HomeMy WebLinkAbout11363-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N.Y.
Certificate Of Occupancy
Z10688
September 16 ~!
Date ................................. 1 ..
THIS CERTIFIES that the building ................................................
2725 Wells Avenue, Southold, New York
Location of Property/~/J~s~ ~/o ........................ ~r'~i ....................... ~/~n~/o~
· 070 016
County Tax Map No, 1000 Section ............ Block ............... Lot .................
Subdivision ................... ............ Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
September 4 81 11363'Z
..................... , 19... pursuant to which Building Permit No ......................
September 9 81
dated ............................ 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 .........
Addition of Deck to Dwelling
William Worth
THe certificate is issued to ..................... ; .... xxxxx.x.x xxx.x.x ...................
i ownor, lessee or tenant]
of the aforesaid building.
Suffolk County Department of Health Approval ..........................................
UNDERWRITERS CERTIFICATE NO ..................................................
Building Inspector
Rev 4/79
No. ~ z
FOF,~ NO~
TOWN ~0~
BuiLDiNG
TOwN iHALL
SOUTHOLD,
BUILDING P~ERMIT
(THIS PERMIT MUST BE KEPT ON TH,~: PREMISES UNTIL ~ULL
COMPLETION OF THE wORK AUTHORIZED)
Permission is hereby granted to:
~O ............ j; ........... ,. .....................
;~ ~,~ ~,~,(----, ..~/..z~ ....... .~;:~ .............. ~, ............ ~: ..........................
Map.No. 1000 'Section ,..,~.. ~ ~ '~': .........
cou.~ ~x 2.~ ....... ~,o~ ~...,~.~..~.....~o,,o.~.,.~
Building Inspector.
Fe : ; .........
Inspector
Rev.i 6/30980
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 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 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.
C. Fees:
I. 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.. ,'~?.¢~/.--~,..¢.. ~.~.~. .......
New Building .... /'~ Old or Pre-existing Building Vacant Land
Location of Property . .~.~?*;'.~ ..... % .~ ..................
House No. Street Hamlet
Owner or Owners of Property ..... .~..~ .~..~....~...~..~.. :...~...~...~. ~...~./.~..~.%. ~..
County Tax Map No. 1000 Section ....-~.7,01. ...... Block ..... Lot...~. C.~ ........
Subdivision ~- ,., ,Filed Map No. ' "' .Lot No.
Permit No././. ~..~. ~ Date of Permit .?.~..~/~ ../..Applicant .~/. ~//.~.-¢'¢J~.'~....~-~.~f.. ?.--~.../~.....
Health Dept. Approval ...... ~ .............. Labor Dept. Approval .......... .~-~....
Underwriters Approval ..... ~ ............... Planning Board Approval-~.~ .~.~....
Request for Temporary Certificate ..................... Final Certificate
Fee Submitted $...~7..~! .'~. .....................
Construction on above described building and permit meets all applicable codes aFd regulations.
Applicant~. .... ~J,4~...~'--~...~... L4~.~ ..... ' .........
TOWN HALL o' '
SOUTHOLD, N.Y. 11971~
TEL.: 765-1802
.... ,19& ^pp,ieation
mit
Approvea~. Z ..... ,1 ~
/
Disapproved ~/c ...... ~.' ........................... ~.. /'
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
a. This application mnst be completely filled in 'by typewriter or in ink and submitted in triplicate to the Buildi
Inspector, with 3 sets of plans, accurate plot plan to scale. Fee accordiug te schedule.
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public stre~
or areas, and giving a detailed description of layout of property must be drawn on the diagram which ispart of this apF
cation.
c. The work covered by this application may not be commenced before issuance of Building Pe~it.
d. Upon apprcval of this application, the Build~ng Inspector will issue a Building Permit to the applicant. Such pern
shall be kept on the premises available for inspection throughout the work.
e. No building shall be occupied or used ~n whole or in pa~ for any purpose whatever unt~ a Certificate of Occupan
shall bare been granted by the Bnilding Inspector.
~PLICATION IS ItEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to t
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances
Regnlations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein deschbe
The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, ~d
admit authohzed inspectors on premises and in buildings for necessa~ inspections.
·
..... f~ (Signature of applicant, or name, if a corporation)
(Mailing address of ~ppiicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or bnild~
· . ...........................................................
Nmne of owner of premises .... ~',,r~,. g,,Z,-,~ ~. .....:~.~,~2'-]7' .........................................
(as on the tax roll or latest deed)
If applicant is a corporation, signature of duly anthorized officer.
.,
~ (Name and title of corporate officer)
Builder's License No .... ~. ....................
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
Location of land on which proposed work will be done..~2~,.~...2'7.... (-~',/bZ~. .... ~/g~-:"~-,~,-~... ~.. ~. ~., ....
House Number Street Hamlet
County Tax Map No. 1000 Section . .c). ~..6D. ........... Block ...O.(/. ............ 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 ... ~i~'.~./..)0./..-~--'2~./,-~--~... ~./~,s~....t.t~...,Xff./g'~.~ ' .............
b. Intended use and occupancy ...... .'~".'~..~...~... '~./..-~.~-~,~...~. ',,~,~..~_<'.. .................
Nature of work (clieck wliicb appl'cablel
Repair .............. RemOval...
Estimated Cost .... ~..,~.~.q-, i ......
;. If dwelling, number of dwelling units ..
qew Building .......... Addition .......... Alteration ..........
........ Demolition .............. Other Work/t]OO,~.. ~:W--J~
(Description)
................ Fee .'~./.O'U, o~ .................. , ...........
(to be paid on filing tliis application)
./ ........ Number of dwelling units on each floor../. ............
If garage, nnmber of cars ........ -..., ............................................................
i. If business, commercial or mixed occupa t, specify hature and extent of each type of use ......................
Dimensions of existing structures, if any:
Height . . .[.~ .......... Number of S
Dm~ensmns of sa ne stn ctt re wkh altera
Front ..... ~9 ........ Rear .... .~,'1 ~. ......Depth ~ ............
eries . . [ .....................................................
lions or additions: Front t~?, Rear q~ {
· · lb ............... Number of Stories... ~ ..................
).
t.
2.
l.
Locate clearly and distiJ)ctly all buJldinl
roperty lines. Give street and block number,
.terior or corner lot.
.¢
';
Depth ..... ql.* .............. Iteigl t ...
Dimensions of entire new construction: ;rent ............... Rear ............... Depth ...............
Height ............... Nnmber of ~ories
Size of lot: Front ........... ....... ~ [ ....Rear ............... · ....... Depth ......................
Date df Purchase ........... : ...... ~ ........... Name of Former Owner .............................
Zone or use district in which premises a [ situated .. ~i2---~'~ ........................... i:'. .................
Does proposed construction violate any: oning law, ordinance or regnlation: .tq,O ............................
WiU lot be regraded N. CI ....................... Will excess fill be removed from premises: '~ No
Name of Owner of premisesCiO/.I, Lt~l~t .Ix)O~-71q.. Address .[O.e,-~,h$. }ar~l~.-. .... Phone No ................
Name of Architect ........................... Address ................... Phone No ................
Name of ContractorC..~at...~ ~,t4..~.~-t-.. ~ ~.d.~.~--OIt$l',.e~t~ldress .~Oo·'r'd'.Ol--.~%I .b/,.~. · Phone No. '96 ~'..':'. ~.q .9.~...
PLOT DIAGRAM
s, wlieti~cr existing or proposed, and. indicate all set-back dimensions from
)r description according to deed, and show street names and indicate whether
TATE O F N]
OUNTY S.
(Name of individual signing cent
)eve .named. ~ ~
e is the .... .~.~.../',F~.q~?T?/~,.
f said owner or owners, and is duly autlioi
)plication; that all statements contained in
· ork will be perforined in the manner s
worn to before me this
............. · ~ ..... day of.
tblic, . .....
NOTARY
No.'
Term Expires
........... being duly sworn, deposes and says that he is the applicant
act)
Contractor, agent, corporate officer, etc.)
ized to perform or have performed the said work and to make and file this
this application are true to the best of his knowledge and belief; and that the
hi the application flied therewith.
.. County
S,f~e,l~ ~;?t~:~ F '.. . ' (Signature of applicant)