HomeMy WebLinkAbout221-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
CERTIFICATE OF OCCUPANCY
THIS CERTIFIES that the building located at .~/FM...~I3~B~e.t,~,.....i~. ................... Street
Map No. ~,-~al~..Pe~Lnt,..~.z'l)~lock No ............ XX]C]/X ............ , Lot No.
Cuteho~,ue,
conforms substantially to the Application for Building Permit heretofore filed in this office doted
........................ ~.l~.~.a.?..y...~ .......... 19~...~...., pursuant to which Building Permit No ...... .~....~.~...~. .......... ,
dated ....................... F. 5.b~:~ .?~.....~. ........ 19..~'.~., was issued, and conforms to all of the requirements
of the applicable provisions of the Iow. The occupancy for which this certificate is issued is ............
.............................................. P. ~ ~ ;f.~. ~'.~.. D.~/~ [,~TJ:t~ ............................................................................
This certificate is issued to ..'Z/~lor~t~..~J~.w~a~ ..................................................................................
(owner, fessee or tenant)
of the aforesaid building.
Building Inspector
FOR, M NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES V~I~I.~IJ~,
~~I~I~t'~J~i,q~E~C.i~'~I~D~UNTIL FULL COMPLETION
OF THE WORK AUTHORIZED)
No ..~.~;,~41... · Date .........
Permission is hereby granfed to
Chester gr~L~vsk~... A/a..Th~s .g~s~n .............
to .~d ~ .~dd~lCn .t~..an e~.~., d~e.~.t~& .........................................
~t prem,ses located et . ~ ...~me~eta.~d ..............................................
...................................................... lia~$~...l~.int .......................................................................
pursuant to apphcatmn dated ...... '~]t'6 ................ 19~'~,., and approved by the
Building Inspector
Fee -$~, O0 ...........
Budding Inspector
FOENI NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Approved ................. :..~. ................... 19.~Permit No....~...~.~....~'...~ ............
Disapproved o/c ~~ ................................................................
(Building Inspector) /
Application No .............................
APPLICATION FOR BUILDING PERMIT
...................................
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and sut~rnitted 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 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)
(Add,ess of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
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 ~..~....~..f...~.'...~.......,~L~....I.~.~ ....................................
Municipality
2. State existing use and occupancy of~d intended use and occupancy of proposed construction:
a. Existing use and occupancy ....... ~; ...........................................................................................................................
b. Intended use and occupancy ...... ~.~..~.~......~...,~,,~.~'~,~,,-, ........................................................
3. Nature of work (check which applicable): New Building .................... Addition ....(.k ............ Alteration ....................
Repair .................... R~?val .................... Demolition ............... ~..Other Work (Describe) ....................
4. Estimated Cost ............... ,/..~x..~ ................................ Fee .......... .~i.~.:...C.-~. .................................................................
(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 ....&Z..~?. ...................
Depth ...... 2...0. ................ Height ..~,,.~ ...... Number of Stories ..... ,x~...?..~,~C-,,,~ ....
8. Dimensions of entire new construction: Front ............................Rear,. ........................... Depth ............................
Height ............................ Number of Stories ............................
9. Size of lot: Front ...... /..~....~'. .......... Rear ..... /...~....~,. ........... Depth ~..~,.,~/~4~ - ~.;7 ~'c,-~a
10. Date of Purchase ~./.o...t~<~ ~-...Name of Former Owner
/
11.
Zone
or use district in which premises are situated ......... ~'/.~.~,~.....J~..~ ..............................
12. Does proposed constructiond-~ _ r'~vi°late any zoning law, ordinance or,L z¢/~,_2 ~,.'~regulati°n? ...i...~'r......~
13. Name of Owner of premises~....l.~..~ddress ~f~..:~..~.../..:!.~:....Phone
NO
//
Name of Architect Address ~ Phone NO
Name of Contractor.... '~-~,~--~..~.a'~a.~'. ....... Address .~--~..~..~.;...~.:y,...Phone
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.
STATE OF NEWIYORK, j ) S S
COUNTy/,,)~ ~ ~-~ r ' OF '~'~'{!'/q("t"~'~'c:'"") ' X ~'~~ ~ ~ --
~.~"~.~...~.~:~..~L.."....~ ...................... being duly sworn, deposes and says that he is the applicant
(Name of indi~'Mdual signing application)
above named. He is me ........................................................................ x ..................................................................................
(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 ~nner A~t fo~ in the application filed therewith.
Sworn to before me this __ -~ ~E_ ~Wo~ ~ ~ ~ ~, ~ F
...... ~..~1 ........ day. or ................ ..~ ................ ~:.-~ ~2,~,, ~ c~,~ e [~gnature or app.cant)