HomeMy WebLinkAbout11175-z FO~ ~0. ~
T~N O~ ~OUT"G~
BUILDING D~P~RT~E~N~
TOWN HALL
SOUTHOLD, N~Y.~
BUILDING PERMIT!
(THIS PERMIT MUST BE KEPT ON THE PREAA~si
COMPLETION OF THE WORK AuTHO~RIZED) '
iS UNTIL FULL
Permission is hereby gronted to:
Build~n~ Inspoctor.
FORM NO. 6
TOWN OF $OUTHOLD
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 ~ollowing; 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 epproval of Health Dept. of water supply and sewerage disposai-(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 alt 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. ~..~..~.~.0, ~,....'~ .. ~..~.'..~..~...~../. · .-~O~./.C¢'~..~.~..~,.. ......
House No, ---- ~ ,Street '~ ' Hamlet
Owner or Owners of Property ....~.~..~.'~ .~.. ~.. ~'.?,¢/~.4~.'?: .~...~..~., .~/...,~.. ................
County Tax Map No. 1000 Section .... .(~, .~, ..... Block .... ,~.~. ...... Lot....(~../..~. ......
Subdivision ................................. Filed Map No .... . .'~.....Lot No ..............
Permit No.///..~'~.~.... Date of Permit,'~..~.Applicant... ~~, .~../~.~.. .........
Health Dept, Approval ........................ Labor Dept. Approval ........................
Underwriters Approval ~l~../'~~ ..... Planning Board Approval.. ~
Request for Temporary Certificate ..................... Final Certificate .....................
Fee Submitted $. ~
Construction on above described building and permit meets all applicables an
d regu lations.
Applicant ................... ~ .............
FOUNDATION (1st)
FOUNDATION (2nd)
ROUGH FRAME &
PLUMBING
INSULATION PER N.
STATE ENERGY
G,ODE
FINAL
ADDITIONAL COMMENTS:
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y, 11971
TEL.: 765-1803
Disappro, d a/c ....... ........... X ............ ," ,
(9uildin8 Ipspector)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
a. This application nmst 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 according to 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 Un the diagram which is part of this apt:
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 pern
shall be kept on the premises available for inspectmn tl~roughou[ file work.
e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupan
shall have been granted by the Building Inspector.
APPLICATION IS ttEREBY MADE to the Buildh~g 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
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein descdbr
The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and
admit authorized inspectors on premises and in buildings for necessary inspections..-.,
(Mailiug address of applicant)
State whether applicant is og(ner, lessee, agent, architect, engineer, general contractor, electrician, plumber or build.
Name of owner of premises ................................
~(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. o'~0 ~
Plumber's License No .........................
Electrician's License No .......................
1. Location of land op which proposed work will be done .... ~" ~ · ....
House Number Street Hamlet
c; >- .... Lot.
County Tax Map No. lO00 Section ....... 9~.i ........ Block ...................
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 ... ' .T. ~ ~ ...................
~ .
b. Intended use and occupancy ....... ~~.~. 7. ~. ~.'. ,~~..~ ......
Repair .............. Remoyal .............. De,nolition ...... Other Work .............
, F,~/~._o~~ (Description)
~.z 3o 0 oO
Estimated Cost '
(to be paid on fding this application)
If garage number of cars '
If business, commercial or mixed' occupancy specify nature and extent of each type of use ...................
Dimensions of existingstructure~,ifany:Front.....w .... .--7......Rear ........... ... Depth......... ..
Height ............... Number of Stories ......................................................
Dimensions of same structure wi!h alterations or additions: Front ~ Rear
Depth ............ ~ .... ,;. Height ...................... · .'~. ~' .~. Number of S~ories .......
Dimensions of. entire new constrnction: Front ....... Rear ..... ~?~,' ...... Depth ,. ....
HeiSt ... .q..~ Number of Stories .....................
Size of lot: Front -- ' Rear Depth
Date of Purchase .': Name of Former Owner
Zone or use district in which premises are situated .....................................................
Does proposed constructionviol~teanyzoninglaw, ordinance or regnlation: ............. ......... ..........~
Will lot be regraded ......... , ................... Will excess'fill be removed from premises.~_ ,, Y~es. ,~,..n No
Name of Owner of premises .. l.-e~t.7~- ............ Address ................... Phone No .........
' Phone No
Nmne of Architect Address
Nmne of Contractor ........................... Address ................... Phone No ................
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from
:operty lines. Give street mid block number or description according to deed, and show street names and indicate whether
~terior or corner lot.
TATE OF NEW ~K> ~ ,~
OUNTY OF~...
S.S
.... being duly sworn, deposes and says that he is the applicant
(Name of individual~ contract)
bore named. ~ ~.. ~J ....~ ..
e is the..~ ........... ~.~..~..."f~..'~.. ..............................................................
,I (Contractor, agent, corporate officer, etc.)
f said owner or owners, and is duiy authorized to perform or have performed the sa. id work and to make and file this
pplication; that all statements contained in this application are true to th'e best of his knowledge and belief; and that the
will be performed in the manner set forth in the application filed therewith.
'x~rokrn to before me this ; ._.~ /~,
............... /7. . . o, . .- . . ...... . . . .
s f,o,
THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
in the followi~g locatlon; ~ Basement ~ 1st Iq, ~ 2nd Fl. Section Block Lot
was examined on ~q~d~ ~/ , [90.~ and found to be in con~pliance with the requirements of this Board
RX;Uaa FIXTURES RANGES OVENS DISH WASHERS EXHAUST
OUTLETS ~ECEPTACLES SWITCHES FLUORESCENT
DRYERS
OTHER APPARATUS
PER ~
2
Th,s cerhflcate must not be altered in any manner, return to the office of the Board if '
~OP¥ FOR BUILDING DEPA THIS COPY OF
I
OF CC NO OF HI-LEG
4/O
~kic, 242-1~
C
A W G NO OF NEUTRAl A W G
OF HI LEG OF NEUTRAL
6/0
may be
their credenhals
D IN ANY MANNER.
,[00077t THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICIT~
~.~T~,~~ ~ ~ 85 JOHN STREET, NEW YORK, NEW ~ORK 10038
THIS CERTIFIES THAT
o~[y the e~ectr~ca[ e~ip~e~t ~ described belo~ and ~trod~ced by t~ ff~J[ca~t ~me~ on ~hE~b~ve ~plica~ number ~t~ premlses of
~.~ ~..,i,,~d ,,,~ Da~ 7, 1981 ..d /o..,d to be in co,npliance w~th the require,nents of this Board.
FIXTURE FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS
17 3 9 t2 5
DRYERS FURNACE MOTORS FUTURE APPLIANCE FEEDERS TIME CLOCKS UNIT HEATERS MULTI-OUTLET DIMMERS
SYSTEMS
NO OF FEET
SERVICE DISCONNECT S E R V t C
OTHER APPARATUS:
AWG
OF HI
NO OF NEUTRALS
AWG
OF NEUTRAL
143
Mattim~k, ~ 11952
This certificate must not be altered in any manner, return to the ofhce of the Board if
BU~ILD,NG DEPAR~/VlENT. THiS C~PY~ OF
lie. 262-E
GENERAL MANAGER
1i
may be ~dentffled by thmr credentials.
IN ANY MANNER.