HomeMy WebLinkAbout14042-zFORM NO. 4
TOWN OF 5OUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
Certificate Of Occupancy
No....Z.l.q 55.h ........ Date ......... 4.u.n.e...2.4 ................ 19.8.6.
THIS CERTIFIES that the building ...... d..e .c.k.. a. 0 .d.(L. ~. 9 .n ...........................
Location of Property .... ~35 ............ 2.e.B .n.e.c.q ~..~..D.r.: ............. .S.qu. ~..h.o.~.d. ......
House No. Street Hamlet
County Tax Map No. 1000 Section ...~.5 ....... Block ..... 3. ......... Lot .... 1. 0. ...........
Subdivision ........... ~ ................... Filed Map No .... X. ....Lot No ...... ~. .......
conforms substantially to the Application for Building Permit heretofore fried in titis office dated
·.. 4 ~. 1 ~ ........... 19 ~5. pursuant to which Building Permit No ..... .1 ,~.q ~..2.Z ..........
dated .......... O.u.r~..1 ~ .......... 19 ~5., 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 .........
.De c~..add~.tJ, on .................................................................
The certificate is issued to ............... F. BMq* .~. ~.~.I~¥ .~.A..P..L.E.~.~.C..H .................
(owner, ~e~
of the aforesaid building.
Suffolk County Department of Health Approval ................ i~ ./g .......................
UNDERWRITERS CERTIFICATE NO ........................ ~t/. ~ .......................
Building Inspector
Rev. 1/81
1~'O~ NO, lB
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN HALL
SOUTHOLD, N. Y,
BUILDING PERMIT
(THIS PEP. MIT MUST BE KEPT ON THE PREMISES UNTIL FULL
cOMPLETION OF THE WORK AUTHORIZED)
N~ 1404~ Z
Dote ................. ~ ............................. , 19...
Permission is hereby granted to: _
.............. ~e,?.~.~..o.~6...~.:~ ...............................
,o ............ .b~.d.~ ......... ~,~. ........ ~_~?~.~ ............................................................................
premise* located at ............................................. ~ ........... v .............................................................
County Tax Mop No. I000 Section ~1~ Block "~ Lot No. /C)
pursuant to application dated ........................................................ , 19......~..,~and approved by the
Building Inspector.
,5'0,00
Fee $ ........................
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 application must be filled in typewriter OR ink, and submitted I~ to the Building Inspec-
tor with the following; for new buildings or new use:
I. 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 pZOperty 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 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 $15.0 0
3. Copy of certificate of occupancy $1.00
4 .Vacant,Land C.O. $5.00
5.Updated C.O. $15.00 Date .......................
New'Building ............. Old or Pre-existing Building ............ Vacant Land .............
Location of Property ......... "~ .~...C~.-'/~.
House No. Street Ham/et
Owner or Owners of Property ............................................................
County Tax Map No. 1000 Section ............... Block ............... Lot ................
Subdivision ................................. Filed Map No ........... Lot No ..............
Permit No ........... Date of Permit .......... Applicant ..................................
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 p~er~it meets all applicabl, e codes and regulations.
~, ~,~c_~ q~c~ Applicant ............................
l
765,,1~02
BUILDING DEPT.
INSPECTION
FOUNDATION 1ST [ ] ROUGH PLBG.
[] FOUNDATION 2ND [] INSU/L&TION
[]FRAMING [~] FINAL
REMARKS: ...........
/
F1ELD INS[~ECTION COMMENTS
FOU__NDLTI~N I~stl
FOUNDATION
(2nd)
ROUGH FRAME &
PLUMBING
INSULATION PER N. Y.
STATE ENERGY
C~ODE
~INAL
ADDITIONAL COMMENTS:
7GS,.'~ 802
BUILDING DEPT.
INSPECTION
FOUNDATION ~.ST [ ] ROUGH PLBG.
FOUNDATION 2ND~ INSULATION
FRAMING [ ] FINAL
REMARKS:
INSPECTOR
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGH PLBG.
FOUNDATION 2ND [ ] INSULATION
[ ] FRAMING
REMARKS:
~FINAL
INSPECTOR
~FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
$OUTHOLD, N.Y. 11971
TEL.: 765-1803
Examined ..... .~/.ff.~?' ...... 19. ~j~-. .
Approved ....... ~//.~:.., 19 ?../'~errnit No. /· .~. .~.~. · .~. .''
Received ........... , 1 9.0~..~
Disapproved a/c .....................................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date .................. , 19...
INSTRUCTIONS
a. Tins 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 taws, 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 corporation)
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
0~0~- .........................................................................
Name of owner of premises .... .~..~..t~/. ?.~. .... ?..~... ~. ~
(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. 'Y'd-'/"J~'
Plumber's License No .........................
Electrician's License No .......................
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 . .~.4'.~'..~.~..~../?. .... Block .................. Lot ...... C.~.. .......
Subdivision ..................................... Filed Map No ............... Lot ...............
(Name)
2. State existing use and occupancy of premises and intended }~se and occupancy of proposed construction: .
a Existing use and occupancy
b. Intended use and occupancy
3. Nature of work (check which applicable): New Building ..... ' ..... Addition .......... Alteration ..........
Repair .............. Removal .............. Demolition ......... Other Work ...............
(Description)
4. Estimated Cost ..... (g~(,7~,,, .o..O. ....................... 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 .... ' ....................................................................
6. If business, commercial or mixed occupancy, specif:~ nature and extent of each type of use .. ....................
Height ............... Number of Stories ..................................... .... ' ...........
Dimensions of same structure With alterations or additions: Front ................. Rear ..................
Depth ! Height Number of Stories
8. Dimensions of entire new cons~ruction: Front Rear ... Depth
Height ....... . ........ Number of Stories ........................................................
9 Size of lot: Front i Rear Depth
10 Date of Purchase ' Name of Former Owner
11. Zone or use district in which premises are situated .....................................................
12. Does proposed construction viglate any zoning law, ordinance or regulation: ................................
13. Will lot be regraded .................... , ....... Will excess ill[be removed from premises: B.~.¥es_ $ No
Name of Architect ........................... Address ................... Phone No ................
Name of Contractor Address Phone No
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and. indicate all set-back dimensions from
property lines. Give street and bloci: number or description according to deed, and show street names and indicate whether
interior or corner lot.
STATE OF NEW YORK, · ~. o o
COU.NTY OF... ,$.k-L ~..~.. 0 ! .[7..,
...?.l..[.~..C,M,5 .C~ ..... I~..17..~..t.~. ['~ ................ being duly sworn, deposes and says that he is the applicant
(Name of mdlvLdual slggmg contract)
above named.
-~e is the .......... ~.kk~.~..~..... . .................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is drily authorized to perform or have performed the said work and to make and file this
application; that all statements con[dined in this application are true to the best of his knowledge and belief; and that the
work will b~ performed in the mann?r set forth in the application filed therewith.
Sworn to before me this
...................... day ......
Notary Public, ;.
L{ND~, F: KOWALSK!
NOTARY PUBLIC, State of New Yore
No. 5:2-4524771 ...........................
Qualified in Suffolk County j (Signature'of applicant)
,~0111missi0n Ex~iras MarcB 30