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Home My WebLink About15093-ZFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Office of the Building Inspector Town Hall Southold, N.Y. CERTIFICATE OF OCCUPANCY No Z-22220 Date MARCH 26{ 1993 THIS CERTIFIES that the buildin~ ALTERATION Location of Property 10095 (17) MAIN ROAD MATTITUCK, N.Y. House No. Street Hamlet County Tax Map No. 1000 Section 142 Block 1 Lot 26 Subdivision Filed Map No. Lot No. conforms substantially to the Application for Building Permit heretofore filed in this office dated JUNE 25{ 1986 pursuant to which Building Permit No. 15093-Z dated JUNE 25~ 1986 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 ALTERATION TO STORE #17 FOR VIDEO STORE The certificate is issued to (owner) of the aforesaid building. SU~'~'OLK COUNTY DEPARTMENT OF HEALTH APPROVAL UNDERWRITERS CERTIFICATE NO. PLUMBERS CERTIFICATION DATED ALAN A. CARDINALF. N769784 - SEPTEMBER 18~ 1986 Rev. 1/81 /Ow~t~' NO. ~1 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) N°. 15093 Z Permission is hereby granted to: .~.?....x...3.2 ................................................... ..... ..... L*.......?" ....~... ' .~ at premises located at. ...~. ......... ~ ................. County Tax Map No. 1000 Section ..~/...~.....~. ......... Block ...... .0...,~ .......... Lot No...,~.~ ............. pursuant to application dated ........ ...~..~ ........ ..~.~.. ........... , 19..~..(~., and approved by the Building Inspector. Building Inspector Rev. 6/30/80 Form No. 6 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL 765-1802 · A. APPLICATION FOR CERTIFICATE OF OCCUPANCY ~ This application must be figled in by typewriter OR ink and submitted to the building inspector with the following: for new building 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 from Health Dept. of water supply and sewerage-disposal(S-9 form). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Sworn statement from plumber certifying that the solder used in system contains less than 2½10 of 1% lead. 5. Commercial building, industrial building, multiple residences and similar buildings and installations, a certificate of Code Compliance from architect or engineer responsible for the building. 6. Submit Planning Board Approval of completed site plan requirements. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and Vpre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, buildimg and unusual natural or topographic features. 2. A properly completed application and a consent to.inspect signed by the applicant. If a Certificate of Occupancy is denied, the Building Inspector shall state the reasons therefor in writing to the applicant. C. Fees 1. Certificate of Occupancy - New dw~ll±ng $25.00, Additions to dwelling $25.00, Alterations to dwelling $25.00, Swimming pool $25.00, Accessory building $25.00, Additions to accessory building $25.00. Businesses $50.00. 2. Certificate of Occupancy on Pre-existing Building - $100.00 3. Copy of Certificate of Occupancy - $5.00 over 5 years - $10.00 4. Updated Certificate of Occupancy - $50.00 5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00 Date . ~..d~....~M .~ .~.~. ................... ........... Or Pre-existing ildimg. New Construction Location of Property H.~ou~~.~, ''~~ee~ ~' '~' ~~~~ ...... Onwer or Owners of Property.~..~:..~<~~Z .................................. County Tax Map No 1000, Section.~ ....... Block ....... ~ ........ Lot .... .~. ............. Subdivision .................................... Filed Map ............ Lot ...................... Permit No.f.~.~.~.?...~. .... Date Of permit ................ Applicant..~...~.....~..~~..... Health Dept. Approval .......................... Underwriters Approval .... .'..~.~.-~.~..7~..~ Planning Board Approval ........................ Request for: Temporary Certificate ........... Final Certicate ........... Fee Submitted: $~.~.~-~ ...................... APPLICANT FIELD I~SFECTiON iIDATE !! CO:-;:.iEN'i.~ FOUNDATION ( 1 st) FOUNDATION (2nd) ROUGH FRAME & PLUMBING INSULATION PER N. Y. STATE ENERGY ~TS: CODE FINAL · FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN HALL ~OUTHOLD, N.Y. 11971 TEL.: 765-1802 ~xamined, i ...~..]. ¢..., 19g.~. ~,pproved .t ~..., 19 ~(~. Permit No..].~...-P.? .~..~'.. )isapproved a/c ..................................... (Building Inspector) APPLICATION FOR BUILDING PERMIT INSTRUCTIONS TO ~'~.~ ' Date ................... 19.o.6 a. This application must be completely filled in by typewriter or in ink and submitted to the Building Inspector, with 3 :ts 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 r areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this appli- ition. 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 roll 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 tall 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 uilding Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or egulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described. he applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations, and to tmit authorized inspectors on premises and in building for necessary~~ _ (Signatu~ of ap"ffff~nt, or name, if a corporation) ..... . 7. (Mailing address of applicant) tate whether applicant is ~ lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ,lame of owner of premises . .,¢~ff,~.~... ~.-....~.~..~.~. ~.'.,0( .~. 4. ~.. .......................................... (as on the tax roll or latest deed) f applicant is a corporation, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No .......................... Plumber's License No ......................... Electrician's License No ....................... · ,-,,,~, ,,,~u~ ~ Lice,se No ...................... ~ J 0 Location of land on which proposed work will be done: : .,d~.~.< .,y....~.~eC....~.~..4 .~T,....../~.~..rr/.;:?..cF. ,.' ............................ .~..~.4.~.cr....~..,,.4 ~?.-.' .~.~ ....... ~..~.,~. .r.~.~..-. . . t~..~.~,,O.'.,~. ~. .... '~"~'f'~' StreeO~''tZ/t~/v'rt c,'~,,~ ~, ~ ltouse Number Hamlet County Tax Map No. 1000 Section ... ~'. ~.~-. ......... Block ..... ~. ........... 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 ' ~'a,-~,~eae¢,,o C- b. Intended use and occupancy ~C?'~ ~ 4 ,-C~'~,~e'~r t~,,'~ ~.,' ' - ' ... ~ .....'. .... ....................................... ... ~ ;...,.; .:. ,. -Nature of work (check which applicable): New Building ' Addition .......... Alteration ~ Re~air ~ Removal .............. Demolition .............. Other Work ............... ,~ (Description) Estimated Cost.. ~.,.?.~.o. ............. Fee · (to be paid on filing this application) If dwelling, number of dwelling units ............... Number o£ dwelling units on each floor ................ If garage, number of cars ........................................................................ If business, commercial or mixed occupancy, specify n,atu,re and extent of each type o,,f use .., ..~r.4/.~..' .C..~.~?/-,, Dimensions of existing structures, if any' Front ~/~ ~' ' Rear / a ¢ ' ' ' ..... - - De ......................... pth ..... ~. ........ Height . ~.~.e .... '.."i ~'..'~ :~[i'mber of Stories..../. Dimensionsof same structul-e Mth alterations or additions: Front ................. Rear .................. Depth ................. ~ .... Height ...................... Number of Stories ...................... Dimensions of entir~ flew Construction: Front .......... ..... Rear ............... Depth ............... tteight ............. '.. Number o~. Storiea .... Size of lot: Front q,q .~.,t'. ~ '~)~ ~- ~"¢'l~ehr ................ ;-" ~'.' ....................... ................ ," ........................ L~e tn .................. _Date of Purchase ...4 ~_~.~.,_d4'.Z~. .................. Same~ of Former Owner .-.~.~.~.~q..~..~...' .w~a.~.',,~ty .,:,,,,~,~2 ;'-., Zone or use district in which premises are situated. ,"fi,4. rt., t,~c~r. ' ........... ' Does proposed construction violate any zoning law, ordinance or regulation' ~.. o Will lot be regraded ............................ Will excess fill be removed from premises: Yes Name of Owner of premises . ~'.-&--,.~..q.~..~.'.'e..'y :.. Address ................... Phone No ................ Name of Architect .~..eq4,~¢.. ,~.,?./.,~.e.~. .......... Address '~.o.,,..~.~:?.d'. · .... PhoneNo..7.6~..-.:~.~..~... Name of Contractor ' Address .... : .............. Phone No. Is this property located within 300 feet of a tidal wetland? *Yes ..... No ..t..~... · If yes, Southold Town Trustees Permit maybe required. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and~ indicate all set-back dimensions from .>erty lines. Give street and block number or description according to deed, and show street names and indicate whether rior or comer lot. TE OF NEW YORK, tNTY OF ................. S.S .... .,a~...~..,q..,~.~..,(.,v,..~,~- being duly sworn, deposes and says that he is the applicant (Name of individ ualsidli; ' ;i 't;a' i3.......... e named. -- (Contractor, agent, corporate officer, etc.) fid owner or owners, and is duly authorized to perform or have performed the said work and to make and file this ication; that all statements contained in this application are true to the best of his knowledge and belief; and that the .~ will be performed in the manner set forth in the application filed therewith. rn to before me this .... 4~. ............. day of..'4.~.~..'ff~. .............. 19 ~ '' Q"~~' ('~ ~']~"~4~ County No. (Signature of applicant) j ~d Ao