HomeMy WebLinkAbout13401-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. 2~q3z. ltl!l .......... Date .............. ~7..'l& ........... 19~.5.
THIS CERTIFIES that the buildin~.-.a.d-.d-..J-.'b.5:.°..~ .....................................
Location of Property . 559.0. ................... 99.x..~.eg.k..R. 9.~.cl. ........ 5.~'q~-.~.u.e.k....
House No. Street Hamlet
County Tax Map No. 1000 Section . .'l..~. ...... Block . .08 ........... Lot . .Q.O.q-. ...........
Subdivision...X ........................... Filed Map No....~ ..... Lot No. X
conforms substantially to the Application for Building Permit heretofore filed in this office dated
·.. ~uglz,~.t;. 30 ....... , 19~q-. pursuant to which Building Permit No...'l~,~Q'l.. ,g. ...........
dated ......... g. ugtza.'l;.. 30 ........ 19 .~zt-, 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 .........
........ a..~..a.4 .d.~.%.o..~' .~.q..e.x.~.~.~..~.n~ .o..n.e.-.~.~..m¢.z.~..d.~.e.~.z..~.n.~,. ...................
The certificate is issued to ..... .0.~...~J..~..~:~.~.O~Q~..Zg.g. ................................
(owner;-, t~ee o~ ,~n'r)
of the aforesaid building.
Suffolk County Department of Health Approval ..... n..,('.~ ..................................
UNDERWRITERS CERTIFICATE NO ............. I}T...~.~.~555 ............................
Building Inspector
Rev. 1181
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
cOMPLETION OF THE WORK AUTHORIZED)
N? 13401 Z
Date ,~.4,~' ~
....~.....~..,., ................................... ,1
County Tax Map No. 1000 Section ...... ,,....~ .......... Block ...... .~. ........... Lot No ......... .,.. ............
pursuant to application dated ..... ~.~l~.~. ....... ~ ........ , 19..~..i.~.., and approved by
the
/
Building Inspector.
Building Inspector
Rev. 6/30/80
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 following; for new buildings or new use:
,~ 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 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 p~perty 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 informa-
tion required to prepare a certificate.
C. Fees:
1. Certificate of occupancy $5.00
2. Certificate of occupancy on pre-existing dwelling $15.0 0
3, Copv of certificate of occupancy $1.00
Date ...........
New Building .~..~ ....... Old or Pr_e-existing Building ~ ~ ......... Vac d .... ~ .......
Location of Property...~..Qq. .... ~ .~., .~0. _. (.~Z~ .... .~.~.~ , [~ .~fd~ l k'
House No, Street Ham/et
Owner or Owners of Property ................ ..................................
County Tax Map No. 1000 Section ..... ~,,% ..... Block ....~. .......... Lot... ~,~. ...........
Subdivision ........... ~ .................. Filed Map No ............ o, No ..............
........ ..........
PermitNo ...... Date of Permit ...... Applicant ......... ~,_,, ~.~.,.~ eY'
Health Dept. Approval ........................ Labor Dept. Approval ........................
Underwriters Approval ....................... Planning Board Approval ......................
Request for Temporary Certificate ..................... Final Certificate .., J~ .. ~..
Construction on above described building and permit meets all applicable
Rev. 10-10-78
F1E~D INS F~CTI~N COMMENTS
FOUNDATION
FOUNDATION (2nd)
2.
ROUGH FRAME &
PLUMBING
INSULATION FERN. Y.
STATE ENERGY
~,ODE
FINAL
ADDITIONAL COMMENTS:
765-1802
BUILDING DEPT.
INSPECTION
£ UNDATION 1ST [ ] ROUGH PLBG,
[ ~'~OUNDATION 2ND [ ] INSU ,/.~TiON
[ ] FRAMING [ ] FINAL'
REMARKS:
DATE ~ iNSPEL~i.OR
BUILDING DEPT.
INSPECTION
FOUNDATION '"ST [ ] ROUGH PLBG.
[ FOUNDATION ZND'[ ]'INSULATiON
[~RAMING [ ] FINAL
REMARKS:
INSPECTOR
THE NEW YORK BOARD OF FiRE UNDERWRITERS
100~381 BUREAU OF ELECTRICITY
kl A.Dril 30,1~5~°HN STREET, NEW YORK, NEW YORK
Charles Eido~itz, ~ox s N~CK ~;~ ~rGen Ave.,
in thefollowlnglocation; [~ Basement ~ /st Fi. [] 2nd FI. Section Block Lot
· . April 25t1985 and fou,~d to be i,~ complia,,ce with th, r~qui~e,nentsofthlsBoard.
FIXTURE FIXTURES RANGES COOKING DECKS ~ OVENS
OUTLETS SWITCHES FLUORESCENT
1 5
DRYERS
DISH WASHERS EXHAUST FANS
OIHER APPARATUS:
S E R
Pat Lane, Box 182A
GENERAl, MANAGER ~ /~1
Mattituck, N.Y., 11952 II ~ 1 ~ ~/ ~1
This certificate must not be altered in any manner; return to the office of the Board if incorrect. Inspectors may be identified by thek creden
COPY FOR BU LD NG DEPARTMENT THIS COPY OF CER-flFICATE ~U~T NOT BE/~TERED INANY MANNER. -- _
' FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
~OUTHOLD, N.Y. 11971
Approved 19 . 1. Permit No. . !.
Disapproved a/c .....................................
................................
(Building Inspector)
APPLICATION FOR BUiLDU'qG PERMIT
INSTRUCTIONS
Received ........... ,19...
a. This application must be completely filled in by typewriter or in ink and submitted 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 st'~eets
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 issued 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 building for necessary i~~
. . , , i . . . . ia.; ....
(Signature of applicaht, or name, if a corpo t'o )
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises
(as on the tax roll or latest deed)
uly authorized officer.
...... (Nam~ ~ 'f 'c;~or'~al~'~r') .........
Builder's License No..~.'..~.~. · .(~.~.~.~;~'..~. ....
Plumber's License No ..... ~.-~ ............
Electrician's License No./O'~..~.
Other Trade's License No .......................
I. Location of land on which proaosed work will be done ..................................................
House Number Street Hamlet
County Tax Map No. 1000 Section .... ~ .~....~. ....... Block ..... ~.....: ...... Lot. · · · .~. · ............
Subdivision ..................................... Filed Map No. ""'"- Lot ~
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of propo~d construction:
a. Existing use and occupancy ...~f~...~....~.%..~...~.C~ ..... , ..,,jl ................
b. Intended use and occupancy ............. ~...x~..~.~p.... ,'fv~4~"'~t ~o1,1 ...........
3. Natur~ of work (check which applicable): New Building ..... ' ..... Addition . ..~- .... Alteration ..........
Repair .............. RemOval .............. Demolition .............. Other Work ...............
4. Estimated Cost .......... /' ' i .......................... Fee ..........................
I q' (to be paid on filing this application)
5. If dwelling, number of dwellingi units ............... Number of dwelling units on each floor ................
If garage number of cars '
6. If business, commercial or mixeld 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 with alterations or additions: Front ................. Rear ..................
Depth ................... [.. Height ...................... Number of Stories ......................
8. Dimensions of entire new construction Front ........... Rear Depth
Height Number of Stories
9 Size of lot: Front ' Rear Depth
10. Date of Purchase .......... I .................. Name of Former Owner .............................
11. Zone or use district in which premises are situated . ' ' . .
12. Does proposed construction yin!ate any zoning law, ordinance or regulation: ................................
13. Will lot be regraded ........ i ................... Will excess fill be removed from premises: Yes No
14. Name of Owner of premises .. i ....... Address ................. Phone No ................
Name of Architect ~ .%-.~...~. ~.'~. Address . .~.'?? ~.' .c~. .... Phone No.g~q..~.-.'2/?.(t ......
Name of Contractor ........ ! ................. Address ................... Phone No ................
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and, indicate all set-back dimensions fr"om
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 NEW Y~R~. ~,/ SS
COUNTY QF ~..~-~n~....
..... ~~'7~~ ......... being duly sworn, deposes and says that he is the applicant
(NamedSf individual signing conti~ft)
above named.
He is the ..........................................................................
: (Contractor, agent, corporat~ officer, etc.)
of said owner or owners, ~d is dul~ authorized to perform or have perfo~ed the said work and to m~e and file ~is
application; that all statements cont~ned ~ this application are true to the best of his knowledge and belief; and that the
work will be perfo~ed in the m~ne~ set forth in the application filed therewith.
Sworn to before me this..
................ ~..~ .... day o~ ....... ~19 .~
N°ta~ Pub~i~ :~~CountY ~ ~
w Yom ......... .......