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Home My WebLink About13684-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. Certificate Of Occupancy THIS CERTIFIES that the building ........... £.~t 3, ~..c.q 3. ~ ~;c ................. · Location of Property ..... 1 ? 5.51 ............. ~ ~ g~.he e. J~A .............. ~I~.t~ ~ $ g.mq!~... House NO. Street Harnle~ County Tax Map No. ]000 Section .... l.~.q .....Block ........ ~ ...... Lot ....... ~. 3 ........ Subdivision ............ × .................. Fi]ed Map No .... ~ ....Lot No ....... ~ ..... conforms substantially to the Application for Building Permit heretofore filed in this office dated .... 4 ~ r.~a r Ir. 2,3 ..... ,1 9 S 5. pursuant to which Building Penuit No ...... ~ $ 6.8.q ~ ......... dated ...... 3anuarir..E3 .......... 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 ......... The certificate is issued to ....................... J. 0~t~l..~.,. ¢.0~I.I~ Q~ .................... of the aforesaid building. Suffolk County Department of Health Approval ' iq//~ UNDERWRITERS CERTIFICATE NO .................... lq //[ Building Inspector Rev. 1/81 FOB,M NO. fl 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) Date/~ .......~....~.. 19.Z~.~' NO 13684 Z .................. , County Tax Mop No. 1000 Section ..../....4~....<~.. ....... Block .~.~.. ........... Lot No. 4~.~.,~.. ............ pursuant to application dated ......~.......~....~..~ ......................... , l~..~..~ond approved by the Building Inspector. BuJJding Inspector Rev. 6/30/80 TOWN OP $OUTHOLD Building Department Town Hall Southold, N.Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted ~ ~1~ 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, B. 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 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 v/ 2. Certificate of occupancy on pre-existing dwelling $1 5.0 0 3. Copy of certificate of occupancy $1.00 4.Vacant Land C.O. $5.00 Date ..... / ......... New Building ............. Old or Pre-existing Building . ..~.., ..... Vacant Land " . .... ..... Location of PropErty ./. ~.~, ........... : ........ House No, Street Ham/et Owner or Owners of Property...~'~..(~0. ~1.. -z~,~. .................................. County Tax Map No. 1000 Section ............... Block ............... Lot ................ Subdivision ................................. Filed Map No ........... Lot No ............... Permit No./b.~3.%,~-~ Date of Permit .5.App,icant ......... Health Dept. Approval ........................ Labor Dept. Approval ...................... Underwriters Approval ........................ Planning Board Approval ........ Request for Temporary Certificate ..................... Final Certificate . ....... Fee Subm tted $ ......................... Construction on above described building and permit meets all applicable codes and regulations. Rev."~'~'10-10-78 ~'~ 1 ~ /~ppl~cant .~,, ,/,~',,, ,~'~.~,, THE NEW YORK BOARD OF FIRE UNDERWRITERS BUREAU OF EI. ECTRICITY E5 JOHN STREET, NEW YORK, NEW ,YORK t0038 in the follo~ing locatio~; ~ I]~enW~nt ~ Ist Fl. ~ 2nd Fl. ()l)~ Section Bl~k Lot FIXTURE OUTLETS DRYERS SWITCHES FIXTURES RANGES COOKING DECKS OVENS DISH WASHERS EXHAUST FANS FURNACE MOTORS :UTURE APPLIANCE FEEDERS TIME CLOCKS MULTI-OUTLET D~MMERS ' SYSTEMS NO. OF FEET SERVICE DISCONNECT ~THER APPARATUS: S E R V I C A W G ~O OF HI-LEG j A' W. G OF CC, COND OF H~-LEG E AWG. OF NEUTRAL This certificate must not be altered in any manner; return to the office of the Board i~f inc~orrect. COPY.FOR BUILDING DEPARTMENT. THIS COPY OF CERT ! G['NERAL MANAGER may be identified by their credentials. MUST HO~ BE ALTE~RED IN ANY MANNER. 765-180Z BUILDING DEPT, INSPECTION FOUNDATION 1ST FOUNDATION :)ND FRAMING REMARKS: ROUGH PLBG. INSULATION [ '~FINAL DATE SPECTOR FIELD INSPECTION f'OUND~TION (~st) FOUNDATION (2nd) 2. ROUGH FRAME & PLUMBING INSULATION PER N. STATE ENERGY G~DE FINAL COMMENTS ADDITIONAL COMMENTS ~_ c"- ~, J ' FORM NO. 1 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN HALL SOUTHOLD, N.Y. 11971 TEL.: 765-1803 Examined ~ Approve ')/ .......... i., Disapproved a/c ....... ~:-~ ...... ./5.7. ..... ..................... ......... ....... ....... (Building Inspector) APPLICATION FOR BUILDING PERMIT BLDG. DEPT. TOWN OF 80UTHOLD Received ........... ,19... Date .................. 19 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 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 necessary,,~nspections. · .................... ' (Signaff~re of applicanl, or name, if a corporation) (Mailing address of applicant) (Name and title of corporate officer) Builder's License No. /~/./..~.-~.. ............ Plumber's License No ......................... Electrician's License No ....................... State whether applicant is owner, lessee, agent, architect, engSneer, general contractor, electrician, plumber or builder. .................................................. · APPRO¥t~D -_~' flt~i) ........ Name of owner of premises . ~)~.. ~ 0.~..~. ?. · .'f~Q.. · · · · ~ ...... D~.TE; ........ B,P...'.~ ......... ' ...... (as on the tax roll or~p~..st deed) BY: If applicant is a corporation, signature of duly authorized officer. , NOTIFY BUILDING DEPARTMENT AT 765-1802 9 AM TO 4 PM FOR THE FOLLOWING INSPECTIONS: 1. FOUNDATION - TWO REQUIRED ~FOR POURED CONCRETE 2. ROUGH ~ FRAMING & PLUMBING 3. INSULATION 4. FINAL - CONSTRUCTION MUST BE COMPLFTE FOR C. O. ALL CONSTRUCTION SHALL MEET THE REQUIREMENTS OF THE N, Y, Other Trade's ~,]cense No ...................... STATE CONSTRUCTION & ENERGY COD~ES. NOT RESPONSIBLE FOR 1. Location of land on which proposed work will be done. ~. 1.~'.]~..~7. 19N .E.~.~.Q%...." . ................................................. .c,r,. . . .... House Number Street Hamlet County Tax Map No. 1000 Section ...... /..~..~: ....... Block ... ~. J ........... Lot.. ~. ?./..~ ..... 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 occupancy... ~.~J. fi). ,4./]. ..~.' ..................................................... b. Intended use and occupancy ...~.~.]. ~ ~ ~ .~.'....~....~.~..~..~... :.~../ff ............................ 3. Nature of work (check which a~plicable): New Building ..... ' ..... Addition .......... Alteration .......... Repair ................. Removal ........ ..~., .... Demolition_ .............. Other Work ............... 4. EstimatedCos~/r&~'~ ~ ...Fee.~.PJ ............... . . ~ ~' (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, specify nature and extent of each type of use .... . ................. 7. D~ensions of existing structures, if any Front .... Rear .............. Depth ............... Height ............... Number of Stories ........................................................ D~en runs of same structure lth alterations or addmons: Front ................ Rear .................. Depth ................... i' · ' Hei~t ...................... Number of Stoffes ...................... ' .8. Dimensions of entire new construction: Front ............... Rear ............... Depth ............... Height Number of Stories 9. Size of lot: Front .......... i ............ Rear ...................... Depth ...................... 10. Date of Purchase ... .................. Name of Fomer Owner ............................. 11. Zone or use district in wh~ h premmes are situated ..................................................... 12. Does proposed construction vi61ate any zoning law, ordinance or regulation: ................................ 13. Will lot be regraded ......... ~.~ ................. Will excess fill be removed from premises: Yes No 14. N~e of Owner of premises .7~. 3...~.0 ~D.~. Address x~.~t7 ~C.~ .... Phone No ................ Nme of Architect .. ~ ...... ~ .................. Address ................... ~hone No ................ Nme of Contractor ~ ~ ~ Addressd~q~ ~ PLOT DIAG~ · ~ Locate cle~ly ~d dis~ctly ~1 bufld~gs, whether existing or proposed, ~d~indicate ~1 set-back d~ensions from according to deed, ~d show s~reet nines and ~ndicate whether property lines. Give street and block number or description interior or corner lot. STATE OF NEW YORK, !S,S COUI~Y OF ............. .,, .... , ~'Name of ind'~I/duai signing contract) above named. He is the~..~ :~.. -~-~'~ ' ~ . . ~ .... (Contractor, agent, corporate ~fficer, etc.) ....... of said owner or owners, ~d is du~y autho~zed to perform or have perfo~ed the said work and to m~e m file this application; that all statements cont~ned ~ this application are true to the best of his knowledge and belief; m that the work will be perfomed in the m~n~r set forth in the application filed ~herewith. Sworn to before me this ............ ¢.} ~ ..... day o~ ...... ~ ........... 19 Notary Public, . ~ ~] D~--~ Count ........ :~ ..... ..,.,, ....... y H[:I No 4707t~78, ltun Lxp;res {&~rch 30, DCJ5- ~ (Signat I applicant) ,I q . .Lv.D_ .. ;z, tsz(~- j CASE i~0._ ~o~ ' ' SLDR'S JOB NO,_.___~ /