HomeMy WebLinkAbout14693-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y,
Certificate Of Occupancy
No. Z14313 Date March 25
.................................................. 19.86..
THIS CERTIFIES that the building ..... DO ~k ......................................
Location of Property .. .... .2.1. Q..~AqO. 9.N..~.o..~p .............. M.~..T.T.!T..U.C~ ................
Mouse NO. Street Hamlet
County Tax Map No. 1000 Section 1.0.6 ......... Bloc]( .... 1 0 ......... Lot .......... 0P.? ....
Subdivision ............................... Filed Map No ......... Lot No ..............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
·.. H&n c h., .2 ~ ........ 19 8.6 pursuant to which Building Permit No ...... 1.4. ~ 9 ~.Z. .........
dated ....... M a r c ~. · 2 5 ............ 19 8/5., was issued, and conforms to all o f the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is .........
... D.e. qk. a.cld, i .t.i.qn. ~;P..~>; ~-~.L.~og..qr~ .e..l?.a.m..5.1y.. d..w.e.l.l.i, p,~.. ......................
The certificate is issued to ....F~.T~. R. ~IC DONNELL
.......... /o~;.~;,'r/~¥~x × x ..................
of the aforesaid building.
Suffolk County Department of Health Approval ........... ~./.A. .........................
UNDERWRITERS CERTIFICATE NO .................... ~.Z P, ..........................
Rev. 1/81
Building Inspector
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y.
BUILDING PER~IT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
14693 Z
Permission is hereby gronted to:
..... ~?~..~.....~...~.~ .....
.. ........... ~-, ~......~.~.~ ..e...~ ........ ~.~..u....~.~..
.~.~~...;.~:..~.,...!.!..~.~.~. ........... ~
::::::::::::::::::::::::::::::::::::
pursuant to application dated ...~..~.(~)....~...I ...................... , 19.~....~., and approved by the
8u)ldln9 Inspector.
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 OCCUP~
Instructions
This application must be filled in typewriter OR ink, and submitted ~ ~ 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, 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 property showing all property lines, streets, buildings and unusual natural or
topographic featu res.
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. Updated C.O. $15.00
$15.00
New Building ............. Old or Pre-existing Building ............ Vacant Land .............
Location of Property .....................................
Street Harrilet
Owner or Owners of Property ... ~ ......... ~..~...(-v ......................
County Tax Map No. 1000 Section .../.~'.'..0..C/... Block ... /.~.,.~..0, .... Lot .... C,~.(~.~.', ~ .~....
Subdivision ................................. Filed Map No ........... Lot No ..............
Permit No ........... Date of Permit .......... Applicant..)~. '~.~ .... 2,.....~..~h.O'/~./~. ~...~C~
Health Dept. Approval ........................ Labor Dept. Approval ........................
Underwriters Approval ........................ Planning Board Approval ......................
Request for Temporary Certificate ..................... Final Certificate .......................
Fee Submitted $ .............................
1.
FOUNDATION (1st)
COMMENTS
FOUNDATION
(2nd)
· ROUGH FRAME
PLUMBING
INSU'LATION PER N. Y.
STATE ENERGY
~ODE
FINAL
ADDITIONAL COMMENTS:
· FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
8OUTHOLD, N.Y. 11971
TEL.: 765-1802
Approved...~. *,~ ~...., 19~.(¢. Permit No.]. . .~.~.~.~...
Disapproved a/c .....................................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
BLDG. DEPT,
TOWN OF SOUTHOLD
Received ........... ,19...
Date . . ~./~/Z/. ~. .... , 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 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 neces~rd~snections, ex
h :. . f¢. . ..............
(Signature of applicant, or name, if a corporation)
(MailingS, iddress of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises..r~' ~ /~....~.,.../?'./..~..~/wrAJ. LT~ C~ .......................................
/' (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 .... 0-Xq,t'~-,Ot~. .............
Plumber's License No .........................
Electrician's License No .......................
Other Trade's License No ......................
1. Location of land on which proposed work will be done ..................................................
· ................ ·.. £.j.. .......... .......................
House Number Street Hamlet
County Tax Map No. 1000 Section .. /.~. ~'.~/.~ ...... Block ../¢{.(¢1. d ........ Lot...~..0..2t .~..~.~. .....
Subdivision ..................................... Filed Map No ............... Lot ............... (Name)
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancsff)~r~/} .~./.z~ .~... ~.~ .~.{.~,4~. ~' e~...T..0.~. ~/..~t~x .........................
b. Intended use and occupancy .. ~ ~.l.{.'T../'~.0//~{)g7~/~.~/~z ..... ~' ~ .~-G./~ ........................
3. Nature of work (check which applicable): New Building .......... Addition .. i ........ Alteration ...... i.
Repair .............. Removal .............. Demolition ........... :... Other Work..~.. ~.~,~...
~ (Description)
4. Estimated Cost........ ....' ... ..................... . Fee ............................. ...
* (to be paid on filing this application)
5. If dwelling, number of dwelling units ............... Number of dwelling units on each floor ................
If garage, number of cars .................................. ......... 'l ............................
6. If business, commercial or mixed occupancy specify nature a,nd extent of e~h ,type of use ....... .....
7. D~rnensmns of exastmg structures, ffany: Front...~.,~?, ........ Rear .~.~..,3.. ....... Depth . .~.~.7..'.~. ......
Height . . Number of Stories ..... /. ~..2~.. .......t .......... ! ........................
Dimensions of same structure with alterations or additions: Front ,,4./..e~. ....... i... i Rear..~i~.' i ..........
Depth ...... ~] ~.. ........... Height ..... ~ ~ ........... Number ofiStories . . . .q].q-~-. ..............
Dimensions of entire new construction Front ,./~..~ ......... Rear . ./,d ./.. ....... Depth .,l[~../O..z.ff.f~...
Height ... ,3.' .......... Number of Stories .. ,OON~. =.. t,g../k. J:~¢/< ........ ~ .....................
Sizeoflot Front /..~..~:,.t/.,(,( .... Rear ...,/,g.~/.,/..~c~-. ......... ,Depth~..~.7..2:../~.(Lj...~97c].
10. Date of Purch~e.... .... ."~'/?'r/.:/' · · · j ..... ,a,.~ Name of,Former~ Owner ,.~ ...... ~..
11. Zone or use dastnct an whmh premises are s~tuated~z. .t.(.e. ~. l ~d. 7;.~/..-//4,/] .,5'.te. t4{tSz~.,,~ ........................
12. Does proposed construction viqlate any zoning law, ordinance or regulation: .... i.../x~.Q .....................
13. Will lot be regraded ...... .~vQ ..... ~, ............ Will excess fill be removed from premises: Y_es No
14. Name o f Owner of premises 'j~l~,~. ,/~.[LI~¢~! .... Address/?/d.~.0~.//$..~/../:~/~/~one No..~. ~ .~?~..~77...
Name of Architect .: :'~:l 0-': .................. Address .............. : ... Phone No.
Name of Contractor .................. Address ..............
..... Phone No ................ '
Locate clearly and distinctly all buildings,
property lines. Give stre ~ and block number o~
interior or corner lot.,
PLOT DIAGRAM
whether existing or proposed, and. indicate all set-back dimensions from
d,e, scri,'p!ion, ac._co,rdin._g t~ dee_d, a,_nd_ sh_o~f_street names and indicate whether
STATE OF NEWYO/RtK - -
COUNTff._OF..'~:~ 1~ ,-..... :S.S
..... :. ............. being
(Name of individfial signing contract)
above named.
duly sworn, depCses and says that he is the;
He is the ............................................................. i ............................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the ~aid work and to make and file this
application; that al/ statements contained in this application are true to the best ofhi~ knowledge and belief; and that the
work will be performed in the manner set forth in the application filed therewith.
Sworn to before me,his
................... · / .... day of ..... ~..~t?'..c. ...... , 19 .?d~
Notav/Public, Stat, of ,~w¥ork ::' (Signature o;
Qualified Jn Suffolk Count/, §2-462736~ "'
Commission Expires, Ma rch 30,1 ~,,~ :,
,,~" ~ '~' ~d~LD]Nfg; DEPART~t*~ENT AT
' ~ ,~(:~ 9 ~ 'tO 4 PM FO~ THE
3 IN~ULAF~ON
ALL CON~TR~,~CT~C;:,
~EStGN OR CO¢~3THUCT",ON 5~RORS,
6 6~8/v?L