HomeMy WebLinkAbout15344-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No. z15176 Date January 7 , 1986
THIS CERTIFIES that the building ...A. q c..e.s.s.o..r .y..s.h..e .d .............................
Location of Property 860 Pvt. Rd. #7 Diedrick Rd. Orient
- - ....................... .......................
County Tax Map No. 1000 Section 18 .Block 3 .Lot 29
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
S~p,t. 26~. 1986 pursuant to wtfich Building Permit No. 15344Z.
dated .. ,S.e.p.t.:. 2.7....198.6. .... , 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 .........
.... AB..ac.q 9 ~.s qr. y..s.h.e..d: ...................................................
The certificate is issued to . .W~L.T.~I~. ~I.q..M~,4O .R.Y..8.!~;~;j~ .................
(ownerfilc~.~c~ t~tat~/'at~tp ~' .........
of the aforesaid building.
Suffolk County Department of Health Approval N /A
UNDERWRITERS CERTIFICATE NO. N/A
PLUMBERS CERTIFICATION DATED: N/A //
Rev. 1/81
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PERJ~IT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N9 ~5344 Z
Permission is hereby granted to: ~) ,
...... ~...~...~~%.~
.~.e..~....q..~.~ ................................................
.... ..m...~....~..~..~.......z.z.~.~.-....7. .......... _ /~
.......
at premises located at ..~..~.0...~,,~.~..-~.....~ ......... .-~-~ ...................................
County Tax Map No. 1000 Section ..... .(;~.~..~ ....... Block ..... ..C~.....~.. ........ Lot No......~....o~. .............
pursuant to application dat~ ..~~...~ ......... , 19.~.~., and approv~ by
the
Building Inspector.
Fee $ ........................
..............................
Rev. 6/30/80
FORM NO. $
TOWN OF SOUTHOLD
Building Department
Town Hall
Southold, N.Y. 11971
765 - 1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
This application must be filled in typewriter OR ink, and submitted m~ 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
natura~ 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 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 survev of p~operty showing all propertv lines, streets, buildings and unusum 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.
Fees:
1, Certificate of occupancy $5.00
2, Certificate of occupancy on pre-existing dwelling
3. Copy of certificate of occupancy $1,00
4.Vacant Land C.O. $5.00
5. Upda%ed C.O. $15.00
$15.00
Date
New C on s t r uc % i on ...... Old or Pre-existing Building ............ Vacant Land .............
Location of Property ~'~O
House No. Street Hamlet
Owner or Owners of Property ................................ ;/~, .........................
County Tax Map No. 1000 Section ,.
Subdivision .............. '~. .................. Filed Map No .... % ...... Lot No... - .....
.
Permit No../..,~..3. ¥.~/?Date of Permit .2 . .Applicant .../~..~..~...7-.?../¢.....~..R~.. ,z.7-./¢ .......
Health Dept. Approval ........................ Labor Dept. Approval ........................
Underwriters Approval ........................ Planning Board Approval ......................
Request for Temporary Certificate ..................... Final Certificate .......................
Fee Submitted $ .............................
Construction on above described building and permit meets all applicable codes and regulations.
Applicant. ~ ...........................
FOUNDATION (1st)
FOUNDATION
2.
ROUGH FRAME &
FLUMBING
(2nd)
INSULATION PER N.
STATE ENERGY
CODE
4.
FINAL
ADDITIONAL COMMENTS:
'FORM NO. 1
TOWN OF SOUTHQLD
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD, N.Y, 11971..
TEL.: 765-1802
Approved · .~. ~J'...90~...~.. ~.~.., 19~.~.. Permit No.I. '~ .~ .Ur.~ .~..
Disapproved a/c .....................................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
.Date
INSTRUCTIONS
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 ahd of buildings on~p~[nises, relationship to adjoining premises or public streets
or areas, and giving a detailed description of layout of,,~c~pe~ust be drawn on the diagram which is part of this appli:
cation.
c. The work covered by this applicati_o~a~fll!ijl~l~'~o.,m~k~'~l'e ih~ce of Building Permit.
d. Upon approval of ti)is applicat~t~~I~l~i~s~.~.~Tl~dalg,Permit to the applicant. Such permit
shall be kept on the premises available
e. Nb building shall be occupied or. ~,~dgm '~le ~.I~in~.t~h~' purpose whatever until a Certificate of Occupanc~
shall have been granted by the Building I~s~t~d~. ~ ~,~'~
APPLICATION IS HEREBY MADE t~"~3 .~¢~_~~.~r the issuance of a Building Permit pursuant to tb~
Building Zone Ordinance of the Town of ~b%t'hol~.~f~Ou'nty, New York, and other applicable Laws, Ordinances
Regulations, for the construction of buildin~d~h'~o~ alterations, or for removal or demolition, as herein describec~.
The applicant agrees to comply with all apl~ble-Iaws, ordinances, building code, housing code, and regulations, and to
admit authorized inspectors on premises and in building for necessary inspections.
'...
(Signature of applicant, or name, if a cor~TCVtation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises . ~./¢.~'./77~..~.....,~z~. "~'/¢.4 D../ff..~/. . .~./d7./.7'.~. ............... ~ ............
(as on the tax roll or latest ~e~O'¢~
If applicant is a corporation, signature of duty authorized officer, g t. rE:
.............................................. Fc~ ....... ~h.:
(Name and title of corporate officer) , ~, q~:~
~uilder's License No .......................... i ;~;,, ~
Plumber's License No ......................... ~:(;~
Electrician's License No ....................... 3 Ii'4S*
Othdr Trade's License No ...................... ~;t
MEET
1. Location of land on which proposed work will be done ............ ~¢~~I~N.h.E~E~GY ....
House Number Street hamlet
County Tax Map No. 1000 Section .... //. ............ Block ~ Lot .... .~. .............
Subdivision.. · -- ........ Filed Map No ..... 'Z ......... Lot .... -7 ..........
(Nan)e)
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ...... ~.~'-r/23 ~:/oc ...................... ~ .................. ¢,5r~(~'x,:} '~,~ V~'~'* ' .............
b. lntended use and occupancy ....... "7-00/- .~'/¢~...p, ~'c:¢'~'*¢1v"*'~:!, ~ ~;',~" ~
3. Nature of work (check which aOplicable): New Building .......... Addition .......... Alteration ...~ · .'..'. ·
Repair .... "' '2 ........ Rembval .............. Demolition .............. Other Work ...............
4. Estimated Cost ....... ~. c~ ! ' . · · .....Fee ....................................
,' ~ '"~ ' (to be paid on filing this application)
5. ill dwelling, number of dwellin~ units ...... ~ ....... Number o'f dwelling units on each floor....'T ........ '. ·.
Ifgarag number of ca i "--
6. If business, commercial or mixqd occupancy, specify nature and ext~n[ of each type of use ..... .-:7. ............
7. Dimensions of existing structurbs, ifany: Front. ~/../ ....... Rear ...~... ~f. .... Depth .~/./....
Height ............... Number of Storms ..............................................
Dimensions of same structure With alterations or additions: Front ................. Rear ................
Depth ................... ]... Height .......... . ............ Number of Stories .......... ;. .........
· / .....' ..... Rear...g .......... Depth f.~. .........
8. Dimensions of entire new cons[ruction: Front . g.
Height ....Z ~./. ....... Number of Stories ...... ",~.. · ............................................
9. Size oflot: Front ................. Rear 3.0. ............. De ~ ...............
10. Date of Purchase ..,f)f/..~.i./~'.P.3 ............. Name of Former Owner .~,/PZp../-4.~t) .~.tab... ......... .....
t 1. Zone or use district in which premises are situated... ' ./~-.~ ...........................................
12. Does proposed construction vi61ate any zoning law, ordinance or ~egulation: ..../~..O. ......................
13. Will lot be regraded ....... ~ ................ : Will excess.fill be removed from premises: Yes Qo~
Name of Architect .... i ................. AddreSs ... D g~ ~.,'~. ~ ..... Phone No ....... ~ ....
Name of Contractor Address : Phone No
t5. Is this property locatediwithin 300 feet of a tidal wetland? ~Yes ..... No .
· If yes, Southold Town TrCstees Permit maybe required.
.. i PLO~T~,DIAG RAM
Locate clearly and distinctly all buildings,
)roperty lines. Give street and blocl~ number or
nterior or corner lot. ~.~ ~ .
roposed, and. indiCate all set-back dimensions from
ce,d,, and show street names and indicate whether
'4TATE OF NEW YORK, S S
:OUNTY OF~ ..... '
........... ~,L?~.4_..7?~ ~ .... Z--!.... :-~..Ol ,'/-Z./:. ........ being duly sworn, deposes and says that he is the applicant
(Name of individual signing contract)
.bore named·
te is the ..............................................................................
(Contractor, agent, corporate officer, etc.)
~f said owner or owners, and is duly authorized to perform or have perfonned the said work and to make and file this
q)plication; that all statements contained in this application are true to the best of his knowledge and belief; and tha~ the
~ork will be performed in the manner set forth in the application filed therewith.
;worn to before me this
....... (~..~...-AT~. ...... day o,f ~ .... 19 .~...
qotal~ Public, . ............. r/.~County
'
UNDA& COC)PllR , * ..............
Notary Pub,o, $~te of NewYod~,..,/ (Signature of applicant)
! No. 4822663, Suffolk County
~Term F. xplres December 31,