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BUILDING
TOWN HALL
SOUTHOLD, N~ Y.
BUILDING ~ PERMIrr~
(THIS PERMIT MUST BE KEPT ON TH,E PP, EM S~S UNTIL FiULL
COMPLETION OF THE WORK AUTHORIZED)
Dote :..::,.~..,.~,.~-.~,....~.~ .................... ,
Permission is hereby granted to:
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' ~. . ~Lot No .~
~,~ ,~ ~o~ ~o. ,0o0 ~,~.o~ ....~ ...... ~o~ .... ~. ........ ....... ¢ .......
pursu*nt to ~pplic~tion d~tod ..~ ~ ~ I~ .,
..................... ~....:~ ...... on~ opproved by tho
,Building Inspector
Building Inspector.
^
~e *.~,~ ........
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 instaIla4
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.
B. 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
topograph ic 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 ~ 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-exi?ting Building(~:). _.._1~,. _ ~/Vacant Land ~ ...........
'" .............
Owner or Owners of Property .. . .............
, ...................
Subdivision ............... - '
.................. Filed Map No .... Lot No ..............
Health Dept. Approval Labor Dept Approval
Unde~ritersApproval~.~'~/ ...... Planning Board Approval ..~.......~ ...... ~,.~
Request for Temporary Certificate ............ Final Certificate .................
Fee Submitted $ .............................
Construction on above described building and permi~mee~all apP~cabl~ode~ulations.
AOOHcant .... ,..,~ ....... . ..............
Rev 10-I0-78
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL.: 765-1802
...........
(~uildm~
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
a. This application must be completely filled'An 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 descriptiou of layout of property must be drown on the dia~'am which is part of this apl:
cation.
c. The work covered by tins application may not be commenced before issuance of Building Permit.
d. Upon approval of this appbcation, the Building Inspector will issue a Building Permit to the applicant. Such porn
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 Occupan
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 t
Building Zone Ordinance of the Town of Southotd, Suffolk County, New York, and other applicable Laws, Ordinances
Regulations, for the construction of buddings, additions or alterations, or for removal or demolition, as herein descfib,'
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.
.......... .........
(Sigt~ature of appl[car3t, or ~ame, if a corporation)
-- ..
(Mailing address of applicant)
State whether apphcant~..,, own~ lessee, agent, architect, engineer, general contractor, electrician, plumber or buitdt
............... ./. ..................................................................
Name of owner of premises ................. : ...............
(as on the tax roll or latest deed)
If apphcant is a corporation, signature of duly authorized officer.
(Name and title of corporate officer)
Builder's License No ....... . .~.~..~. ............
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
House Number Street ltamlet
County Tax Map No. 1000 Section .................. Block .. ' .......... Lot ..........
' Filed Map No Lot
Subdivision ..................................................................
(Na~ne)
2. State existing use and occupancy of premises and intended use and occupancy of proposed constmctmn:
a. Existing use and occupancy ....... ~ ;-...
b~~ ~~~ ~Q~, ~,.b' Intended use and occupancy ............ ~~ ... .... '.... ~~ .~. .
Nature of work (check which applicable): New Building ........ . ~Addition ....... ... Alteratmn ........ ,..
Repair .............. Remo al .............. Demolition ....
escription )
Estimated Cost... .. · ·
I (to be paid on ~ing this application)
If dwelling, number of dwelling ffnits ............... Nmnber of dwelling~uni~s on each floor ................
If garag6 number of cars ' ~..
If business, commercial or mixedi occupancy, specify nature and extent of ea~. t~ype of use ~/.~,~..4~..~'.~
Dimensions of exis~ting structure~, if any: Front .... ~..~. ...... Rear . .'-r~. Y. ........ Depth .~/~.,,:3. ..........
Height .............../3 Num her o f Stories ........ .~ ..............................................
Dimensions of same structure with alterations or additions: Front ....... -~.."~'/. ...... Rear . .~./. ............
Depth ."~..-~. +' Height ./-P~" Number of Stories . ?.
' ,,Z- ~ pth ./..0~..
Dimensions of. entire new constniction: Front ...... ~,X. ....., Rear ........... De .........
Height .... ~,/./.~. ...... Number of Stories ........... ~.,/. ........................................
~ Rear Depth
Size of lot: Front .................................................................
Date of Purchase Name of Former Owner
district in which premises are situated
Zone or use , ....................................................
Does proposed construction violate any zoning law, ordinance or regnlation: ................................
Will lot be regraded ......... , ........ Will excess fillJ~e removed from premises: , Yes No
Name o,f'Owner of premises ....~.~..~... ....... Address .... .t~/.e~ ~q .';~./..<~.... Phone No. ~,.~i~..~...~?.~....
Nmne of Architect i Address Phone No
Address ' Phone No
Name of Contractor
PLOT DIAGRAM
Locate clearly and distinctly all ibuffdings, whether existing or proposed, and. indicate oJ1 set-back dimensions from
:operty lines. Give street and block humber or description according to deed, and show street names and indicate whether
TATE OF NEW YD~K t ._ ~
OUNTY OF.
............ .',~,,,~.~?...~f2~. ~. ............... being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
~ove nam ed. ~ '~" //~..,~../ .
is the ...........................................................................
(Contractor, agent, corporate officer, etc.)
said owner or ownem, ~d i~ du~y authorized to perform or have performed the sgid work and to m~e and file ~is
oplication;, that all statements contained ~ this application are true to the best of his Bmwledge and belief; ~d that the
;ork will be performed in the m~n{r set forth in the application filed therewith.
wom to before me this ' ~~
........... ~ ....... day or ........ ,19.
~ EOT~Y PU~UC~te of New York
I . r..... ~ / / ~ L~gnature et appncam)
rio. 5z-8i~58~0, Suftotn ~'ou~
THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
Da,e ApplicationNo. onfile N 5~,9~}~
THIS CERTIFIES THAT
only the electrical equipment as described below and introduced by the applicator named on ~he above application number tn the premises of
~n the follow~ag locatlon ; ~ Basen~ent ~ /st Fl, ~ 2~d F[. Section I}Ioc~ Lot
was examined on J~'W ~ ~ ~98~ and ~ound to be in compliance with the requirements of ti, is Board.
FIXTURE RANGES =OOKING DECKS OVENS
OUTLETS SWITCHES
DISH WASHERS EXHAUST FANS
SYSTEMS
NO. OF FEET
)THER APPARATUS
R V I C
AWO NO OF HIL~G AWG AWG
PER ~/ OF CC COND OF H~ LEG OF NEUTRAL
2 1410 6/0
E
Thts certificate must not be altered in any manner; return to the office of the Board ~f ~ncorrect Inspectors may be ~denhfle~ their de Is
COPY FOR BUILDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.
10O0??t THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
~ ~:L 85 JOHN,STREET' NEW YORK, NEW YORK 10038
THIS CERTIFIES THAT
only the etectrlcal equipotent ~ described beJ~ and int~duced b~ t~ aoolicant ~ed o~ the ~bove ~ppllcatlon number in the premises of
~et~ ~ V~y~ n/~ ~ ~.~ 10~~ ~/o L~ ~ IA., Se~x~c,
~., ~.,..~,,.a,,. De~ 7, 1981 ..,d lo..a to be ~. co.~pli.nre with ~he requirements of this Board.
17 9
DRYERS
FIXTURES RANGES OVENS DISH WASHERS EXHAUST FANS
FEEDERS
SYSTEMS
SERVICE DISCONNECT
OTHER APPARATUS
E R V I C
AWG
OF CC COMP
NO OF HI LEG
E
P~O~ Bo~ 143
~,~t:it~, l';'Y, 11952
OEN$1~AL
L1
This certificate must not be altered in any manner; return to the office of the Board If incorrect inspectors may be identified by their cred~enfials
COPY FOR BbllLDING DEPARTMENT. THIS COPY OF CERTIFICATE MUST NOT BE ALTERED IN ANY MANNER.