HomeMy WebLinkAbout266-zFOR1Vf NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
CERTIFICATE OF OCCUPANCY
THIS CERTIFIES that the building located at .. ~.~..~(~.~,~.~ ............ Street
Map No .............. Block No .................. ~ ..... .. Lot No
conforms substantially to the Application for Building Permit heretofore filed m th~s office dated
~'""~ ......... ~" .~.~"~.~..~L~ 19...~. C pursuant to which Bu,ld,ng Perm,t No ...~...~__~..~ ,~'~ .....
ate .... ,~ ~ ~_r.. .............. ~, was issued, and conforms to all of therequ,rements
of the apphcable prowsions of the law. The occupancy for which th~s certificate ~s ~ssued
T h,s cert,f,cote is issued to ~.~.....~~)..~. ~.
of the aforesaid building
FOruM NO. ~
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)
N°. 266 Z
Per nission is hereby granted to'
lge. :m'o~k lJallae~..-.-~t'O--..l~t, ez'. -g~..ak ..........
...... ttt'~"-St~! ............................................
........................... I~,.tg~-¥ .... N'~'s ........................
to -.R~. ~...~w..P~mtli~ ............................................................................................................
at premi.~es located at ..]~.J?.~l.~.....~l~.~'l:jt,l~O~ ........................................................................
............. i ......................................... ~ ~%l.t~ets~.- · W-,~'2'~ .............................................................
pursuant to apphcat~on dated
Bu,ldmg i, lnspector
Fee $~,~ JiD~ ...........
...................... .~I~Z.~t..~ ....................... l~;~...., and approved by the
Building Inspector
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Approved ............. !~! ................. .~:.....19..~.....~.Permit No.....~.....'.~.....~...~. ........
(Buildln~ Inspector) (
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 application 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 Certificate of Occupancy
shall have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuanae 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 all applicable laws, ordinances and regulations.
~Signature of applicant, or name, if a corporation)
............... r. .......... ..............................
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Nam(of owner of premises.~...~...~.....~....~~..~-,.~...-~.~ .........................
If applicant is a corporate, signature of duly~'l~rized officer.
............... (Name and title of corpora~fficer)
1. Location of land on which proposed work will be done. Map No: ~...~..~7~.~.../.~.'f...~..~...e..~.~ ........ Lot No: .:~.......~... ......
Street ~/~ Municipality C/
2. State existing use and occupancy of premises and 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 ...... L.c~...........Addition .................... Alteration ....................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ....................
4. Estimated Cost .......... ..~..~ ...... .~...~...~...o..~....o...?. ............. Fee .J....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 ,,c>2 Number of Stories /
9. Size of lot: Front ..~..'~...~.../. ............... Rear ...... ~..'. ............. Depth ......'~..../-~...7...../ .......
10. Date of Purchase ........................................................ Name of Former Owner ..... ',~..C~,~.~.~.,~.~.'''''/'1 ~ ,, .........
ll. Zone or used str ct n wh ch prem ses are stuated ................. /~.....~..~.~..r..~..~ ...................................
12. Does proposed construct on v o ate any zen ng Iow, ordinance or regulation? .......... ../~....d.
..............
13. Nome of Owner of prem sed.;.6.~.t(.u...~..~.o z. ................... Address/.~.~. ........ ~/;~./14.~,...f..~..A../..~,~'.~..Phone- NO.~.;.~..~..~,,,('
Name of Architect ........................................................ Address ............................................ Phone O ........... ; .........
Name of Contracto~.,~.~.~.~.,~.~' ~' .~ /. ....... ~ Address ' ~''
J~.i.'...w(.,.L¥..~/.., ...... / ............ PhoneNO'~'~F .......... ~'~,~/~-~, 4,'... ....... .
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 NEW~.,~O~,~:~/(~ ) S S
....................... ~~...-~....~......'~~ ......... being duly sworn, deposes and says that he is the applicant
(Name of individual sig~ing opplication)~
above named. He is the ........................................... ~Z~..r~..c....~4~- .........................................................................
(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 thiJJl~j~p~,gtion are true to the best of his kno~'d~e and belief;
and that the work will be performed in the manrl~r s~n~.he application fj.le~'tTi'~ewi~h. ,~---~//'~
Sworn to before me this , ~l'~,,.~t'~ ;,~'~'.~.~.// ~" ~--~ _4 ~/~-~,
Z...~..f?... day of .............
............... _
Notary Public, ...."(,.~,~:~&~.../.~,~.~....'.....C'o[Jnty