HomeMy WebLinkAbout12833-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Cedificate Of Occupancy
THIS CERTIFIES that the building dormer addition
.......... ' Sour. hold
Location of Property . .5. Q .5 ................. .Fp.u.n, .d.e,r.s. Path. ...................
House No. Street Hamlet'
. . .......
County Fax Map No. 1000 Section 06 4 .... Block 0 2 .Lot ..
Subdivision ..... X. ......................... Filed Map No .... X. ....Lot No....X ..........
conforms substantially to the Application for Building Permit heretofore flied in this office dated
.... .J.a.n.u. 5.ry.. ~ .......19 .8.4. pursuant to which Building Permit No.. 1 2 8 33 Z
.dated ..... JArl¢~r,Y..6 ............ 19 8,4., 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 dormer addition to existin¢ d.w..e~.li.n.$r:
The certificate is issued to ..... J..O.S.E,P.I.t. E. & JOAN DOROBKOWSKI
(owner,/~-Dr renaT~
of the aforesaid building.
Suffolk County Department of Health Approval N/R
638011
UNDERWRITERS CERTIFICATE NO ............ N. .....................................
Building Inspector
Rev. 1/81
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)
12833 Z
Permission is hereby granted to:
........ .~..~. ..~~......z~.~c~ ....................
~o .......... .~x~.'-'/,,~.~..~.~ ...... ,z..~ . .~,_~.~....~_.f...~..z.~x2....~......,4YxiJ..
~t ~,e~i~ ~t~ .t ....~.~....::....'...~~....~z~ .....................................
.............................................................................................................
County Tax Map No. 1000 Section ..~.~..z..~.. ...... Block __(2. .............. Lot No,
pursuant to application dated .... ~--~..~..........~.... .......... , 19....?/.~, and approved by the
Building Inspector.
Fee $.. ~:Z..~ ..............
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 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, propertv 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 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 buildings.
3. Date of an,/ housing code or safetv 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/ land use
3, Copy of certificate of occupancy $1,00
--Pre-Existing C.O. $15o00
Vacant land C.O. $ 5.00
Date ..........................
New Building ............. Old or Pre-existing Building ............ Vacant Land .............
Location of Property .................................
Owner or Owners of Property .. .~. ~ .,, . ,o~..~.~,.~/~, .... ~-.. ...............................
County Tax Map No. 1000 Section ~'z~' Block .4~,.,~. Lot ,.~,~..,~J~ ,~.
Subdivision ................................. Filed Map No ........... Lot No ..............
PermitNo //~2~',.-~__ Oate of Permit -~--'~.~,~.. licant ..~.~..~.~, ,~,,,,~,z .~,,~.,~..~,.,~.,/~..o.
.................... App ..... .. , ............
Health Dept. Approval{~ ....................... Labor Dept, Approval ........................
Underwriters Approval.. ~ .'.~..~. 0 .(.~. ........ Plarming Board'Approval ... ~/ ..............
Request for Temporary Certificai? .................... Final Certificate .......................
Fee Submitted $... ,~. [~., .0~,,.. Z, ...............
Construction on above described building and pe~,fri~ meets ,all app_licable.eodes and ragu lations..
~ a3mO~ Applicant...~ ~ .... ' .... ~ ~~~ ........
THE NEW YORK BOARD OF FIRE UNDERWRITERS
1~3~/~ BUREAU OF ELECTRICITY
85 ,JOHN STREET, NEW YORK, NEW YORK 1OO3,6
~ ~.~ch 26F 19~ ~359/~
THI~ CEETIFIES THAT
only the electrical equipment as described belo~ a~d introduc~ by the applicont named on the abobe application number in the premises of
J~ ~robn~ ~5 Fo~m&~r~ P~h~ ~ut~ld~ N.Y.
in the following locatlon; ~ Basement ~ 1st FL ~ 2nd FL Section Block Lot
was examined on and found to be in compliance with the r~qulrements of this Board.
FIXTURE
OUTLETS SWITCHES
4 5
ORYERS
FIXTURES RANGES 300KING DECKS OVENS DISH WASHERS EXHAUST FANS
4
MULTI-OUTLET
SYSTEMS
NO, OF FEET
)THER APPARATUS:
pERCC~COND'
OF CC COND.
NO OF HI-LEG
A. W. G NO OF NEUTRALSr A W.G.
OF HI4EG ] OF HEUTRAL
Charles M. Hall Elect.
760 Long Creek Drive
~outhold, N.Y. 11971
Lic#657
DEPARTMENT. THIS COPYOF CERTIFI(
FIELD INS-F EC T~ON DATE COMMENTS
FOUNDATION ( 1 st)
FOUNDATION ( 2nd) _
FLUMBING f
INSULATION FERN. Y.
STATE ENERGY
FINAL
ADDITIONAL COMMENTS:
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
REMARKS.'
0
0
¢-
FORM NO.
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N.Y, 11971
TEL.: 765-1803
....... ,.:.? ..........
Approv ......... it No.. ~ ......
Disapproved a/c .........
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
Date. J,/.3. ............ 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 streets
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 promises 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 a licant a rees to comply with all applicable laws, ordinances,~ou_~ing co~e, and regulatbuildin~ e, hou.sjng cos[e, and regulations, and to
PaPuthorize~ inspectors on premises and in building for necessa~ins~ ~7'-'-ff-~--~6~
admit
~/~ '~ (Sfgnature of applicant, or n~me, if a c~o~p;;a'tio'~)~/~ ~ff' ....
4Zo..,ff...-Fo..~.~.¥~.~,./~.~2 ~ .S.o. ~/, 0 J,l, JO, ch./.t~.?.t.
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
(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. ~q= I [ ~
Plumber's License No...~,. '.O..'7..-,~..~..?. ...........
Other Trade's License No ......................
1. Location of land on which proposed work will be done ..................................................
................. ....
House Number Street Hamlet
County Tax Map No. 1000 Section .. ?..O..~/. ......... Block ....~...- ...... Lot. ~3~.~./ ...........
Subdivision.....~-?..6~..vt: .~.~ .r'.~...~?.~ ~.~..~_.$.. .......Filed Map No .... ~..~..~. ..... Lot..~...O.?..~. J .....
(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 .... ,-.D~L/'T) ~ .....................................................
3. Natur~ of work (check which applicable): New Building .......... Addition ..........~ Alteration ..........
P, epair .............. Removal ... } .......... Demolition .............. Other Work ...............
4. Estimated Cos j. . ,..O.O .................. Fee ..........................
(to be paid on filing this application)
5. If dwelling, number of dwellingmnits.. :. :/ ......... Number of dwelling unit~ yn.?ch ilo.or.. :]. .........
lfgarage, number of cars ..].i ................................................. i ....... ii.
6. If business, commercial ormixed occupancy ..... specify nature and extent ofeach type ofuse, , . ...'7'~...__..!Depth .~,~. .........
7. Dlmens~ons of emsttng structures, ff any Front .d~ ........... Rear . .~.~. ................
Height .... .~. ......... Nm ~ber of Stones .. ! .................. ~ ................. :..._.~ ............
Dimensions of same structure v ith alterations or additions: Front .Zc~-A~... ............ Rear . ¢-~ .-~ .............
Depth . ¢, ~. ................. Height ....~.... j ....... Number of Stories .. ~ ...........
8. Dimensions of entire new const ruction'. Front..'3...~.. ........ ]] 'l~r..Q~.~ ......... Depth .2~..2-.t. ]]. ]]i.. ]
Height . I $.t. ......... Nm 1her of Stories .... .-~.... ] ............... ...............................
/ '*: ' I ~.O ~. pth J,.~.~.~.
9. Size of lot: Front .... O.~.. [ ........... Rear ................. De ..............
10 !)ate of Purchase Name of Former Owner
I 1. Zone Or use district in which pr~mises are situated... ~0.~.$.~. ~.r~.~. l ;a } ................................
12. Does proposed construction vioiate any ~oning law, ordinance or regulation: ..t~ ..........................
13. Will lot be regraded . ~. O.~.~ ~'¢L., ~'d-',~ '~a~- ............ ,~ , Will excess,~,~. ~'*~-a,~-~-~fill be ~emov~4 from~.~, premises: Yes ~
14. Name of Owner of premises .~io.r.*. , ~.t<o. ~*g~ ..... Address ~o~,~.t~td,. N'q ..... Phone No .............
Name of Architect ......... L..'i ............ Address ....... ~ ....... Phone No..'..... ..........
Name of Contractor *-~. ~. r.~ .......... Address o, ........ Phone No. . .2~...
PLOT DIAGRAM '
Locate clearly and distinctly all buildings, whether existing or proposed, and, indicate all set-back dimensions from
property lines. Give street and block number or description according to deed, and show street names and indicate whether
interior or corner lot.
· '~' :', '._-_' '~ -_-__ / -_ ' ' -' i /' ......... ,oeing duly sworn, deposes and says that he is the applicant
~// (Name of individual signing conttact' "' -' "" ' ' ' )'
~ove named. .' ; .
He is the .. ......................................................
F ~Contract~agent, corporate officer, etc.)
of said owner or owners, ~d is duly autho~rform or have perfomed the said work and to m~e and file ~is
application; that all statements cont~ained ~ this application are true to the best of his ~owledge and belief; and that the
work w~l be perfomed in the mm~ndr set forth in the application filed therewith.
Sworn to before me this