HomeMy WebLinkAboutBlaschack, Florence (Adult Home)?
BUrLDING INSPECTOR'S OFf:ICE
307 Founk Street
Tel. Gmenpor~ 7-0101 .I
CERTIFICATE. OF OCCUPANCY
THIS CERTIFIES ~lt ~ building located
Map No. , BJodr No,
in tim Town M Seuflmld, cenforms sUbr~eMidly to ~he ....... ' ....,..a ..... -. ......... ,,, , .*.
M tl~ ,~m)~d4 bulMin(j,
~ne I~, end in ~fmmlty w~h ~ ep~m)ved ldens end speeifl~m.)
FOKM NO. I
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Application No .......~'....~.....o. ............
Approved ........................................ 19 ........ Permit No..~...~...~....~..'~/'~/~' ~L/~-~
Disapproved a/c ......~..~......,,D~..:..%.~,,. ....... .,,'~.....~..~..~.,"l ......
(Building, Inspector)
APPLICATION FOR BUILDING PERMIT "" ~(~/~'
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building
Inspector.
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 location.
c. The work covered by this application may not be commenced before issuance of Building Permit.
d. t;~x~n approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such
~oermit shall be kept on the premises available for inspection throughout the progress of the work.
e. No building shall be occupied or used in whole or in part for any pul'pose 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 a Iterations, or for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances and regulations. .
......................................................
(Signature of applicant, or name, if a corporation)
.....
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
................. ~ ..................................................~4,r../~.....~.. (...~ .. ~ ~..t~.~cu.. :: ..............................................
Name of owner of premises ............ ~~ .................... ; ..........................................
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
1. Location of land on which proposed_work will be done. Map No: ............... ~; ................ ~.. Lot No: ~....'. ..............
Street and Number .!~.........~....~...~.....~.' ............ i~~ ....................
l~//* Municipality
State existing use and occupancy of premises and intendqd use and occupancy of proposed cOnstruction:
a. ' ' "' ~,~u'l~' c> ' -- ~:~,- .
Ex,st.ng use and occupancy ............ ~~... ......................... .~..,.~...?,.,~..~Z...=.'C,,~I, ...................
b. Intended use and occupancy ........ ..L~r.....~.....°~..'....~......-~:.... .................. ~.~. ......... ~. ..................
3. Nature of work (check which applicable): New Building .................... Addition .................... Alteration ....................
Repair ......... ~ ....... Removal .................... Demolition .................... Other Work (Describe) ~
4. Estimated Cost'~r.....~.O...O....O.. ......................... ~ ................... Fee ~.....~...0....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 ............................ Rear ............................ Depth ............................
Height ............................ Number of Stories .............................................................................................................
Dimensions of same structure with alterations or additions: Front ................................ Rear ................................
Depth .............................. Height .............................. Number of Stories ................................
8. Dimensions of entire new construction: Front ............................Rear ............................ Depth ............................
Height ............................ Number of Stories ............................
9. Size of lot: Front ....Z.~....~.. ............. Rear ..... ~...1~...7... ......... Depth..~....~'....~./......c~....7..~
10. Date of Purchase ............. ./...?.....~'....~'.... ...................... Name of Former,Owne, r ..~.....~. -~.......~ ..............
11. Zone or use district in which premises are situated ........... ~ ......... ~..'Td ........................................................
12. Does proposed construction viol,~te .a_rxv zoning law, ordinance or regulation? ....~ .......................................
· OJZ Phon O
13. Name of Owner of prem,ses .......... I.~...~.~ .......... Address ....................... ~ ........... e N .....................
Name of Architect ........................................................ Address ............................................ Phone NO .....................
Name of Contractor..~.[~-~'nl~J~R~... ....... Address ...~.....~ ............... Phone NO .....................
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate oil set-back dimensions from
property lines. Give street and block numbers or description according to deed, and show street names and indicate
whether interior or corner lot.
lo-/
STATE OF NEW~--YO_9_~j~C. ) S S
. 1~.....~~~ be ng duly ~orn, deposes and s~s that ~ is the applicant
.............. .i,ning opp, .tion
above named. He is the ........................... ~ .....................................................................................
(Contractor, agent, corporate officer, etc.)
of ~id owner or ownem, and is duly ~uthorized to ~rform or ha~ performed the said work and to ma~ and file
this application; that all statements contained in this[~li~ a~me to the ~st of his ~ledge and belief;
and that the work will be performed in the ~n~u~h~i~ ~,~plication filed ther~ith.
Sworn to) be~ore me~is ~ ~i~i,g i. ~0~0~ ....
L.~ ..... day of ..~....~' '~.~: ~' "~ (Signature of a~isan
Original for Municipal Building Deportment
STATEMENT OF REGISTRY
To be filed in duplicate with the municipal building department or local enforcement agency
by every owner of a multiple dwelling, as defined in subdivision 33 of section 4 of the
Multiple Residence Law.
Within 30 days offer the filing of this statement, the municipal building department or en-
forcement agency is required by section 300, Multiple Residence Law, to file a duplicate
copy hereof with the State Building Code Commission, ]740 Broadway, New York 19, N. Y.
1. Location of multiple dwelling: . ~
(o) Street and number ...~./~....~.~.].~....~...T...' ................................................
(b) Municipality .~.O..[J...~...~..O..~.g .............. ~..:..J.., ....... ..~...'.~.. ..........................
2. Description:
(a) Type of construction ........... gl~.~....~/~..'.~... ........................................................
(b) Height of building, including number of stories ....... ...~......~.....-~'....O.../~,..L.~.'...~. .......
(c) Type of heating facilities ...... .~..,.~../~../~.J~.......'......~.]..~.....~..,~.-~...~.O. .....
(d) Number of apartments ..... i~.'.~.'~ ............... ~i'~ ........... -"'"~
(e) Number of living rooms .............. ~.....~ .................... fl....~'~..'~... .........
(f) Number of kitchenettes ....... /.../.....~..~ .......................................................
(g) Number of bathrooms ....'~:~ ..........................................................................
(h) Number of water closets ........ ~ .................................................................
(i) Number of occup(~ts for which building was designed or intended to be occupied
or used ....... ~ .......................... · .......................................................................
3. Age of
multiple dwelling:
(a) Date when constructed ........ ./..~.....~.~-..0../..4,...~..../...~..,.o....O,. .........................................
(b) Dates of substantial additions, alterations or modifications of dwelling, with
brief description thereof .................................. ,,~ ...............................................
...................................................... ...............................................
(c) If now under construction, state when construction commenced and anticipated
.......
4. Use:
Describe the principal use made, or, in the case of buildings under construction, to
be made, of the multiple dwelling (such as apartment house, hotel, apartment hotel,
lodging house, boarding house, school, convalescent, old age or nursing home, pri-
vate dwelling two or more stories in height with five or more boarders, roomers or
lodgers, or other classification of multiple dwelling including those specified in sec-
tion 33, Multiple Residence Law).
(Name of Owner)
(Address of Owrler)
..., STATEMENT OF FILING.,
Filed with the ~~/~......~...~ ........................... of the
~L' --(Bulldln~ Depe~aent or Other N~forceme~t A~enc~)
/~.....d....~...~. on the ...... ~~.......~... ........... 195.7.,
/(Name of ~Munic~paltty) (Date of
(Signature and Deal~matton ~f Official ~rlth
~hom Statement of Registry was Plleli)
' rNE~i ~ ARD FiRE UNDERWRITERS
[~1 ;!i; /¥C BO
........ BUREAU OF ELECTRIC TY . ;-
..........
SERVICE DISCONNECT
CE:FEEDER$~
UNIT HEATERS MULTI-OUTLET
-- : SYSTEMS
1NO, OF FEET
DIMMERS
...... P 0 BOX '
......... Lic.242E
This cerhf~Eat~ must not be altered'in any manner; r6turn to th~ office of the ~brd if [n~o~rect.;JnspeCfo~s may be identified their credentiaJs.