HomeMy WebLinkAboutZ-30100FORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Office of the Building Inspector
Town Hall
Southold, N.Y.
PRE EXISTING
CERTIFICATE OF OCCUPANCY
No: Z- 30100 Date: 03/19/04
THIS CERTIFIES that the building DWELLING
Location of Property 1075 SMITH DR N SOUTHOLD
(HOUSE NO.) (STREET) (HAMLET)
County Tax Map No. 473889 Section 076 Block 0002 Lot 001
Subdivision Filed Map No. __ Lot No. __
conforms substantially to the Requirements for a ONE FAMILY DWELLING
built prior to APRIL 9, 1957 pursuant to which CERTIFICATE OF
~C~JPANCYlqHMBER Z- 30100 dated 9L~RCH 19, 2004
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 ONE FAMILY DWELLING WITH GARAGE UNDER *
· ~ne certificate is issued to LEONARD D & BERYL E DANK
(OWNER)
of the aforesaid building.
SUFFOLK CO~fI~fDEPART~K~T OF H]~ALT~APPROVAL
ELEC~i~ICAL CERTIFICATE NO.
PLUMBERS CERTIFICATION DA'r~u
*PLEASE SEE ATTACHED INSPECTION REPORT.
N/A
N/A
r /~th~ized ~ignature
Rev. 1/81
BUILDING DEPARTMENT
TOWN OF SOUTNOLD
HOUSING CODE INSPECTION REPORT
LOCATION: 1075 SMITH DR N SOUTHOLD
SIIBDIIKISION: ~ NO.: LOT (S)
~ OF (~ (S): LEONARD D & BERYL E DANK
OCCUPANCY: SINGLE FAMILY DWELLING
ADMl'l-ritUBY: GWENDOIJ~NGROOECOCK
K~Y AIL~LA~I~: SIIFF. CO. T~J~ P-~P NO.: 76.-2-1
SOURCE OF I~UF~: BERYL E. DANK 2/9/04
LEONARD D & BERYL E DANK
~: 03/19/04
PORCH TY~E:
ACCESSORY STRUCTURES:
VIOLATIONS: CWAPTER 45 N.Y. STATE UNIFORM FIRE PREVENTION & BUILDING CODE
LOCATION DESCRIPTION ART. SEC.
P~: BP #5783Z-COZ-6273 (ADD}
Da~ o~ ~ms~cr~o~: o2/z3/o4 reinspected 3/18/04
Form No. 6
TOWN oF SOUrHOLD
~ e~ ,,, BUILDING DEPARTMENT
TOWN HALL
765-1802
APPLICATION FOR CERTIFICATE OF OCCUPANCY
This application must be filled in by typewriter or ink and submitted to the Building Department with the following:
AD
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.
Bo
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.
Co
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- $25.00
4. Updated Certificate of Occupancy - $50.00
5. Temporary Certificate of Occupancy - Residential $15.00, Commercial $15.00
Date. February 2, 2004
New Construction: Old or Pre-existing Building: X
LocationofProperty: 1075 Sm±th Dr±ye North
House No. Street
Owner or Owners of Property: Leonard D. Dank and Beryl E. Dank
Suffolk County Tax Map No 1000, Section 076.00
Subdivision
Permit No.
Health Dept. Approval:
Planning Board Approval:
Request for: Temporary Certificate
Fee Submitted: $ 100.00
Date of Permit.
Block 02.00
Filed Map.
Applicant:
Underwriters Approval:
(check one)
Southold
Hamlet
Lot 001.000
Lot:
Final Certificate:
X ~- (check one)
~Apt~icant Signature
BeS:yl E. Dank
CONSENT TO INSPECTION
Beryl E. Dank , the undersigned, do(es) hereby state:
Ownex~'s) Name(s)
one of
That the undersigned (is)far-,) the owner(s) of the premises in the Town of
Southold, located at 1075 Smith Drive North, Southold, New York ,
which is shown and designated on the Suffolk County Tax Map as District 1000,
Section 076.00 , Block 02.00., Lot 001.000
That the undersigned (has) ~avc) filed, or cause to be filed, an application in the
Southold Town Building Inspector's Office for the following:
Certificate of Occupancy on pre-existing building
That the undersigned do(es) hereby give consent to the Building Inspectors of the
Town of Southold to enter upon the above described property, including any and all
buildings located thereon, to conduct such inspections as they may deem necessary with
respect to the aforesaid application, including inspections to determine that said premises
comply with all of the laws, ordinances, roles and regulations of the Town of Southold.
The undersigned, in consenting to such inspections, do(es) so with the knowledge
and understanding that any information obtained in the conduct of such inspections may
be used in subsequent prosecutions for violations of the laws, ordinances, roles or
regulations of the Town of Southold.
Dated:
February 2, 2004
ff (Signature)
Beryl E. Dank
(Print Name)
(Signature)
(Print Name)
2.1
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