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Home My WebLink About12933-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy No ....... Z.l 8 ~.2.9. .... Date .............. J.u.n..e..8. ............ 19.8.~. THIS CERTIFIES that the building .... -..a.c.c.y....q t. 9.r.~.~e.. 9,h.e.d. ..................... Location of Property .6. q .2 ~ ........ Skun.k Lane .... ~..u .~.c.h.o. ~ .u.o ....... hi, dsc ,Vo. ' ............'s't/e~[ ....... Hardier County Tax Map No. 1000 Section .. 3.0.4. ...... Block .... .~ .......... Lot ....... .5 ......... Subdivision ............ x. .................. Filed Map No....x ..... Lot No ........ x conforms substantially to the Application for Building Permit heretofore filed in this office dated ......... ~.a.r.ch.. ] .4..., 198..4. pursuant to which Building Permit No .... 1. 2. .9 .3 .3. Z. ........... dated .......... ~. a. r.c.h.. ~..6 ......... 198.4.., was issued, and conforms to all of the requirements of the applicable provisions of the law. The occupancy for wlxich this certificate is issued is ......... .... Ct ¢.c.y.,. 0.g.qz?. ~g.o... ~ ig.e.d ....................................................... The certificate is issued to ...... .R~C.I~..Rp .&...iq3~oJ,.~ ZSi~YAK rownor, ~ _ _; _kid~ .................. of the aforesaid building. Suffolk County Department of Health Approval iq/A UNDERWRITERS CERTIFICATE NO .................................................. Rev. 1/81 Building Inspector FO~ NO. ~ TO~N OF $O~THOLD BUILDING DEPARTMENT TOWN HALL $OUTHOLD, N. Y. N? BUILDING PERMIT {THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) ,Lt 12933 Z Date ...... County Tax Map No. 1000 Sectiork ....[...0....~. ......... Block .......... ~ ......... ,Lot No ...... ~ .......... pursuant to application dated .... .~..~....~.~....~..../..~. ................... , 19.~...~.., and approved by the Building Inspector. Fee $ ........................ Rev. 6/30/80 FORM NO, 6 TOWN OF SOUTHOLD Building Department Town Hall ~;outhold, N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted-kYe~ut~ 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, Ihdustrial 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. 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 topographic features. 2. Sworn statement of owner or previous owner as to use, occupancy and condition of bu ildings. 3. Date o'i: 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 / 3. Copy of certificate of occupancy $1.00 landuse--Pre-Existing C.O. $15.00 Vacant land C.O. $ 5.00 New Building .... ~ ...... Old or Pre-existing Building ............ Vacant Land ............. Location of Property ............................. Hou~ No. Streat / Hamlet County Tax Map No. 1000 Section ...~..~..~. ....... Block ..... ~. ........ Lot..~.". ............ Subdivision ................................. Filed Map No ........... Lot No .............. .,Applicant.. ~.. ~.~-., .~3N~j~K...~ Permit No.]~??.~.~:. '.~'... Date of Permit Health Dept. Approval ........................ Labor Dept. Approval ........................ Underwriters Approval ........................ Planning Board Approval ...................... Request for Temporary Certificate ................... 'Final Certificate ................... Fee Subm~tte .. .......................... Construction on above describedApplicant...building and~ll.~.~plicable~7'~'~'c°des arid regulations. ................ Rev. 10-10-78 INSPECTION COMMENTS FOUNDATION {1st) FOUNDATION (2nd) ROUGH FRAME & PLUMBING INSULATION PER N. STATE ENERGY C,ODE FINAL ADDITIONAL COMMENTS: AS ,A802 9 AM TO zt PM FOR THE ~/~A.Z/ON '--?WO REQUIRED ~ ~cl~ co~CRE'TE :OR C,,35,~VL~-TF ~z(hR C. O, CON% rp~ IC-I'~O%~ S~ALL- MEBT ),llp. VM,,-:~,~TS OF TH~ ~'~floT REsPONSIB~ ;~GN OA coNSTRUC1'JO~ K ....... FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLO, N.Y. 11971 TEL.: 765-1802 Received .......... ,19... Disapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. Tt~is 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 streets or areas, and giving a detailed description of layout of property m. ust 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 authorizedinspectorsonpremisesandin building fornecessaryinsp~_.~t~,,; //~ ~/~,~-Yr~Y (~ffgnature of applicant, or 9gaae, ~ a corporation) (Mailing address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises./~.t&..'~r~ k-.cl...~.', ..~. ~.~..~. ~ ~...80~..~.~.~.~'. ............................. (as on the tax ro[l~6r latest deed) If applicant 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 ...................... 1. Location of land on which proposed work will be done .................................................. .... .4. ............. ........... e. ...................... House Number Street" Hamlet County Tax Map No. 1000 Section ] C) Block 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 ............................................................... b. Intended use and occupancy ..... r~;~.O.b.O-.~ ~,...~.~. ~...4 ....................................... 3. Nature of work (check which applicable): New Building .......... Addition ...~.. .... Alteration .......... .............. Removal .............. Demolition I .......... Other Work ............... Repair ~'~ J ~.~ ' ,,,, (Description) 4. Estimated Cost ~ ...... Fee . ~ * - · ...... i i (to be paid on filing this application) 5. If dwelling, number of dwelling iunits .............. Number of dwelling units on each floor ................ If garage, number of cars ..... i .............................. . .................................... 6. If business, commercial or mixe~t occupancy, specify nature and extent Of each type of use ..................... 7. Dimensions of existing structurOs, if any: Front ............... Rea~ .............. Depth ............... Height ............... Number of Stories .................... ~l .................................... Dimensions of same structure wlth alterations or additions: Front .... I ............. Rear .................. Depth ................... !.. Height ...................... Number of Stories ...................... 8. Dimensions of entire new const hction: Front .......... . .... RearI. ... ~ .......... Depth .......... Height ............... Nur ~ber of Stories .. .................. I .................................... 9. Size of lot: Front ........... Rear.. ~ Depth 10, [)ate of Purchase ............................ Name of Forme!Owner .......................... 11. Zone or use district in which p~ ~mises are situated ................. ~ .................................... 12. r)o~s p, roposed construction vi~ [ate any zoning law, ordinance or regulalion: ............................... 13. Will lot be regraded ........................... Will excess fill De removed from premises: Yes No 14. Name of Owner of premises ................... Address ................... !~ Phone No ................ Name of Architect .......................... Address ....... ! ........... Phone No ................ Name of Contractor ......................... Address ................... Phone No. ............... PLOT DIAGRAM Locate clearly and distinctly al buildings, whether existing or propose, d, and. indicate all set-back dimensions from property lines. Give street and blocklnumber or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, COUNTY OF .................. ............................ * .................... being duly sworn, deposes and says that he is the applicant (Name of individual signing contract) above named. He is the .................... ,.. ~ ................................................................... (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this apphcatlon; that all statements contmned, m th~s apphcatton are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this ¢E~ day f' ~F~a.~4~. 19 ~r.~. .......... ! ............ i ' ///£; / Notary Public, . .~.....~..d~.~ . County NOTARY ['0BLtC, State 0I Nov/Y0r~' ~F'~ -- /'~' ~' ' '~'/ ~/ feSignature of applic~t) N0, 4707878, gu[~01k l't~rm Fx~ros ~qarch 30, 19'~