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Home My WebLink About11467-zFORM TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. :Certificate ::Of 'Occupancy No.. Z.I.Q8 1 5 ......... :Date ...... ~.ecemhe~'..1.1 .............. 19 8.1. THIS CERTIFIES that thg building ................................................ ~Location of Pro, petty . ,1. z~ 9 0 ............ ~.:[,],3.{~ge.. I~[a.e. ............... {)Fj.~O.t, ........ House IVo. ,~treet Ham/et ~County Tax ~;~ap No.. 1000 Section . . .Q2/* ..... '.'Block .. ~).2, .......... Lot ., I:).1./~ ........... Subdivision ...... :/ .......... ....... ~' . ..... Flied Map No.. X...:..Lot No .... [ ......... conforms substautially to the Application for Building Permit hei:etofore filed in this office dated .... ll.o.v, em b.o.r.. ~, ..... 19 8.~. pursuant to which Building Permit No .... ~. 1 t~ 6.7.. g .......... dated ...~gy.e. rob~te..1.9 ............ 19. I~.1, was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupaucy for which this certificate is issued is ......... ..... .a..~..t;9?.a.g.e' .b.u.l...1.d.;[.n.g.-.--.a. qc..e.~.~.qlT, y..u.~.~, ~ .................................. The certificate is issued to ....... .14.~.],l..J. ialll .oO.d,..49,g..S. g, .l?9.n.g ........................ (o wrier, ~.~ of the aforesaid building. Suffolk County Department of Healtl~ Approval ...... ~[It ................................. UNDEI~.WRITERS CERTIFICATE NO .............. 8/'It ................................. Building Inspector Rev. 1/81 TOWN ~0 F,.~ TOWN HALL SO~TH'OLD, N~ BUILDING (THIS PERMIT MUST BE KEPT ON H,E PRE/~ISJ~S UNTILI~ULL COMPLETION OF THE WORK AUTHORIZED) Permissior is hereby granted to: at premises located at ................................ ~.;; .................. ..' · ...... ~. ........ ....................... pursuant ~0 appl cation dated ......................... ~....,....~...,,....;, 19~.;, and approved by the Rev 613C180 TOWN OF SOUTHOLD , Building Deportment Town Clerks Office 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 Inspector 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 installations, 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. B. For existing buildings (prior to April 1957), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey.of property 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 in- formation 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 Dote ..../...~.?/. Pi..~.'/. ........................... New Building ........../~...... Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Location Of Property ./.v//O J////~.~CL ~/~.~.,4 ..~....~.'~-~-~ /~/" OwnerOr OwnersOf ProDertv ~'r //; ~' ~ ~ '~ ................................. '"'. ............................................................... ~ ........................ 0Z-..~,. .............................. Lot No...Z.~...... Block No ...... '..Z~:.... House Health Dept. ^pprovol .................. ~. ......................... Labor Dept. Approval ............. ~:: ................................ Underwriters Approval ................. :.:T:..: ..................... Planning Bo~rd Approval ....... --....--'i.-. .......................... Request For Temporary Certificate ..... Final Certificate Fee Submitted $ 5C ~ Construction on above described building and permit meets all applicable codes and regulations. Applicant ...... .......................................... Sworn to before me this · ~..('~ ..~.,.... day of .'.~....~.~.e~g...~.~ .................... Notary Public ........ .~. / ,~. .................. County (stamp or seal) NANCY E, NORKLUN NOTARY PUBLIC, State ot New York No '~641336. Suffolk Cou~lty Ccm,nlssion Expu'es March 30 19~ ~. FL.'. LJ:~ ;-",q~,t,4 · '~- &O° O'd, '~:'- - 14-4.90 · 7¸ d -'Fi+lo LICENSED LAND ~ Lk~ NOTIF'Y BUILDinG 'D EP~ R"'~' El~'f' -k T 765-1802 9 A~'TO 4 pM c~'-~-~- 0 LOWING INSPECT!ONS: l. FOUNDATION . TWO REQUIRED FOR POURED CONCRETE 2 ROUGH- FRAMING & PLUMBING 4. FINAL - CONSTRUCTION MUST BE COMPLETE FOR C.O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N.Y. STATE CONSTRUCTION & ENERGY CODES. NOT RESPONSIBLE FOR DESIGN OR CONSTRUCTION ERRORS. OCCUPAt~~,~~ ..... t_ USE IS UNLAWFUL WITHOUT CERTIFICATE ----OF-~ · /~y:- · i -__::~ .... --: :: :::.' .. _:... ~Jr- Jr- - ...... ~: ==.:: '1 , Jl Approved . .~./.4 ...... , 19,~. Permit FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 Disapproved a/c ..... c._ .... ' '~'<,' ....... .. ............ ..........................- (Building Inspector) APPLICATION FOR BUILDING PERMIT Application No...././. ?~..~..Z ..... 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 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, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. (Signature of applicant, or name, if a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, ~ral contrac~ engineer, general contractog, electrician, plumber or builder. Name of owner of premises .......................................... ;J ................................ (as on the tax roll or latest deed) If applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No.. d~.</.,~... ~,..../~/. 9 ~. Plumber's License No ......................... Electrician's License No ....................... Other Trade's License No ...................... Location of land on which proposed work will be done .................................................. .... ..... :....V. ! ................ ....... ...................... House Number Street Hamlet County Tax Map No. 1000 Section ..... (~ .'2-...~. ....... Block ....... '..Do:~. ........ 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 . V' ~ ~, d ~-~ ~ ~'J/~ Intended use and occupancy ... ,~-: .~..s ...~.~..~?.(! ..t~.I- .... .~.....~.~c} .~.~ .,.yp.o~f~. ,. ,,~'/t44 ~ .c~....¢.~. ............ b. 3. /~attlre:ofwork (check which apPlicable): New Building .....~. i... Addition .......... Alteration .......... Repair .............. RemOVal .............. Demolition ............ Other Work ............... q~.~. ,5~ [ .~ ~ (Description) 4. Estimated Cost ...... : ........................ Fee ............................ (to be paid on filing this application) 5. If dwelling, number of dwelling l~nits ........ ~ ...... Number of dwelling units on each floor....."7. ......... If garage, number of cars .... .-~.7 ................................................................. 6. If business, commercial or mixed occupancy, specffy nature and extent of each type of use ....~.~.. i'. ............ 7. Dimensions of existing structure~, if any: Front ............... Rear .............. Depth ............... Height . .............. Number of Stories ........................................................ Dimensions of same structure with alterations or additions: Front ................. Rear .................. Depth ...................... Height ...................... Number of Stories ...................... ...... . ........ Rear .... /. ~.. ........ Depth .. l ~. .......... 8. D~mens~ons of entire new construction: Front.. / ~. t ~ Height ..... .O. ...... ,.,. Number of Stories ........ ~t .z~. ............................................. 9. Size of lot: Front ..... J/.6~. · .i ........... Rear .... .~.~. .............. Depth ./..0 .................. 10. Date of Purchase ........ I.~.0. ................ Name of Former Owner J~.,~.r*...A.~. ~.x-o ......... 1 I. Zone or use district in which pr~mises are situated.. C.¢~.~de,~lt~.~.. ..................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: . .Dt~ .......................... 13. Will lot be regraded .... '~ 'i ................... Will excess fill be removed from premises: Yes Name of Architect . .?} ....... i. ;r) .............. Address ................... Phone No. Name of Contractor .cAt .r-ff .~...~..,.. / o~ lc.- ' ............... 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 number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF,,~ >~'f.~ ~,~'NEW~JTR"~ ~'~~.~ S COUNTY ......... t . .~'. ..... ~..//...,/.°7-....~'~-..~'"~'k~eing duly sworn, deposes and says that he is the applicant (Name of individual signing conlract') above named. : He is the ....................... ~ . . . ~ ................................................. f'~ (~ (Contractor, agent, corporate officer, etc.) of saki owner or owners, and is duly aut'llm4zod to !*erfO~m 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 ......... ..~.~ ...... day of...~....~m,r~ ~,~t ,~,,~/~,~ 19~. Notary PuBlic, . .... :...,,~ ...... :.,~~ Co nty ~