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TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
CERTIFICATE OF OCCUPANCY
No.....Z.,..4.~) ........... Dote .................... .0.~.?)~. ....................... , tg..~.?....
THIS CERTIFIES that the building located at.,J~orLt~.'l..~.~l~li~.,A.v/~ ...................... Stree,t
Map No, .~..~..~.~ ............. Block No...~f ................ Lot No...~;......~.~iB~t~l'~..~.~,l~t.~..,,[t~.~ ............
conforms substantially to the Application for Building Permit heretofore filed in this office doted
.......................... ~a,~'....6. ................. ~ 19.5~..., pursuant to which Building Permit No...~fo67 ..................
dated ..................... J~.....~t .................... , I~....., was issued, and conforms to oil of the requirements
of the applicable provisions of the Iow. The occupancy for which this certificate is issued is ..............
............. lP~.iv~a..cma..f.~il~...dwelling ............................................................................................
This certificate is issued to ..I~.~..~X'~0~..A]~D......{~C~;~lr). ................................................................
(owner, lessee or tenant)
of the aforesaid building.
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)
N? 667 Z
Date ........................ U~y ........ .'/ .................. ] 9.~9...
Permission is hereby granted to:
C~Z"~.O~ ... ~U~ .......................................................
.......... ge~'~,~..Ave..&.]~a~el~e..A.ve .................
....................... .~'shere-.~e.l~nd ~....~.,-Y., ...............
to ...... :~,a~.t~ · .~n ..a · e ~ %.¢ aa.. on..a a.. ex~.a.~.~. ~e 11~g ...................................................................
at premises located at .~./i[...~r.~.~7.....~.~t.~r~.~...z.~..v.~...~...~p~.~.p.~.~.~..~ffg ...............................................
....................................................................... F£~er.,~.,I~l~nd~.... ~,I'., ...............................................
pursuant to application doted ............................... ..~P,~. ....... .~. ................ 19..~.9..., and approved by the
Building Inspector
Fee $.~,.~Q ...............
Building Inspector
FOR~I NO. 1
TOWN OF SOUTNOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Ex°mined ........ ........
Approved ........................................ l~ ........ Permit No
(BuHdin~ Inspector)
Application No ..........~.. ~...~ .........
APPLICATION FOR BUILDING PERMIT
Dote ...... .......
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and su0mitted in duplicate to the Building
Inspector.
b. Plot plan showing IDeation 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.
e. 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 shah be kept on the premises available for inspection throughout the progress of the work.
e. No building shaft 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 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 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.
Name of owner of premises ...... '.',%Z[,4...~( ..,rhea..~.**~. ............................. -..'. .....................................................................................
If applicant is o 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: ....................... ~;T.:; ...... Lot No: ..........~-~;'~ ........
Street and Number .......... .G. ........ ,, ........... .¢. ..........................................
Municipality
2. State existing use and occupancy of pr, emise~nd intended use and occupancy of proposed construction:
a. Existing use and occupancy ........................ ~...~. .............................................................................
b. Intended use and occupancy .............................. t..¥ ............... :(~....C~?_~.?...L~......~..-~,..X~,Z~,. .........................
~A
3. Nature of work (check which applicable): New Building .................... Addition .................... Iteration ....................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ....................
4. Estimated Cost....f~..O..~.....~.. ......................................... 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 ........... ..~,.,,~,.f ....... Rear ...... .~....O..~ ............ Depth .~.,~....~ ..............
Height ............................ Number of Stories ~ ........................................
Dimens!ons of same structure with alterations or additions: Front ................................ Rear ................................
Depth .............................. Height .............................. Number of Stories ................................
8. Dimensions of entire new construction: Front .......... ./..?,. ............ Rear ........ ./....?... ........... Depth
Height ............................ Number of Stories
9. Size of lot: Front ......./...O...~ ............ Rear ....... ././?-~.. ............ Depth /~5 '~
]0. Date of Purchase ........................................................ Name of Former Owner ........................................................
11. Zone or use district in which premises are situated ............... : ................................................................................
12. Does proposed construction violate any zoning taw, ordinance or regulation? ............ ,.~,,,?.. ...............................
Name of Architect ........................................................ Address ............................................ Phone NO .....................
Name of Contractor ..................... ',: ............................ Address ............................................ 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 description according to deed, and show street names and indicate
whether interior or corner lot,
STATE OF NEW ~ORK~__,~J~- ) S S
................... :..~...~..~_"?:~. ..... ~.2.~2:.~. :'..~. .... be n~ duly sworn, deposes and soys that he is the applicant
(Name of individual signing application)
above named. He'~s the .................................. ~~ .........................................................................................................
(Contractor, agent, corhorote 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 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 ~nner set forth in the application filed therewith.
Sworn to before me this
Noto~ Pubhc~, -~
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined ........................~l....(z ........ 19 ........
Approved ........................................ 9 ........ Perm t No ...............................
Disapproved al cl......./~. ........ 7~~ .......... ~, ........ ~¥ ......... ~_T..~
(Building Inspector)
Application No ......... ..~....G...Z ........
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and sut~mitted in duplicate to the Building
Inspector.
b. Plot plan showino 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 drown on the diagram which is port of this location.
c. The work coYered 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 port for any purpose whatever until o Certificofe of Occupancy
shall hove 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)
(Address of applicant)
State whether applicant is own~z,, 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 whj~ch proposed, work wiJJ be done. Map No: ~,, ..................... r~,,.....~-, .....Lot No: ....................
Street and Number ....................... ...............................................................................................................................
Municipality
2. State existing use and occupancy of pr. emisesc~nd intended use and occupancy of proposed construction:
o. Existing use and occupancy ....................................................... % ..........................................................................
b. Intended use and occupancy ................................................................................................................................
3. Nature of work (check which applicable): New Building .................... Addition ....................Alteration ....................
Repair ....................Removal .................... Demolition ....................Other Work (Describe) ....................
4. Estimated Cost......,,~.~..O. ............................................... Fee ..........................................................................................
(to be paid on filing this application)
5. If dwelling, number of dwelling umts ................................ Numb 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, ,f any: Front ........... ...:~....O...~ ....... 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 ............................ Number of Stories ............................ ,/-/~
9. Size of lot: Front ..... ./..~..'.~. ............. Rear /z~'~ Depth
10. Date of Purchase ........................................................Name,of.?orma,r Owner ........................................................
11. Zone or use district in which premises are situated ................................................................................................
12. Does proposed construction violat~ any zoning law, oraJnance or regu~a' n .....................................................
]3. Name of Owner of premises ..................... ~,.: ................ Address ............................................ Phone NO .....................
Name of Architect ........................................................ Address ............................................ Phone NO .....................
Name of Contractor .................................................... Addre s ............................................ Phone NO.
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate alt set-back dimensions from
property lines. Give street and block numbers or description according to deed, and show s~reet names and indicate
whether interior or corner ~ot.
STATE OF NEW ~ORKj ~. ~ J~ ) S S
(Name of individual signing application)
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 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 manner set forth in the application filed therewith.
Sworn to before me this
~"~ do' of r-)'l~"~ 19*~"''7 (Signature of applicant)