HomeMy WebLinkAbout13344-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. Z]4468 Date June 3 ........ 19~.
THIS CERTIFIES that the building ad d i t i on
Location of Property ..... 4.2. 5. .0 ............... B..e ¥g.e.n...~.v.e.: ........... ~ .a.t.t.i.t..u.c.k. ....
House No. Street Hamlet
County Tax Map No. 1000 Section ....1.1.3. ..... Block .... .7 .......... Lot .... .1 2. ........
Subdivision .............. X. ................ Filed Map No .... .X .... Lot No .... X. .........
conforms substantially to the Application for Building Permit heretofore filed in this office dated
·.. Au. ~ .u ~s,t., 9~ ......... 19.8. 4. pursuant to which Building Permit No....1.3.3.~. ~..Z ............
dated .... ?.u. g .u.s.~.. 1. .3 ............. 19 .8.4., was issued, and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which ttfis certificate is issued is .........
. .a.d.dA t..i.o.n., t..o..e.x.i..s.t.i.n.~..one. ~ f.a.m.i..~ y..d.w..e ~.~.i.n. ~ ........................
The certificate is issued to ............ J. QI~I..A. Qg.T.[IE. ~.I.N.E.. $.I.~I.q .I.C ~ ................
(owner,zI~ ~t~q~
of the aforesaid building.
Suffolk County Department of Health Approval .............. N/. g...: .....................
UNDERWRITERS CERTIFICATE NO .................. iq 7.~.zt q 5 {) ........................
Rev. 1/81
Building Inspector
TOWN OF SOU*I'HOLD
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD, N. Y,
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? ~33~ Z
· 11~ , .......................
County Tax Map No. lO00 Sec~. ...................... Bock .... ..~1. .............. Lot No. I' oo ~
pursuant to application dated .~V~..~,.~0..~.....~. ...................... , 19.~..~..., and approved by the
Building Inspector.
Rev. 6/30/80
FORM NO. 6
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N.Y. 11971
765- 1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
This 0plication must be filled in typewriter OR ink, and submitted -,~ to the Building Inspec-
tor with the following; for new buildings or new use:
1. Fidal survey of property with accurate location of all buildings, property lines, streets, and unusual
nam rat 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~*operty showing all property lines, streets, buildings and unusual natural'or
top~)graph ic featu res.
2. Swbrn 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 $15.00
3. Copy of certificate of occupancy $1.00
4.Vabant Land C.O. $5.00
............
New Building ............. Old or Pre-existing Building . ./~..~,~; ..... Vacant Land .............
Location df Property .4'~, 2 ~,~. ~C~). . ~..~,/~. ~-7,~.~... ,~.~.. ~./ ...... /~ ./.~.~'...~'/'. ~,,. ,~z..C,~<. ~..~
' House No. Street Haml/~t
Owner or Owners of Property . ?.(~/(. ,/~/..~...~./¢~..~. ?.~, ././~/:'~....*,~. ~ ../~/, .~L./..~._/.¢:, .......
County Tax Map No. 1000 Section . .~ / .~ ......... Block .... .~. ......... Lot.. ,/.'. ~ .........
Subdivision ................................. Filed Map No ........... Lot No ..............
Permit No. ~ ~.. ~.. ,~..z~', .~-Date of Permit .(~/~.'; .~/~..Applicant..~. ¢.~../~..-~././~./,4~. ,/.C.//~. ........
Health Dept. Approval ........................ Labor Dept. Approval .....................
Underwriters Approval ........................ Planning Board Approval .....................
Bequest for Temporary Certificate. ,t ................... Final Certificate .....................
Fee Submitted ..............
Construction on above described building and 9¢rmi~t; meets/a~ applicable co. des and regulations.
"1" ............. .......................
Rev. 10-10-78
TOWN OF SOUTHOLD
OFFICE OF BUILDING INSPECTOR
P.O. BOX 728
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL. 765-1802
CERTIFICATION
Building Permit No.
Owner~0/~ /~[C~<-~ (please print)
(please print)
I certify that the solder used in the water supply system
contains less than 2/10 of 1% lead.
(plumber' s signature)
Sworn to before me this
Notary Public,~2~O6-~ County
Notary Public
DANIEL V. BRISOTTI
NOTARy PUBLIC, Slate of Neyv Yor;(
No. 4732371
TOWN OF $OUTHOLD
OFFICE OF BUILDING INSPECTOR
P.O. BOX 728
TOWN HALL
SOUTHOLD, N.Y. 11971
TEL. 765-1802
To Whom This May Concern,
We are unable to complete your Certificate
of Occupancy because,of the following reasons.
/~X/ An application for Certificate of Occupancy
is not on file.
/~ No Underwriters Certificate on file.
/~ The check is(~X~X~not on file.)
/5/ No Health Dept. Approval on file.
/5/ No final inspection has been made.
Please contact our office on this matter.
Thank you for your cooperation.
Building Permit # 1 3 3 4 4 Z
Building Dept.
***/~/ NO Plumber Solder Certificate on file.
( all permits involving plumbing being
issued after April 1,1984 )
*Application for C.O. and a form for your
plumber.
Sincerely yours,
Dorothy ~ Midgl~ k 1
Building ~ept. secJ ~ 3
FOUNDATION (1st)
FOUNDATION (2nd)
ROUGH FRAME &
PLUMBING
INSULATION FERN. Y.
STATE ENERGY
QODE
FINAL
76S.'1802
BUILDING DEPT.
INSPECTION
FOUNDATION 1ST [ ] ROUGH PLBG.
[~/~FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING
REMARKS:
[ ] FINAL
, INSPECTOR
THE NEW YORK BOARD OF FIRE UNDERWRITERS
BUREAU OF ELECTRICITY
~ 85 JOHN STREET, NEW YORK, NEW YORK 10038
Oate 0c'lz)ber 2.8.~ Z~ ~0/~
THIS C~ETIFIE5 THAT
only the e~ctr~al eq~ip~nent ~ described belo~ a~d i~t~duced by t~ applicant named on the able applicaTion number in the premises of
Jo~ S~cich~ 42~0 ~r~m L~ne~ ~tti'~u~, N.Y,
0c~ber 2~ igS~ ~'
was exa~ni~ed on and~ound to be in compliance with the r~quiremen~s of this Board.
FIXTURE
OUTLETS
~ECEPTACLES
SWITCHES FIXTURES RANGES ~ OVENS DISH WASHER
FLUORESCENT
DRYERS
FURNACE MOTORS FUTURE APPLIANCE FEEDERS
TIME CLOCKS UNIT HEATERS MULTI-OUTLET DIMMERS
SYSTEMS
NO. OF FEET
SERVICE DISCONNECT
OTHER APPARATUS:
?~oke Der ec~x)r
S E R v I · C
NO. OF C¢~ COND
1
AW.G, NOOF j A,W.G
OF CC. COND HI.LEG OF HI-LEG
310 :
NO, NEUTRALS OF NEUTRAL
3/0
t~tor Bogovic
North Bayvl¢.~t PcJad
~outhotd, N.Y, 1107]
This certificate must not
kic.
GENEI~AL MANAGER
11
altered in any manner; return to the office of the Board f nco~rect. Inspecto~ may be identified by their credentials.
N ANY MANNER. ~
' FORM NO. 1
ToWN OF sOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
souTHOLD, N.Y. 11971
TEL.: 765-1802
,xamined~,t~.~. J.~. ..... 192'I.
~,~, .~ ~. ~ ~ , 19~.'1 Permit No..).3.R:.~. .~. '~:' ·
kpproved ·..'rf~. ~ .........
)isapproved a/c .....................................
................................. ;;¢2
.~. ~_ ~',J . .~f~.¥ .~ 7 ...........
(Building Inspector)
APPLICATION FOR BUILDING pERMiT
Received ........... ,19...
Date ................... 19...
INSTRUCTIONS
a This aPP licati° ~nl ~t~a~b et ;°s cma~e, t ~Yeefial~tdo ~d mbgy tt~o Psce~e~tuelre°r in ink and submitted t° the Building Inspect°r' with 3
· · relationship to adjoining premises or public streets
sets of plans, accurate p .P ..... ~ ~* ~nd of buddings on premises: ~ -- *h~ a,aoram wMch ~s part of tMs appli
h. Plot plan showing !ocauuu ~.- ...... c *,~,,~ertv must be drawn un
or a~eas, and g~vmg a detailed description oz tayou~ -- e-~r ~
cation. . manced before issuance of Building Permit..
' 's a licat~on may not be cum . · · ' permit to the applicant. Such permit
c. The work covered by thi ..PP ..... .,~:~- ~-s~ector will assued a Bmldmg
{Jpon approval of this appllCarlon, rne ~m~um~ -- v
d.
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
. . . · for removal or demolition, as-herein described.
Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or
Building. ...... ,gtruction of buildings, add,t,ons or ,a. lter,a~t~,on~,n~l~, g code, housing code, and regulations, and to
Reguiat~ons, ior me ~ ...... ,...,.:+h all annlicable laws, orulnanc~, ~--- m_
The applicant agrees to compt~ ,, ....
-' ctors on premises and in building for necessary)n~ect[on(s,,,
m~t anthonzeO mspe ' ' ..............
ad ' ' ~.Q~~,'J '~; ~ cornoration)
0 (Signatuf~ of appucant, or name,
. . . ,Z'27 ;: . . :,. ...........
.. ~/~i (Mailing address o[ appucant/
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
a/d./fi .....................................................
...... ' /Ez /2d ............................
Name of owner of premises ............... (as on the tax roll or latest dee
If applicant is a corporation, signature of dul.y ~uthorized officer.
........ (Name and title of corporate officer)
Builder's License No..~t .~. ~.~,~ ...............
Electrician License No ........ ,
'Other Trade's License No ...................... x? ~-~ ~c'~J////~--/fJU~..~.~. · ·-/U.4T.l' .~- · ~- '~' · ·
Locahon of land on which proposed work wilt De OO - .~ · · ~' ' ' ' '
,. · . .............
· ...................... ..........
House Number
~ Block 0.7: ..~.. Lot. ~.~/-,- ~..~..'~" '
· . . · · ' .......
........ Lot ..............
County Tax Map No. 1000 Section J/~. .....
Filed Map No ...............
Subdivision ................ d~a'r~;)' .......... i ....
intended use and occupancy of proposed construchon
State existing use and occupancy of premises and .~.
2. ' ..fO.E. .......
a. Existing use and occupancy ...~./.~ '&' '~' '~' "'~'/~' '/~' ' .... ' ..................
b. Intended use and occupancy ..............
3. Natur~ of work (check which apphcable): New Building .......... Addition ......... Alteration .
Repmr .............. Removal ............ Demolition ............. Other Work ..............
' (Description)
4 Estimated Cost , Fee
: ~" (to be paid on filing this application)
5. ]f dwelling, number of dwellinglunits ............... Number of dwelling units on each floor ..............
l'f garage number of cars
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use .....................
7. Dimensions of existing structures, if any: Front. ~..4/...,q'.Z:: ...... Rear .~..Y.. ff ....... Depth .. ~.. ~, BF.. .....
Height ,~9. ~. ~ ...... Number of Stories ... *,~ ...................................................
Dimensions of same structure with alterations or additions: Front ....~..~. ......... Rear .... .4Z..O. ..........
........... i" Height... ?Z .Jg.A ........... Number of Stories.... .................
Dimensions of entire new construction: Front ............... Rear ............... Depth ...............
h
· Iteig t ............... Number of Stories ........................................................
Size of lot: Front .../.,.7.d: .)~r~<?7... ....... Rear... ATgi. ........ Depth . d~..~.,Z~?.... ..........
Date of Purchase . ~:~/.~.., ~ .................. Name.of Former Owner d, fd. 4.../.,~.~.. ~ ~. ~ .~?..//~.,~ ....
Zone Or use district in which pr~mises are situated. ~f~4~..~../~..J .~..6- ............ Cb ...........................
Does proposed construction violate any zoning law, ordinance or regulation ~ .....
Will lot be regraded ........ I ................... Will excess fill be removed from premises: Yes No
Name of Owner of premises ~,;d, gd~'?~.?....~/'~fc/.cf~.. Address/~"~ .~?.o../7'/./b.c. 0.&..~.. Phone No..2-. ~.
· i ~...~,~4-/-/e.'c/<- ' '
Name of Architect ......... i ................. Address ................... Phone No ................
Name of Contractor . .~.~. ~.Z~,i ~/.'~/. ~/.~, ~ .... Address .~/;f .~?..~. .......... Phone No .... f: ..... ? ....
-8.
10.
11.
12.
13.
14.
PLOT DIAGRAM
Locate .clearly and distinctly al! buildings, whether existing or proposed, and, indicate all set-back dimensions from
property lines. Give street and blockinumber or description according to deed, and show street names and indicate whether
interior or coruer lot.
STATE OF NEW/JizORY[,, . ,o o '
..... ~~ ~ .e~.... 'i .................... being duly sworn, deposes and says that he is'the applicant
~/ (Name of individual signling contract)
above named.
He is the ................. ~G~wr. .......................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is dul~ authorized to perform 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 mannelr set forth in the application filed therewith.
Sworn to before me this
(S~gnature of applicant)