HomeMy WebLinkAbout251-zFOENI NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
CERTIFICATE OF OCCUPANCY
THIS CERTIFIES that the building located at ~i~.~W~..~ ~f~ ~.~;.~.~... Street
Map No. ~'a~_~ .... Block No .... t*.t ..Lot No. SG ..............................
conforms substantially to the Application for Building Permit heretofore filed in this office
, 19~ pursuant to which Building Permit No.
dated ...................................................
4ated .... ..........~ ......... ~5 , 19 ~8 , 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
PRI~ATE ONE FAMilY DWE?.~T. NG
This certif~caie is issued to
of the aforesaid building.
(owner, lessee or tenant)
Building Inspector
FORM NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
No. 251 Z
Perr:nission is hereby granted to:
J,~,ll~l~y, (ag~n~;~....~/C. l~a~y..l~l~l~l~tel- ..............
.............. !~t$,:~tt~ek~ ..... 1I,-~ .......................
pursuant',to apphcat~on dated .................... l~l~....~.~ ................... 19...~., and approved by the
Building Inspector
Building Inspector
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Exam in ed.......~....~.~'..~...~?.. ~.... 19 ~.~'.....~
Approved ........................................ 19 ........Permit mo .................................
Disapproved
a/c
................ :::: ..........................................................
.......... ' ................. i'f' ............................
Application No ............................
APPLICATION FOR BUILDING PERMIT
Date .~~....,.~,. ......... 19...~...~. .....
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 o 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 alterations, or for removal or demolition, as herein described.
The applicant agrees to comply with ali applicable laws, ordinances,~g~nd regulations.
...... ........ : ..... ................................................
'~ g ure or applica, nt, or name, if a corporation)
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrican, plumber or builder.
...A...
owner of premises...?.....~....J.~ .......... ....... i...~..~~ ................................................
Name
of
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
1. Location of land on which pro,posed work will be done. Ma,~No.~,...~,.~.... Block~......,~'....,~. ......
Street and Number ~ ~~ '- ~ ',."',"'
2. State existing use and occupancy of premieses end intended use and occupancy of proposed construction:
a. Existing use and occupancy .................. ~..0~.....c:T' ~ -,~-- ~
b. Intended use and occupancy ....................... ~..'~ ............................................................
3. Nature of work (check which applicable): New Building .................... J Addition .................... Alteration ....................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ....................
...l.p. ........................................................
4. Estimated Cost ....~ ..................................................... Fee ..
(to be paid on filing this application)
FEES:
5. If dwelling, number of dwelling units ............................ Number of dwelling units on each floor ............................
If garage, number of cars ........................................................................................................................................
6. If business, commerical 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 ..... J..i'Z..ff .......... Number of Stories ....~.~ .........
9. Size of lot: Front ..../..~-..~.. ............. Rear ........ /.....0Z~.. ........... Depth .....~-.O...O_ ...........
10. Zone or use district in which premises are situated ....... .~.........f..~.~-...~.. ........................................
11. Does proposed construction violate any zoning law, ordinance or regulation? ............. ~.....O.. ............................
12.
Name of Owner of premises..~ff/.~¢~l~ ..~.J.l~. Address/.~.~..i?.~...~...~....Phone I~O .....................
Name of Architect ...................................................... Address ............................................ Phone NO .....................
Contractor..~.:~:..~'~ -- ..................... Address ..../~l~.~..,~...~c..~ ........... Phone NO. ~..~-....~.. ........
Name
of
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from
property line~. Give street and block numbers or descripltj~, according to deed, and show street names and indicate
whether interior or corner lot.
STATE OF NEW YORK. )
s
(Name of individual signing opplicati~)
above nome& He is the ..................... (Contractor, og'~ht, corporate officer, etc.)
of said owner or owners, and is duly authorized to perform or hove performed the said work and to make and file
this application; that oil statements contained in this application ore true to the best of his knowledge and belief;
and that the work will be performed in the manner set forth in the application flied therewith.
Sworn to before me this /~,~ ~/-'
, · ,9
...... /,}~77x ....... ~, aay t~r ..... ~.:.,~-._ .......... ;~.~.. .................
Notart Public,. ............ ~.~.,.: ...... : .......... County