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HomeMy WebLinkAbout764-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 II/V 0Zd ~?l~.e ~,~I~t ~..~.~t Map No ......................... Block No ......................... Lot No ................................................... ~ ...... ~'..'; ....... conforms substontially to the Application for Building Permit heretofore filed in this office dated ~]-Y 0 19....~...~., pursuant to which Building Permit No. dated ,,T~l~y 11 19....~.?.., 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~. ............. PRXVATE ONE FA~LI DIIEZJ~IgG (owner, lessee or tenant) of the aforesaid building. FOI~M NO. 2 TOWN OF SOUTHOLO 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? 764. Z Date .............................. ~a~l~....11 ........... 1 g~.~. .... Permission is hereby granted to: ....... ~latah~ue~....]~,]~ ~ ........................................ to. ~a~Lld. ~t~. ~dd J,t,~,on..~..a~..t~,~,~g..~g ........................................................................ at premises located at ..~.,~).~d..~T~e..~ ........................................................................................ .................................................. ~a. bt-i.t, aek.~. · - - ~. ~, .............................................................................. pursuant to application dated ................................ ~T~r ........ .~. ............. 19.~c)..., and approved by the Building Inspector Fee $5,,.(~0 ................ Building Inspectbr / FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. ! ........ Disapproved a/c ..¢.~ ............ ~,~ ......................... ~,.~, ........................... ............ ................................. Application No ..... .(........./L .......... APPLICATION FOR BUILDING PERMIT INSTRUCTIONS o. This opplication must be completely filled in by typewriter or in ink ond su~omitted in duplicote to the Building Inspector. b. Plot plon showing location of lot and of buildings on premises, relationship to ~djoining 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 issuanc.e 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. "~'Jgnature of appallS-anal, or name, if a corporation) .................... · ............................. ('*~¢~J~;;; ' ;~ applicanti' ...... State wheth,er applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ....... /.....,......~,..~....¢~X,4,~v:%.*.-...;~..c~m~¢¢.~;~4~,~ .................................................... If applicant is a corporate, signature Let duly aLChorized officer. (Name and title of corporate officer) , 1. Location of land on wh~h propose, d wo~r~k will be done. M, ap N°~"~d~"~c~NO:' .................... Street and Number ...~.).~,/~~.~..)..,....~.....~..-~!'J.~..,.:."'"~'" ........................................ ~,~ Municipality ~ 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 ....... ..x.OfT;..; .................................................. .~.. ......................................................... 3. Nature of work (check which applicable): New Building .................... Addition ...... ;.~ ........... Alterat on .................... Repair .................... Removal .................... Demolition .................... Other Work (Describe) .................... 4. Estimated Cost ....... .?/.....¢..~.....U.. ...................................... Fee ............ .6....:....~/~.. .................................................................. (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 ...... C./..~ ............... Height .......... ./...~..! ........... Number of Stories ....... ~ .............................................................................................. Dimensions of same structure with alterations or additions: Front .......... ,~..~. ............... Rear ..... ~....~ .................. ............................. ! z~ Depth q~v . Height .............................. Number of Stories ................................ 8. Dimensions of entire new construction: Front ............................Rear ............................ Depth ............................ Height ............................ Number of Stories ............................ 9. Size of lot: Front .........(~...% ............ Rear ....... /....~.....~. ......... Depth 10. Date of Purchase ......~.~?'......~..~....~.~. .............Name of Former Owner ...~...../~..~...~ ..... 11. Zone or use distric~n which premises are situated ...... .................................................. 12. Does proposed construction violate any zoning law, ordinance or regulation? ...... ~ ....................................... 13. Name of Owner of premises.~..:.~.:....¥.~...Address .~:~.v..Z:..~'.~.).t..cT~.....Phone NO Name of Architect ........................................................ Address ............................................ Phone NO ..................... Name of Contractor..~.~-m~..~: .............. 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 Jot. STATE! OF NEW YORK, ) S S. COUNTY OF ............................ ) .................................... .~.~.~.~ ........................... be n§ duly sworn, deposes and soys that he is the applicant above named. He is the .............................. ~ ..................................................................................................... (Contractor, agent, corporate officer, e~tc.) 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 befo~rne this ~ ~'i~,,~.~ ~-?,,t~,~-~- .~' .............. ~......--l:]ay of ............... ~;~..~ 19.....N~¥~' I~ot,~l,c, st~t~($1gt~et~r~ at applicant} Notary Public, FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD~ N. Y. Examined ......... -~ ...~..t ...... 19 ...... ~. . ..... Approved ........................................ 19 ........ Permit No. Disapproved a/c .......................................................................................... ................................. ............... '--¥-"'"'"-"'- ;;;i ................................. Application No ..... i..~...~....~... .......... 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 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 Icept 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 a Iterations, or for removal or demolition, as herein described. The applicant agrees to comply with all appllcable laws, ordinances and regulations. ........ ...................... '(~c~ature of applicant, or name, if a corporation) ................. ..................... (Addr~s of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises.......~....'.......~,.~ ...~..~~.... ,~...~.'~''~ ............................................... If applicant is a corporate, signature o~duly authorized officer. 1. Location of land on wh~i~ch proposed work will be done. Map ,No: ~.~.~.~.....~...~. ............. ~ No: .................... Street and Number .. .1 .......... .c.,,~.. .................................. ~ Mumc~pahty / 2. State existing ~se and occupancy of~mi_~es and intended use and occupancy of proposed construction: a. Existing use and occupancy ....... :..~....~mm....~r~m..~... ....................................................................................................... b. Intended use and occupancy......~....C~.~.~..'~...~....~..-~,..~.%~.. ................................................................ 3. Nature of work (check which applicable): New Building .................... Addition ......... ~ ....... Alteration .................... Repair .................... Removal .................... Demolition .................... Other Work (Describe) .................... 4. Estimated Cost ............ .L/...~..~:~. ........................................ Fee ............ ~..~.:.r.~ ................................................................... (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 ........... ~5......¢~r~, ......... Rear ...... ~z..~... ............ Depth ....c4..o. ................... Height ~ .... /.~r/ .................. Number of Stories ........ ~ .............................................................................................. Dimensions of same structure with alterations or additions: Front ........... ;~..,~.. ............. Rear ...... ..~.....~.. ................. Depth ........ .c.(.p. ................ Height ........... /..~ ............. Number of Stories ..... f~ ................. 8. Dimensions of entire new construction: Front ............................Rear ............. : .............. Depth ............................ Height ............................ Number of Stories ............................ 9. Size of lot: Front .......... /~..S.~.: ........ Rear ........... 4..2~... ......... Depth ............ ..~....°....~...~.. 10. Date of Purchase .......... /...~...,~...~. ................. Name of Former Owner ...~'~.~ .~7~... ...... 11. Zone or use district i~rY'which premises are situated......~.~.~.~..~...' ........................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation? ......... ~.. ...................................... 13. Name of Owner of premises..~..'..~.,..~..c~.~..~..~.....Address .~.~...~..~..~..~...:.~..:...Phone NO Name of Architect ....................... ". ................................ Address ............................................ Phone NO ..................... .. ..~....:..:.Phone N O. ~..V'...z/~..7. ~. Name of Contractor......k~z;~,..~....~..~¢.'~...~....~ ....... Address 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 end indicate whether interior or corner lot. STATE OF NEW '~)RI~, ,.~,~ ~-S .... COUNTY~g,,~< /"~ ,,OF ...~- ' '~ (Name of individual signin~1~ ) 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 ail 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.~e this ~-- ~~ ~ C~ ~ ~ ~' ............. /.~...;~ay of ........... ~..~~9..~.. ~lt~ ~. ~ture of applicant) .......