HomeMy WebLinkAbout29599-ZFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No: Z-29660
Date: 07/23/03
THIS CERTIFIES that the building REPAIR
Location of Property: 5595 PEQUASH AVE CUTCHOGUE
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map NO. 473889 Section 110 Block 6 Lot 1
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Buildin~ Permit heretofore
filed in this office dated JULY 23, 2003 pursuant to which
Building Pex~nit No. 29599-Z dated JULY 23, 2003
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 REPAIR ~ REBUILD EXISTING NON-CONFORMING DECKS ON EXISTING ONE FAMILY
DWELLING AS APPLIED FOR.
The certificate is issued to GUSTAVE A CLAUSEN & WF
(OWNER)
of the aforesaid building.
SUFFOLK COUNT~ DEPARTMENT OF HEALTH APPROVAL
ELRt-£KICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DA'r~u3
N/A
N/A
N/A
Rev. 1/81
FORM NO. 3
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)
PERMIT NO. 29599 Z Date JULY 23, 2003
Permission is hereby granted to:
GUSTAVE A & WF CLAUSEN
230 SOUTHAMPTON DR -#322
VENICE FL, 34293
for :
REPAIR AND REBUILDING EXISTING NON-CONFORMING DECKS AS APPLIED FOR
at premises located at 5595 PEQUASH AVE
County Tax Map No. 473889 Section 110 Block
pursuant to application dated JULY 23, 2003
CUTCHOGUE
0006 Lot No. 001
and approved by the
Building Inspector to expire on JANUARY 23~J2~.
Fee $ 150.00
COPY
Rev. 5/8/02
Form No. 6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This applicatiou must be filled in by type~vritcr or ink and submitted to the Buildiug Department with the following:
A. For new building or new use: 1. Final survey of property with accurate locatiou of all buildings, propet~y lines, streets, and unusual natural or
topographic features.
2. Final Approval from Itealth Dept. of water supply and sewerage-disposal (S-9 fora0.
3. Approval of electrical installation from Board of Fire Undawvriters.
4. S~vom statc~ncnt from plumber certifying that tbe solder used in system contains less than 2/10 of 1% lead.
5. Commcrcia[ building, iodustrial building, multiple residences and similar buildings and installations, a certificate
of Code Compliance from architcct or cugineer responsible for the building ...............
6. Submit Planning Board Approval of completed site plan requirements.
B. FOrl. AccurateeXisting buildings (prior t,o April 9,all1957) non-cm~ fm'nfing uses, or buildingSaud dnusualandnatural"pre-exist~n~Y~0p~-apl~land uses:
survey of propert3 showing prope~y lines, streets, building or ;
features.
2. A propm/v compldcd application aml consent to Jnspcd signed by the applicant, if a Ccrtificalc of Occupancy is
den/ed, thc Btfihling Inspector shall state thc reasons Ihcrctbr in wilting lo the applicat~._.
C. Fees 1. Certificate of Occupancy - Ncxv dwelling $25.00, Additions to dwelling $25.00, Alteratious to dxvelling $25.00,
Swimming pool $25.00, Accessory buildiug $25.00, Additions to accessory building $25.00, 13usinesses $50.00.
2. Certificate of Occupancy ou Ih'c-existing Building - $100.00
3. Copy ofCc~ifica~c of()ccupancy- $.25
4. Updated Cerlificate of Occul~ancy - $50.00
5. Temporary Certificate of Occupancy - Residcnlial $15.00, ('onmicrcJa[
Daic.
New (t ustruct~on: Oki or P~ c-existing Builclin~bf~. .... [cncc~ ( nej
House No. Street I~amlcl '
Suffolk County Tax Ivlap No 1000, Section
Subdivision
Permit No. Cg-Q
Block OOO{,o Lot
Filed Map. Lot:
Applicant: ~_,tX'/'~tJ'_~ ~/~' Wd"/:~tV
Health Dept. Approval:
Plmming Board Approval:
Request for: Temporary Certificate
Fee Submitted:tS
Underwriters Approval:
Final Certificate:
(check one)
Applicant Si~ature
765-1~02
BUILDING DEPT.
INSPECTION
[ ~FOUNDATION 1ST [ ] ROUGH PLBG.
[ ] FOUNDATION2ND [ ] INSULATION
[ ] FRAMING [ ] FINAL
[ ] FIREPLACE & CHIMNEY
REMARKS~
DATE
INSPECTOR
765-1802
BUILDING DEPT.
INSPECTION
[ ] FOUNDATION 1ST [ ] ROUGHPLBG.
[ ] FOUNDATION 2ND [ ] INSUL~JLTK)N
[ ] FRAMING [/p~]~INAL
[ ] FIREPLACE & CHIMNEY
DATE
INSPECTOR
TOWN OF SOUTHOLD
BUILDING ~EPARTMENT
TOW~N I'5~ALL
SOUTItOLD, NY 11971
TEL: (631) 765-1802
FAX: (631) 765-9502
www. northfor~c.netd S outhold/
Approved .~q / ~'~ , 20
Disapproved aye
Expiration
BUILDING PERMIT APPLICATION CHECKLIST
Do you have or need the follo~ving, be~tbre applying'?
Board of Health
3 sets of Building Plans
Planning Board approval
Survey
Check
Septic Form
N.Y.S.D.E.C.
Trustees
Contact:
Mail to:
F -gr'fi~flding Ifi~slPect°r
APPLICATION FOR BUILDING PERMIT
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 waterways.
c. The work covered by this application may not be commenced before issuance of Building Pemfit.
d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such a 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 what so ever until the Building Inspector
issues a Certificate of Occupancy.
f. Every building perruit shall expire if the work authorized has not commenced within 12 months after the date of
issuance or has not been completed within 18 months from such date. If no zoning amendments or other regulations affecting the
property have been enacted in the inter/m, the Building Inspector may authorize, in writing, the extension of the pemlit for an
addition six months. Thereafter, a new p~nfi~ shall be required.
APPLICATION IS HEREBY MADE to the Building Department/hr 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 constraction 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 inspecli~~~.), ~-~ '~-~
(Signature of applicant or name, if a corporation)
(it[ailing address ofapp icant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plnmber or builder
(As on the tax roll or latest deed)
If applicant is a corporation, signature of duly authorized officer
(Name and title of corporate officer)
Builders License No.
Plumbers License No.
Electricians License No.
Other Trade's License No.
Location of land on which proposed work will be done:
House Number Street Hamlet
County Tax Map No. 1000 Section tl/o,
Subdivision
Lot
Lot
Block . OG. (70
Filed Map No.
(Name)
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy
b. Intended use and occupancy
3. Nature of work (check which applicable): New Building
Repair Removal Demolition
4. Estimated Cost
._Cro o o ~ Fee
Addition Alteration
Other Work A:2e'~..,~-- c° ,,~ e-'~,;-
D~OX' o,,g ,e,e~'(Descri~pti,on) o/
(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. Dimensions of existing structures, if any: Front ,,2,P-. ~' Rear
Height/4-P,~,~. /o' -*/47'~' Number of Stories
Dimensions of same structure with alterations or additions: Front
Depth r'~ .~,6 Height _q"..'~r-,~ F Number of Storie~~: ~''~'.' '"
8. Dimensions of entire new construction: Front Rear Depth
Height Number of Sto
Size of lot: Front 50 Rear O / i;2-o
10. Date of Purchase ~/7c~ Name of Former Owner
11. Zone or use district in which premises are situated /)! ~r
Depth
12. Does proposed construction violate any zoning law, ordinance or regulation? YES
NO J
13. Will lot be re-graded? YES NO ~"Will excess fill be removed from premises? YES __ NO
14. Names of Owner of premises
Name of Architect
Name of Contractor
Address ~'-~S"5~--q' ~,~/--'lS~f/ Phone No. F?~}75'/ 7q(dv
Address Phone No
Address,a-ot~,K'/o..q~ Phone No. '7 $5a_ ~ fg~'
15 a. Is this property within 100 feet of a tidal wetland or a fresh~vater wetland? *YES NO /
* IF YES, SOUTHOLD TOWN TRUSTEES & D.E.C. PERMITS MAY BE REQUIRED.
b. Is this property within 300 feet ora tidal wetland? * YES NO /
* IF YES, D.E.C. PERMITS MAY BE REQUIRED.
16. Provide survey, to scale, with accurate foundation plan and distances to property lines.
! 7. If elevation at any point on property is at 10 feet or below, must provide topographical data on survey.
STATE OF NEW YORK)
SS:
COUNTY OF ~'cttr~o/~).
G ~'-~ '5 '1/"~- ~ ff ~-'-/~ ~t S ~ A'-') being duly sworn, deposes and says that (s)he is the applicant
(Name of individual si~ing contract) above named,
(Contractor, Agent, Co.orate Officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to make and file this application;
that all statements contained in this application are tree to the best of his kno~vledge and belief; and that the work will be
performed in the manner set forth in the application filed therewith.