HomeMy WebLinkAbout506-zFOI~M NO. 4
TOWN OF SOUTHOLD
BUILDING DEPART/vlENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
CERTIFICATE OF OCCUPANCY
No....Ta..:~.~. .......... Date .......................... .A.I~.~..t...Z.....~.0.. ............. , 19..5.~...
THIS CERTIFIES that the building located at....C~.t,.t,8ll...~[~,/le ...................................... Stree~t
Map No..~)7.g.~ ..... Block No ........... .~...~... ....... Lot No...~..-...~..O...~...t~..°...2*.~..~.....J.J.t.Lr..?. .....................
conforms substantially to the Application for Building Permit heretofore filed in this office dated
...................... .~..o_?.e.~.lg..e..~......,~. .......... 19_5-%.., pursuant to which Bui.lding Permit No. ,.~.....~.0..~. ...............
dated ...................... .~..o~.p..~..b..e..~.....~ .......... , 19..~..c)...., was issued, and conforms to all of the requirements
of the applicable provisions of the ~ow. The occupancy for wJ~ich this certificate is issued is ..............
............. ............................................................................................
This certificate is issued to ........ ~TI~LO..~.~i~.~]:VJ-~JJ~ ...... .Q~JJ~*. ...........................................................
(owner, lessee or tenant)
of the aforesaid building.
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUT,OU~, N. 'r.
Examined ......... ~.~..~........~ ....... ~9..~i~'~
Approved ........................................ 19 ........ Permit No ...............................
Disapproved o lc(: '~: ~ ~
............... ....................................
(Buildinfl Inspe~for)
Application No ..........~'...~....~. ...........
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and suJ)mitted 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. Upon approval 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 Certificat, e 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 Sou'thold, 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 ap~ ca~t)
Stale whe~h.er applicant is owne~lessee,, agent, ~rchitect, engineer, general contractor, electrician, plumber or builder.
................................................. ........................................................................................................
o, o, -- - " .......................................................................
If opplicont is ~ corporote, sionoture of dulg ~uthorixed o{ficor.
1. Location of land on which proposed work wii[ be done. Mop No: ...................... ~?~.'.~.'. ..... Lot No:
Street and Number ~"--~ ~>
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
se an oocu ~ .... ~ ~-'
o. Existing u d p y ...................... ~ ......................................................................................................
,.,e.ded .n. ..................... ..........................................................................
3. Nature of work (check which applica'ble): New Building .................... Addition .................... Alteration ....................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ....................
4. Estimated Cost ~. ~ 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 .................... ~........C~-...c:.~ ....................................................................................
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 ....... ,f..>,~-,c..:...~....q.:,Rear ....... ..... Depth ............................
Height ............................ Number of Stories ..~ .......
9. Size of lot: Front .../.../..'.'~:. .............. Rear ........ ./.....~...~. ......... Depth ...../....~...~..';...~./.../.~-~
10. Date of Purchase .............. ./...~......~/.....~.. ....................... Name of Former Owner ........................................................
]]. 7one or use district in which premises are situated ......................... : ...................................................................
12. Does proposed construction violate an,/ zoning law, ordinance or regulation? } .......... /.~.~... .................................
13. Name of Owner of premises~...!~...~..~..k..Address .,~.../...u'..rY.:,. ........... Phone NO
Name of Architect.....J~..'...~'.~ ............. Address .~.~..: ........ Phone NO .....................
Name of Contractor.~.~..~,,m'~.......~.....~..~.. ......... Address .....~..c~....6. ................ Phone NO .....................
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 descripti.
wi' ~ther interior or corner lot.
~n according to deed, and show street names and indicate
STATE OF NE~, Y(~R/K,~/~/ ) S S
COUNTY OF ..~..~...~..} '
................ ..~....~..~.~... ~...~.C. ...................................... being duly sworn, deposes and says that he is the applicant
(Name of individual signing~p~t~
above named. He is the ....................... ~.~.~ ...............................................................................................
(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 ali statements contained in this application are true to the best of his knowledge and belief;
and that the work will be performed in the m~er ~ts~or~h in the application filed therewit~
Sworn to before me this '~.PUbhc st~OWDEN~ /~ ~z ~ ~ ~
~ ,, of ...... ~.~,~~d,~.~5;[];. y (S gnature of app cnt)
..................... . .......................... ,,,.. ", ,, :
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined .......... .~.i~' .~. ~ .. '~.J.....~. ...... 19..:~..
,,
Approved ........................................ 19 ........ Permit No ...............................
Disapproved a/c ..............
Application No ........:.....' ...............
(Building I nsp~lor)
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
o. This application must be completely fi~Jed Jn by typewriter or in bk and su~omitted in duplicate to the Building
Inspector.
b. Plot plan showing location of tot 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 ma~ not be commenced before issuance of Building Permit.
d. Upon approval 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 Buildbg Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuanoe 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.
($igDature of applicant, or name, if a corporation)
.....
State whether applicant is owne, r,~lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
...................... .~ ~, .~...'~., ...~ .~...%' ;~ ~. h.... ;. ?. .......................................................
Name of owner of premlses....x,¢
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: '~'~'<'~'2"Y~L~"z">~"'>'~L Lot No
. ~ ~ .. -. 5~ ,
Street and Number "'~ ~ '~ / ~>~"'~ ~.,.,~.~.;,
Municipality
2. Slote existing use ond occupancy of p~emises ond intended use and occupancy of proposed construction:
a. existin~ uso OhO occuponcy ................... ~......(,~:; ............. :: ..................................................................................
b. Intendod ..................... ..........................................................................
property lines. Give street and block numbers or descripti,
wi' ~ther interior or corner lot.
3. Nature of work (check which applicable): New Building .................... Addition .................... Alteration ....................
Repair .................... Removal .................... Demolition ................... .~ther Work (Describe) ....................
4. Estimated Cost.../..~....(~?.'.k.?..~,~--~.. .................................. Fee ..Z...O...~ .........................................................................
(to be paid on filing this application)
5. If dwelling, number of dwelling umts ............ ~ ............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 ....... ~..~/,,:..~..~1." ARear ....... ?.~.~..6- ' ........ ' Depth ...... Z~ ................. ~/ ( ~
Height ............................ Number of Stories ..~,~ ......
9. Size of lot: Front ....Z..Z.~ .............. Rear ........ J..~..~ ......... Depth /"/~/, ~//~
t0. Date of Purchase .............. ~ ....... ~...~ ........................ Name of Former Owner ........................................................
11. Zono or use district in which premises ore situated ........ ~J.[ .... ~.: ..................................................................
12. Does proposed construction viol~te ony zonino Iow, ordinonce or regulation? ........... ~ ................................
13. Name of Owner of premises.~.~:~,,..q~.~..~.,~...Address ............ Phone NO .....................
Name of Architect...~.c..L~':L~.~.~:~ ............. Address ..~.a,'~m~T..[ ........ Phone NO
Name of Contractor.:.~>~ ...... ~..¢,,~,,,,,d~...Address ...... ~:x~./~,..,/~: ................ Phone NO .....................
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from
)n according to deed, and show street names ant indicate
STATE OF NE'v'~/-,YOzP~,/~.~ ) S S
COUNTY OF ....ij~ff.~.~,.-~.~.:?:.....~,..) ·
................. L.%a,.:..;:: ....... ,~..~.,,':%..: ....................................... g duly sworn, deposes ,and says that he is the applicant
(Name of individual signing~.~~gpplica~~~
above named. He is the ....................... ~...,,~.m,,....-;.,,,a~ ..................................................................................................
(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 m.ann[/0~t forth in the application file~ thezewit~
Sworn to before me this ~o~ ,,b/;~,"o,~ow,,~ -~ ,,__ ~ ~" ,~ ~ ~ ~
~ ~ ~'~. ~ ~ ~esidi~at~f NeW w~/ '~' ~ ~"~ ~"~ '
............... ~ ...... day of ........ &. ................ ~.~ ~.h~.~L~,ry JS,gnotyre of o~l~t)//