HomeMy WebLinkAbout418-zFORM NO. 4
TOWN OF SOUTHOLD
BUH. DING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, iq. Y.
CERTIFICATE OF OCCUPANCY
THIS CERTIFIES that the building located
ap ~o ......................... Block No ......................... bot.l~o .....................................................................
conforms substantially to the Application for Buildin~ Permit heretofore filed in this office dated
................................. ~g~...~., 19..~., pursuan{} to which Building Permit No.....~..~ ............
dated ...................... ~...~ .......... , 19..~.,., war, issued, and coHforms to all of the requirements
of the applicable provisions of the law. The occupancy for which th~s certificate is issued is ..............
· ~ ~.m~ ~ ~ ~ ...~.~..~.~...~. ............................................................
(ow~eh ~essee o~ testat)
of the aforesaid building.
HOWAI~D M, ~Jl~Y ~'~'
FOP~M NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD', N. Y.
Approved ...... ~. :..'..~.. ...... ~ ....... 19..~.Perm.t No ............................
Disapproved a/c ....'~...?~.~....~..~.....~.'T....~.........C~..~.....C~T....Z.'~z~... ...............
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
iNSTRUCTIONS
o. 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 tot and of buildings on premises, relationship to .adioining premises or public streets
or areas, and giving a detailed description of Iayout 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. Upon opprovai of this application, the Building Inspector will issue a Building Permit to the applicant. Such
permit 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 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 o Building Permit pursuant to the
Building Zone Ordinance of the 'Fown of Sou'thold, 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 applleable lows, ordinances and regulations.
....... .............................
(Signature of applicant, or name, if a corporation)
...... .................................
~ (Address of applicant) ~
State wheth,er applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises ............ ~-~'./~.~.~.... ~k.~'~.~..~f(.. ..............................................................................
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. Mop No: ....~...~....~'..~...5....~ .............. Lot No: ....................
Street and Number...~...~~...~.~~.~...~.Y. ............
Municipality' ..................
2. State existing use and occupancy of pr,cruises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ........... · .~'~.~..~ .................................................................................
occupancy ' .~..~/~c~-]~r-~.
b. Intended use and ........ ................................... ~ ......................................................................
3. Nature of work (check which applicable): New Building .................... Addition .................... Alteration ....................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ....................
4. Estimated Cost ...................... .-~..~.~q~.,....~. ................... Fee ..........................................................................................
(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.....~.m.~. ............. Rear ......~.~....~.~...~.~ ....... Depth ............................
Height .......... ~..~. .............Number of Stories ........ /. .................
9. Size of lot: Front ......~...¢~.. .............. Rear ...... ./...~.~ ............. Depth .........................
10. Date of Purchase .................. ../....~/..~.Z ........................ Name of Former Owner ..... ~...~:...~ .............
11. Zone or use district in which pr~gmises are situated ............ 4~....~..~.~... ..........................................
12. Does proposed construction violate an, y zgr]ing law, ordinance or regulation? ...... ~. .......................................
13. Name of Owner of premlses~ ............................. Addres~~...~:.~.~.....~..~.~...Phone N .O~.,.~.'..~..m~.W./.~
Name of Architect~.,,~..'/,~(~F-~-~'.~...~ ................... Addres~...~....~.'.~.~....~.'.~.,...%' ...Phone NO .....................
p - _~
Name of Contracto~,/zz~.~.~ .......... Addres~z~./.~,~,~.~.~,..~,. ..... hone N~.~.~.~.~ ...........
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 numbers or description according to deed, and show street names and indicate
whether interior or corner lot.
ISTATE OF ND**'YQR,K ~' )
COUN'rY OF ~C......) S S.
h
I -/-~'~'-~ ~'~~ be n deposes and says that he is the applicant
~ ............................ ~.....(~T~..} ................................................... g duly sworn,
(Name of individual signing a~).~~__~
above named. He is the ........................... ~~-..Z ........................................................................................
J (Contractor, agent, corporate officer, etc.)
~of said owner ar owners, and is duly authorized fo perform or have performed the said work and to make and fiJe
jthis application; that ali statements contained in this application are true to the best of his knowledge and belief;
and that the work w be performed n the manne~,%~tg~h in the applica~i9n filed therew~
ISworn to befo e me thins ~ .,,,~,, ?~,,eo~,~,, / t~ ~ ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Application No .............................
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 aDplicatlon may not be commenced before issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issue o Building Permit to the applicant. Such
permit 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 purpose whatever until .a Certificafe of Occupancy
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuanc,e of a Building Permit pursuant to the
Building ZQne 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 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.
........................................................ ......................................................................................
Marne of owner of premises .............................................................................................
if applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
Location of land on which proposed work will be done. Mai) No: ..... ...~.....~...~..'~..-7...'~..~ .............. Lot No: ....................
. .....................................
Street and Number ' ~unlcipalit~' ,
State existing use and occupancy of pr, emises and intended use and occupancy of proposed construction:
o. Existing use and occupancy ..............................................................................................
b. Intended use and occupancy .................................................................................
4.
5.
6.
10.
11.
12.
13.
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimension,~
property lines. Give street and block numbers or description according to deed, and show street names and in,
whether interior or corner lot.
Nature of work (check which applicable): New Buffding ...... ./rff............Addition .................... Alteration ....................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ....................
Estimated "~ ,~¢?o~. ~
Cost .............................................................. Fee ..........................................................................................
(to be paid on filing this application)
If dwelling, number of dwelling units ............ ~ ................ Number of dwelling units on each floor .............. ../. ...........
If garage, number of cars .............................................................................................................................................
If business, commercial or mixed occupancy, specify nature and extent of each type of use ..............................
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 ................................
Dimensions of entire new construction: Front..~..~.. ............. Rear ..... .z ................ Depth
Height .......... ./.~ .............. Number of Stories .........../. ................
Size of lot: Front .......~.~.~ .............. Rear ........ ./..~.~'. ............ Depth ............................
Date of Purchase ................. ./...?.....~....~ ....................... Name of Former Owner .~.~......~.....~......~-~-~. .....................
Zone or use district in which premises ore situated ...........................................................
Does proposed construction violate ony~ zoning law, ordinance~ or regulotion? ........ ~.~. ................................... '
Name of Architect...~.¢~..'.~~.~ .............. Address ~.-Y~...~j~,..~..fi*~.~...~..c .~,...Phone NO .....................
PLOT DIAGRAM
from
licate
STATE OF NE,~/~Y(~J~,/] ,~ ) S S
....
..................... ~,~.~....~e....x~... ........ ..q~2......'x~.:..x.....~,~.,.~eing duly sworn, deposes end soys thor he ~s tho opplic~nt
obove nomod. Ho b tho ........................... ~~.%~....~2~~/~~ ..............................................................................
(Contractor, agent, corporate 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 true to the best of his knowledge and belief;
and that the work will be performed in the monne~,,~et ,~h in the application filed therew~ _
Sworn to before me th s ~ '~( ~'~,,,,'C~,~?~'~ ~ . ~ ~ * J~J