..~..~..~, .........
O '
If garage, number of cars ...~ ..................................................................
If business, commercml or mixed occupancy, specify nature and extent of each type of use .....................
7. D~menslons of existing structures, if any: Front..~.~.'.~ ......... Rear . ~..~,. 7.6. ...... Depth . .~.~). 7.0.. ~ .....
I-[eight ./.~.t7.~. :~ .......Number of Stories .. (>.13 .~ .................................................
Dimensions of same structure w~th alterations or additions: Front .3.6 ~ .~. '.' ......... Rear . ?--. ~.'.O.~'. .........
Depth . ~. ~ .tO. ~ '. .......... I.. Height . ./.('d: .-.6.': ............ Number of Stories . a3 ~q- ................
8. Dimensions of entire new construction: Front . .~.~ ~-~ .O." ...... Rear . .~-.a '.~..0. '.' ..... Depth ...~:-..o.~ .....
Height ./'.~..-.G ........ Num.ber of Stones ..... /~ .~ ................................. , ..............
9. Size of lot: Front .. ~.O..-..~., ........... Rear . . .~['.O..-: .O. ............ Depth . .~..O. ?'.. ~. ...........
10. Date of Purchase ..... /. ?.~..~ ................ ,~Nam? ~of Fqr/nter Owner . .~. Oct ~ ~ ................
1 1. Zone or use district in which pr6mises are situated../~.~..~.~ .4 a~x-ta~{,. ....................................
12. Does proposed construction viol~te any zoning law, ordinance or regulation: ....Z~..~ ........................
13. Will lot be regraded .~. O. .... i .................. Will excess fill be removed from premises: Yes ,~
14. Name Of Owner of premises .~.l~'.~. ~ .tf.v~. ~.~ ....... Address ?~r..6.r.~:~.a..~.¢~.s.~. Phone No..~,/.~. fi.~. ~..~.~?.$.
Name of Architect ............................ Address ................. ~rPhone No ................
Name of Contractor ~, .t~.~ .~...~?~ .~.c?¢q~... Address h'fd , thl. .q¢ .... Phone No. ).~....Za. 2 ~1'.o....
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 pumber or description according to deed, and show street names and indicate whether
interior or corner lot.
STATE OF NEW ~0.RtKJ,
COUN,rY OF .2~,b.~<... ~.S
............................. ~ ................... being duly sworu, deposes and says that he is the applicant
(Name of individual signihg contract)
above named.
He is the.... ................... ~ ..................................................................
, (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 manne~ set forth in the application filed therewith.
Sworn to before me this :
~0, 52-0344963 Su~[olk Goun~ (Signature of applic~
I/4-"--
OCCUPAHCY OR
USE mS UNLAWFUL
V~iTI~T CERTIFICATE
I~F OCCUPANCY
765-1
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