HomeMy WebLinkAbout10652-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
No. Z10200 Date Ooto~er 1~ ., 1977.
THIS CERTIFIES that the building ................................................
Location of Pronert'v ...~?...0..~...~.e.zl.8..~..~..d~. ?..g..R.o.a..~.~ ........... .~.0.1~,?1..O.~.d?...~.,.~.. ,. ....
~ -'~ House No. ''' Street H~n~let
County Tax Map No. 1000 Section ....0~..0. ...... Block 10 .Lot 18 .
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore f'ded in this office dated
..... .A.p.r.i..1..2.8. ......, 19 ..8.0. pursuant to which Building Permit No. 10~2 Z ·
dated .... .~La.y..~.l ................. 19..8~., was issued, and conforms to all of the requirements
of the applicable provisions of the~aw. The occupancy for which this certificate is issued is .........
The certificate is issued to . .H...el~y.... C1~Lrist .
of the aforesaid building.
Suffolk County Department of Health Approval
UNDERWRITERS CERTIFICATE NO.
Building Inspector
~OEI~ NO. ~
TOWN OF SOUTHO/D
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)
N? 10652 Z
Permission is hereby granted to:
..~..5:...~.....~. .~......C./.. .........................
~o .~.O~.....~...~.../~u..c.z--... a.~v..~. ~..~ ..~...../. ~..%....4~.~.../..././.~.~ ........................
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.............................. :~,.~......,. ..,.~...~z~ ...... z ............................ '.w:"I
o, ~remi,e, ,a~a,ed o, .~...~.~..0. ...... LV~..~...~.~..~.~....~.. ......................
.................................................................................................... ~.o.~..r.~..~r~..=.~...:7,.
p~rs~ant to o~p,,~otia~ d~ted ../~.~Z&.....~.~. .................
approved
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 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 buddings, property lines, streets, and unusual
natural or topographic featu res.
2. F~nal 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 Planhing Board approval of completed site plan requirements where applicable.
B. For existing bdildings (prior to Aprd 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 $5.00
3. Copy of certificate of occupancy $1.00
/ Date ..... ~'..O/.~/~..~. ........
New Building ............. Old or Pre-existing Building ............ Vacant Land .............
Location of Property . ~.. ~',~...~./~..~..~. ,~,'-~'...~', .'~. ,/~.J?//. ~.~,.., ,~,~,-. -~'~
House No, ' ...... Street ............ Hamlet
Owner or Owners of Property #.~',?.~. ff..~ .~--.~.-,~.-.1~... ~?~./, .~. ff .........................
County Tax Map No. 1000 Section .... .(,2..'?.~ ..... Block .... ./.~ ....... Lot .... /.~. .........
Subdivision ................................. Filed Map No ........... Lot No ..............
Permit No./?.~.5'..,~..*. Dato of Permit .~SApplicant ..................... ' ............
Health Dept. Approval ...!~.q~.,..~.~.Labor Dept. Approval ........................
Underwriters Approval ...~..~.9.h;~.? .~ ............. Planning Board Approval ......................
Request for Temporary Certificate ..................... Final Certificate
Fee Submitted $ .~, .0.0. .......................
Construction on above described building and~j{££N~Rj~permit meets~0~,~all app.,licablel~, codes and regulations.
Applicant ........ .~. ............ .j.../~.. ~.. ~..~ ............
,., ,o.,o.,a
THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
85 JOHN STREET, NEW YORK, N~W ~'OR~ 1003~
THiS CERTIFIES THAT
only the elec ~rlcal equipment es described below and introduced by the applicant named on the able applic~t~t ~mSer in the premises of
in ~he foltow.~ loc.~ion; ~ Ba~eme~t ~ ls~ FI. ~ 2nd Fl Sectmn Block Lo~
w.s examined on ~, ~4 ~ ~,~ ~nd found to be i~ con~pliance w~tk the requirements of this Board.
fiXTURE FIXTURES RANGES COQKINGDECKS OVENS DISH WASHERS EXHAUST FANS
OUTLETS SWITCHES FLUORE$CEblT
t9 1,9
DRYERS
SYSTEMS
NO OF FEET
R V I
1
OTHER APPARATUS.
C
Box 1173
Th~s cerhflcate must not be altered In any manner; return to the office of the Board if
GENERAL
m~ be ~dentJfled by
COPY FOR BUILDING COPY OF IN ANY
1.
FOUNDATION (lsd)
FOUNDATION
2.
ROUGHFRAM]{ &
PLUMBING
(2nd)
INSULATION PER N.Y.
STATE ENERGY
cope
FINAL~
ADDITIONAL COMMEN~S:
FORM NO, 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1803
( uil lng nspector)
APPLICATION FOR BUILDING PERMIT
Application No. t/O.~'~. ~..~ .......
Date .................. 19
INSTRtJCTIONS
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 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 applicable laws, ordinances, b, uil4ing code, housing code, and regulations, and to
admit authorized inspectors on premises and in buildings for necessary insp]ections.
...........
~' (Signature of applicant, or name, i~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 ........................................................................
(as on the tax roll or latest deed)
If applicT/t i~a corporation,~i~natjj/e of d~uly a_.uthorized officer·
.....
(Name and titl~ of corporate ~icer)
Builder's License No ..........................
Plumber's License No .... ~../.?.~../.o. ...........
Electrician's L~cense No. ~pz;~
Other Trade's License No ......................
Location of land on which proposed work will be done...~/./(..~...~../4~.~7.' .~.-~..~...'~ ~ . .~.~.~.-~..-/9./.~..~-'.'..~ .~.%~. ...........
House Number Street Hamlet
County Tax Map No. 1000 Section .... .~..?..O. ........ Block .... /..~. ........... Lot /°°
Subdivision ..................................... Filed Map No ............... Lot ...............
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy .~.x~. ~./.?..~.
b. Intended use and occupancy (~/~;'~'o/~7'~/l/~) ~/v/~- /~'/~/Z;)/. //j~9~,~,~:,
Locate clearly and distinctly all
property lines. Give street and block
interior or corner lot.
3. Nature of work (check which apphcable): New Building .......... Addition .......... Alteration ..........
· Repair .............. Removal .............. Demolition .............. Other Work ...............
~ ' ~-~/~0 (Description)
4. EsHmated Cost ............................ Fee ........................................
(to be paid on filing this application)
5. If dwelling, number of dwelling u~its ... ~..~..~'. ....... Number of dwelling units on each floor ................
If garage, number of cars ...... I ..................................................................
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 Numb'er of Storie
Dimensions of same structure with alterations or additions: Front ................. Rear ..................
Depth ..................... i. Height ...................... Numlle~of Stories ............ .,..,.~ .....
8. Dimensions of entire new construlction: Front ..... ~.~.. ~. ..... Rear ...~. ........ ,... Depth .~..7. :'~ .~..* .....
Height Number of Stories ...... ~..,~.~'. .... /~ ·. - ! "~ ....... x
............... ac t ' ' /oo. i~
9. Size of lot: Front ..... /. ..... ~ .......... Rear ...................... Depth/,,~, .................
10. Date of Purchase ........ /..~. '~7..~. ............... I~/aCe of Former Owner . .~.~?.'~-,, · ,~,~..~.°, .~/.C.~. ........
11. Zone or use district in which premises~ are situated . .~..~'..~..~.x~.(.~.. .....................
12. Does proposed construction .viola,ie any zoning law, ordinance or regulation: ,, ./~,~. ..........................
13. Will lot be regraded .... ~..O.... .................. Will excess fill be re.moved from premises: ~_ _~Yes_ No~/
14. N,'une of Owner of premises ~.~.~...~...~./.~'..~ ...... Address , .~,~.~...~.../,4~ ........ Phone No. ~rp..~-...~...~./...
Name of Architect .d~T..~..~.~..~.~./../~-7..../'~. ~ .~.~. .".'~.~. Address . .~ .~..~. ,~..~ .~.A ~. t .~.. Phone No..~..~.~.'T.~.'g-.~..~...
t, .. Address ................... Phone No ................
Name of Contractor ......... ! ..............
PLOT DIAGRAM
jbuildirt, ps, whether existing or proposed, and, indicate all set-back dimensions from
umber or description according to deed, and show street names and indicate whether
I00
S~AT~ OF N~W ¥ORr,
COUNZY OF...~.U.~..~C.~..~:...... , s.s
1
.... /~.f,~...~... ,~,: ,~..~...~......~..'. ............... being duly sworn, deposes and says that he is the applicant
(Name of lnd~wdual sxgmng contract)
above named.
.d~..,qram...~r~ .~.. :.. -. .,,_., - .....,..- ....... :.... ......
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 manner set forth in the application filed therewith.
Sworn to before me this
.......... .~.. ?. .......... day Qr.. ~..~../.~. ............
19
Not a~- Public~,. ~' .~.~..~:.~..~..,~..',~:~c~.~,, ,[~a.[,q' ................. . x County ~~ . .~.,..~
// XI NOTA~ PUBLIC State ,of New ¥ot}~ .......................................
/~/ No, §2-466§418, Su~f~ik~C~°u~n~tY~'.Z~ '
C~mmlssion Expires March ou, ~.,~ (Si f applicant)
.J
i ~he ~e,,rage disDosai a~d water S~ipp!y
'~ ~' ~[~"~s for +als ~ocation have bee~
Chief of General Engine~rin~
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OCCU~AHCY OR '
USE IS L!NLAWFUL
WiTGGUT CERTIFICATE
OF OCCUPANCY
~LLOWPNG tN~PECTFONS-
J., ~NDAT~ON~ - ~ REQUfRED
~. I'NSULAT~ON
4. FINAL - CONS~U~[ON MU~
BE COMPLET~ FOR C, O.
ALL CON~RU~fON SHALL ME~
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