HomeMy WebLinkAbout2787-zFOEM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFF~CE
SOUTHOID, N. Y.
CERTIFICATE OF OCCUPANCY
No ..... Z..Z~0.?. ......... Date ......................... At0r. ll....2? ......... , ~.66..
THIS CERTIFIES that the building located at ~/~...~..~ee~..~..~¢~..~.Oa~ ........ Street
~ , Capt kidd Est ~,0, Pike Ete %~0 ~t Road off '~/ Bergen Ave
~ap ,~o BOCK ,~o ~or ,~o. ~ ~'~i'~k'~'"'..N'~.M~ ........
con,arms substantially to the Application ~or Buildin~ Permit heretofore filed in this office dined
.................................... J~e ........ 8 ........... , 19..6~. pursuant to which Building Permit No...2~.87...Z
dated ............................ ~e.....~. .......... , 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 ........
P~i~e...one..~amilM..~welti~ .................................................................................................
t ~
The certificate js issued o ~a~.von..&.....a~y...B~ad~.~ ............ ; ....... ~e~s...: ..............................
[owner, lessee or teno~t)
of the aforesaid building.
H.D.Approval Feb, 3,
1966
FOI~M NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOU?HOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
Ne 2787 z
Dote .................................. J~lzl~....9 ......... , 19.6~..
Permission is hereby granted to:
W~a'. ,,, ..~, ..~m, e4~..& ..W~,fe ..........................
..... 9.~[..}f~et t...A~e .........................................
....... g, .. ~toho&q~r ....N.,.~~ ...........................
to . ,~,1~1.. zm~. ·ene .. f~m.t .ty...d~e.1.]:$t~g .....................................................................................
at premises located at ....~mJ~.~...R{~ii~.....{)~.g'...W/~l~..~l~p~..{~r.d~l..Dl,4_~,e ....................................
................................................ l~e ~1: '~sakt' "" 'l~i'¥'i ............................................................................
pursuant to application dated ................................ ~TIIZle.....~ ........... 19.~., and approved by the
Building Inspector
Fee $~,0.~.0~ ............
sUFFOLE COI~I~ DEP~HTMENT OF HEALTH
Date
B~da, Per/ai% NO,
TO WHOM IT NAY CONCERN:
The sewage disposal facilities for a structure located at
have been inspected by this Department and found to be satisfaotory.
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
............................
Examined
............................ .................................
APPLICATION FOR BUILDING PERMIT
Do,e ....... ..................... ,,
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 application.
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 o Building Permit pursuant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Lows, 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, ordinance~g ,~-~~tions.
...............................
(Signature of applicant~'or name(, if a corporation)
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engl.neer, general contractor, electrician, plumber or builder.
Name of owner of premises "~'/~'"'?"'~'"'~'"'""~"'":'"'7 ...... ~'~'""~'"'"'~'~-~/~' '"4~"~/ .............................................
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.: ........................
Number ~~.~'~'~ ~.4~..,/~..../.,7'~/~ ,~ ,./ ../L~...'...~...
Street and ........................................... , .......................................... /~.i.l~.li¥~ -:. ...................................
2. State existing use and occupancy o~ises and intended use and occupancy of proposed construction:
o. Existing use and occupancy .,.~..~..,~.,~,.~.....,~.....~_~{. c~'~ ........................................................................................
b. Intended use and occupancy ..... h;..J~,~..~......~.. ........................................................................................................
3. Natvre of work (check which applicable): New Building' ..'....~. ........... Addition .................. Alteration ..............
Repair .......... .,~.... Removal .................. Demolition .................. Other Work (Describe) .......................... i .........
14. Estimated Cos(f~.~...~.~'~.,...Q.~.~. .............. ' .................... Fee ......................................................................................
/ (to be paid on filing this application)
5. If d~elling number of dwelling units ......... ../. ................ Number of dwelling units on each floor .......................
If g<~rage, number of
cars
5. If I~usiness, commercial or mixed occupancy, specify nature and extent of each type of use .......................
7, Dim~ensions of existing structures, if any: Front ............................ Rear ................................ Depth ...................
Height ........................ Number of Stories ............................................................................................................
Dimensions of same structure with a,lterations or additions: Front .................................... Rear ....................... ~
Dep}h ................................ Height ............................ Number of Stories ................................ ,
8. Dimlensions of entire new construction: Front ....... Z..,~. ........................ Rear ........ Z.~ .............. Depth ..~...?..Z..:~.°.'.
Height ~ / ,
.... ~,~;, ........ Number of Stories ..... . ..~...~'~...~ ................................................ v ...........................................
9. Size, of lot: Front ....,~.Q.¢~...,! ....... Rear ....... ..~....O...,~.. ................. Depth .,.../.../...~..~;....~, ..... __ c")
10. Dat~ of Purchase .... 4~//.,~'~/~.~.~.. .............................. Nome of Former Owner'C./.~.~.....,~...~.~...O......~....,.....~..~:,?.%D_~.z...'~...~.
1 1. Zone or use district in which premises are situated ...i~...~..~',.~xJ~.~;;4/,..~...Z.~...~. .................................................
12. Doe~S proposed construction violate any zoning law, ordinance or regu ationP .......,~..~.. ,~ ~
~ ~ c- - ' ~"~'?~'~'~;~?Y'"'"'~'
Na e of Owner of premises ..... Phone
Nar~e of Architect ...................................................... -~ ~. ~ ,.- Address ............................................ Phone No ................
Narhe of Contractor ~;?~ (~)~/.~. ,.~.q.q~ ~ Address ........... ~...~../~..~ .................. Phone No.~.~.~..~.~../.~
PLOT DIAGRAM
/.ocot~ clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions fr
property liines. Give street and block number or description according to deed, and show street names and indic
whether inlerior or corner lot.
STATE OE N E~, YORK, ~, ~ ¢ S
COUNTY !o~_~,.~.Z~N~.....~ ~' ' .-
............. ]'('f~'~'~;';f'i;~i];[J~'~'l";i~ n [g~'~'~'~'(i'~ ;ii; ~i .................
duly sworn, deposes and says that he is the applic
above named. He is the ...... ¢~..~:'.,~.~l~.......~.r.;.....~.~g.~./.~..-.,'L.~~- .................................................................................
! ' (Contractor, agent, corporate officer, etc.)
of said o~ner or owners, and is duly authorized ~a perform ar have performed the said work and to make and
this applic;tion; that all statements contained in this application are true to the best of his knowledge and belief;
~,rk will be performed in the manner set forth in the application flied therewith .... ~
thatswomthetoWb,fore me this ~ / ~ / /~ ~-~,," /7
....... ~..~.~. ...... day of .....~....~....,~Z.~'. .............. .~...., 19....~...~. ~,~/,,~Z,'~ ; ~/ ~ , ~
~-~ '~;'",¢-~, X/ // ', .......... ~.~..~..~..q~...~ ................
Notary Pu ~lic, ....~,~.,~y~...:.../--~.f}~,~-z.r,~,/,4rCgupty, /~ (Signature of a[~plicant) /
~t%~.~'~'o~'§, s~o~k Co,.tY~/.~ C~ ,~r~.,/ ~ - ~
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