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FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
CERTIFICATE OF OCCUPANCY
No Z-20905 Date AUGUST 3, 1992
THIS CERTIFIES that the building ACCESSORY
Location of Property 3015 WEST CREEK AVENUE CUTCHOGUE, N.Y.
House No. Street Hamlet
County Tax Map No. 1000 Section 110 Block 5 Lot 7
Subdivision Filed Map No. Lot No.
conforms substantially to the Application for Building Permit heretofore
filed in this office dated FEBRUARY 24, 1992 pursuant to which
Building Permit No. 20451-Z dated FEBRUARY 26, 1992
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 ACCESSORY SHED IN REAR YARD AS APPLIED FOR.
The certificate is issued to STANLEY DZIADOWICZ
(owner)
of the aforesaid building.
SUFFOLK COUNTY DEPARTMENT OF HEALTH APPROVAL N/A
UNDERWRITERS CERTIFICATE NO. N/A
PLUMBERS CERTIFICATION DATED N/A
n
-eO
1d ng Inspector
Rev. 1/81
FORM NO. f
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)
No 20451 Z Date 19.Y.:).
Permission Is hereby granted
u~.
41 r
.....4-
to r°~~ .......W'~„.° ~ ....?4 fe~7
......................................~v... j
at premises located at ~1~ ....:frT~:.wz
.
County Tax Map No. 1000 Section W Block ....i~~ Lot No 7..............
pursuant to application dated ......rte. ! 19,0~ and approved by the
Building Inspector.
Fee 5.•!••. FYI
qZtc ~ .
ilding r
Rev. 6/30/80
i
Form No. 6
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
A. This application must be filled 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 2/10 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.'
B. For existing buildings (prior to April 9, 1957) non-conforming uses, or buildings and
"pre-existing" land uses:
1. Accurate survey of property showing all property lines, streets, building 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 dwelling $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 Commercial $15.00
Date ..1.7/
.,(.•a/g2i
New Construction ...t:: Old Or Pre-existing Building
Location of Property:.. Q 1............. it f' .r It I~~:. V TCr .(C1~s . /
House No. Street Hamlet
Onwer or Owners of Property....rl.~..°.f.N .1.....FlF.a. ~WL2
County Tax Map No 1000, Section..O.......Block.....-' .........Lot...7
Subdivision ....................................Filed Map............ Lot......................
Permit NoW~~If.'r. Z. q
.....DaAte/Of Permit.~.;~~?:. ,/~}-r~~...W~~(:.~®~?,1~~-
Health Dept. Approval..... fY.4 ................Underwriters Approval ...AA
Planning Board Approval..... IV~
Request for: Temporary Certificate Final
Certicate.6~....
pp 0.
Fee Submitted: a s
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BOARD OF HEALTH
FORM NO. 1 -3 SETS OF PL XNS
a_ a I I';•~" TOWN OF SOUTHOLD -SURVEY .
{ BUILDING DEPARTMENT ,,,,-CHECK
TOWN HALL SEPTIC FORD!
FEB 2 Q 992 SOUTHOLD, N.Y. 11971
TEL.: 765-1802 r:oTIFY;
C/~~~ CALL
Exa inedt. tillirf-'~ 19 MAIL TO:
Approved 19ennit No. 171 , , , , , , , , , , , , , ,
Disapproved a/c
(Buil ing In e or)
APPLICATION FOR BUILDING PERMIT
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 inspections.
(Signature f applicant, or na , if a corporation)
9.(~...till=57 ..G.R.K.y. evrcrroU~
(Mailing address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises !~hG.~....bZ1i4(0(A,) (C2
(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 .
Plumber's License No .
Electrician's License No .
•
Other Trade's License No .
1. Location of land on which proposed work will be done .
3orJ .....................was? ..C fteE.K...~.'~.......~ 4.?Skoc> vE.........................
House Number Street Hamlet
County Tax Map No. 1000 Section fJ ! P Block ...5 Lot. :7
Subdivision Filed Map No. Lot
(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 y Yb.'[ (r ~....5 f 1~ .
3. Nature (check which applicable : New Building . ~R.Addition , , , , . • . , Alteration "
Repair
rature . of work . , . Removal . . . Demolition Other Work , .
Ord a (Description)
4. Estimated Cost .......p, . Fee 4 3J.i
(to be paid on filing this application)
S. If dwelling, number of dwelling II units Number of dwelling units on each floor .
If garage, number of cars .
1.1
erci cture occupancy, specify nature and extent of each type of use
7G. Height Dimensioensio sns of commercig e l or strunes, if any: Front Rear Depth
bof Stories .
Dimensions of same structure with alterations or additions: Front Rear , .
Depth . Height Number of Stories
9. Size of lot: Front , Front ................Rear Depth
8. Dimensions of entire new construction: ber n of Stories Depth .
Height . . . Nu
....Rear...................... Depth
i
101. Date of Purchase . . . . . . . . . . • . Name of Former Owner
1. Zone or use district in which premises are situated . . . . . . . . • ,
12. Does proposed construction violate any zoning law, ordinance or regulation:
13. Will lot be regraded .........I Will excess fill be removed from premises: Yes No
14. Name of Owner of premises Address Phone No.......... .
Name of Architect Address Phone No............... .
Name of Address Phone No............... .
15. If openr Is this property within ithin 00 feet of a tidal wetland? *yes........ No......... '
yes, Southold Town Trustees Permit may be required.
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from
property lines. Give street and block number or description according to deed, and show street names and indicate whether
interior or corner lot.
i
I
STATE OF N YOR,/ $ , S
COUNTY OF.~.'1.p`.~,
S1-ce~ • • • D4 '(4tAOt,,.a t Q_Z being duly sworn, deposes and says that he is the applicant
(Name ofindividual signing contract)
above named. /
He is the 0-W A. .
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is dulylauthorized to perform or have performed the said work and to make and file this
application; that all statements contained in this application are true to the best of his knowledge and belief; and that the
work will be performed in the manner set forth in the application filed therewith.
Sworn to before me this
19
Notary Public, ~p~ County
CLAIRE L. GL
Notary Public, state o .~VII
^
Qualified . 87950f New York
No. Suffal Coun Qq (S nature of applicant)
Commission Expires Deeeinber 8 19~
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