HomeMy WebLinkAbout10743-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
THIS CERTIFIES that the building ................................................
Location of Property . .677...Et..~.? .g.~.O.~...A.V.O.~..~. ?? .......... .~I.~.t;?.~ .~..o.k. ...............
House No Street Ham/et
County Tax Map No. 1000 Section .~. ~? ........ Block .... .0.~. ........ Lot....O.~.'l ...........
Subdivision ............................... Filed Map No ........ Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
.... ff...t~..l!& .7. ......... , 19~.0.. pursuant to which Building Permit No .... .'].O~../43..Z. .........
dated . .0'.11~...e...1.9 ................... 19..8~., 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 ...I)?.o.k...
.~a.x..e.~.o.n., .a~).a. ?.z..e.~.e..Xe.n' .~.9..o.x.X..~.e.x.n.g., .o.n.e.-..~.~. 3.~.¥' .ay?..~.x.x.n.~... .............
The certificate is issued to ....~I9..r~..~...B.: ~?~1$.~...d'?.: ................................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ..... .~./.R. ................................
UNDERWRITERS CERTIFICATE NO .............. ~/.~ ........... · ....,i/ .............
Rev 4/79
~Ol~ NO, ~
BUILDING DEPARTMENT
TOWN GLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PI~EMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 10743 Z
pursuant to application dated ....... ~..(~....X~....~.~....../.. ...................... , 19~....~..., and approved by the
Building Inspector.
,ee .......
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 featu res.
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 Amhitect 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 propertV 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-
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
Date, . . ~../~ .~./~l~],. ..........
New Building ............. Old or Pre-existing Building ............ Vacant Land .............
Location of Property ...z~.~..~. ?~.. ~ ........
I~use'No: ........ "~' ..... $'t/eet Hamlet
Owner or Owners of Property ......... · ...........................
CountyTax Map No. 1000Section .~/.~. · .-~. ....... Block . ..~. ~' Lot. ~.~ ~
Subdivision ................................. Filed Map No ........... Lot No ..............
Permit No.~. ~.~ate of Permit ~/2/~.Applicant..~~ .~..: .......
............ ............
Unde~rite, Approval ..~/~ ............. Planning Board Approval .~./~ ...........
Request for Temporary Certificate ..................... Final Certificate .... ~ ...............
Fee Submitted $ .~ ............... ~~//~ ~ ~
Con,ruction on above described building an~~~nd regulations.
/ ~ /~ ~ ~1~
Applicant. ~~ .~ --~.....z~ ..............
Rev. 10,10-78
FIELD I~SPEg~ION.__. COMMENTS
FOUNDATION
FOUNDATION
2.
ROUGH FRAME &
PLUMBING
(aha)
INSULATION PER N.Y.
STATE ENERGY
COpE
FINAL
ADDITIONAL COMMENTS~
FORM NO, 3
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N.Y.
NOTICE OF DISAPPROVAL
Date .... ~,~,...~.
File No ...... ~ ..........................
· ,~../~.. ~.~a.~ ..................
LooationofP,.op~rty~,~..C.---:. '~'~r',~ ........ "~'~'~ ..... ~;~
County Tax Map No. 1000 Section .............. Block .............. Lot ..............
Su~bdi~ision . . i .~~ .......... Filed Map No ................. Lot No ..................
,~r~.~.. ~,~- ~_.~,-,y~J~,z_/~-- ,L? G-f, l .............
· ./.. ~.~, .,~.. ~. ........... ~ .~:..: ........ .7.. ........ ? T 7'
Building Inspector
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N,Y. 11971
~ TEL.: 765-1803
Examined..~..&./'f.~.. ,/. ?...., 19 .~.~.)
Approved .~./'~.~../. ~. ..... 1~. Permit No/./~)..~..~..~...~
Disapproved a/c ........ ~ .......... i i .~../i ..........
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
Application No.//t~ 7..~.~..~ ......
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 accorc~ing 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 demolit~L~erein described.
The applicant agrees to comply with all applicable laws, ordinances, buildi~ code, housing code,~na r~gulations, and to
admit authoriz ed inspectors on premises and in buildinga for ne cess
~ ( Sign a't uD2p~,c an ~m~e~r a ti~/~. ~, .
(Mailing address of applicant)
State wheth~plicant is owner, less~ agent, ~trchitect, engineer, general contractor, electrician, plumber or builder.
......... .... ii .i i
Name of owner of premises .W~...~ ~."~.'~. (as on the tax roll orlatest deed)
If apphcant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
Plumber's License No ........................
Electrician's License No .......................
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 ....O....g .... ...... Lot..(5.~( .............
(Name)
State existing use and occupancy of. premises and intended use and occupancy of proposed construction:
a. E istinguse and occupancy. !/ ................. * .................
3. Nature of work (checkwhicb ' ' -- '
apphcable): New Bui/ding .......... Addition .......... Alteration .........
Repair .............. Remo~ai .............. Demolition .............. Other Work ...............
(to be paid on filing this application)
5. If dwelling, number of dwelling finits ............... 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 ............... Number of Stories ........................................................
Dimensions of same structure w~th alterations or additions: Front ................. Rear ..................
Depth , Height Number of Stories
8. Dimensions of entire new const~ction: Front ............... Rear ............... Depth ...............
Height ............... Number of Stories ........................................................
9. Size of lot: Front ...........' ........... Rear ...................... Depth ......................
10. Date of Purchase ........... , .................. Name of Former Owner .............................
11. Zone or use district in which pr~mises are situated .....................................................
12. Does proposed construction violate any zoning law, ordinance or regulation: ................................
13. Will lot be regraded " ~I'
~/~.[,~s~.~ ': ~i,/~1~ .~a.,.._,~ · Will e,,xc_gs~fill_be l;em~ved fr~m~premises: Yes No
14. Name of Owner of p .~.~.~:~ ;[~.:~. --..~.._i[~~ddres~,~([...~'. '~.~.~.~.~...~.~t~one No ...............
Name of Architect .... Address'~..~.~.d~. id. Phone No.~'.~..'. ~.~.~..~-..
Name of Contractor ......... . ................. Address ................... Phone No ................
PLOT DIAGRAM
Locate clearly and distinctly alll buildings, whether existing or proposed, and, indicate all set-back dimensions from
property lines. Give street and block laumber or description according to deed, and show street names and indicate whether
interior or corner lot.
STATE OF NEW Y~K, . .. /i ~ .~
· ·.....'~At.-et.,..d~~, .... %~..,-~r~-~ .... being duly sworn, deposes and says that he is the applicant
. (Name of individual sig~ing contract)
above named.
He is the ............ O~,~:x-~,~-i~ ......................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is drily authorized to perform or have perfomed the said work and to m~e ~d file this
application;that ~1 statements con[ained ~ this application are true to the best of his knowledge and belief; and that the
work will be perfo~ed in the m~ner set forth ~ the application filed therewith.
Sworn to before me this~_.. ~' '~ ~ ~
.................. day f .......... 1
J~ NOTA~ PUBLIC,State 0f New York (Signature of applicant)
N0.5~.8125850, Suffolk CO~ ~
lerm Expires March 30, 1~