HomeMy WebLinkAbout2916-zFOI~M 1~0. 4
TOWN OF SOUTHOLD
]~UILDING DEPARTMENT
~OWN CLERK'S OFFICE
SOUTHOLD. N. Y.
THIS CERTIFIES that the building located at . .Fle.(ta~..A~'~ .& .(}OX .I~ck. ~R~Street
TOll~ood
Map No ............. Block No ....... Y~ .... Lot No. ~.0~.1 ..... ~;.%~.~¢lk,..l~,X, ....
conforms substantially to the Applicati.on for Building Permit heretof<~re filed in this office
dated ........... ~.~o.v. el~lher. ]. 19. ~ pursuant to which Building Permit No..2916..Z
dated ........... .~.O.V., .... ~. .... 19.(~., was issued, and conforms to all of the require-
ments .of the applicable provisions of the law. The .occupancy f. or which this certificate is
issued is .P~.~V~.te. ~r~e..f~mil~..dw~l]~in~ ..........................................
The certificate is issued to ...~.1:1.~. ~0~;~], ....... (;}I~'. ................... -..
(owner, lessee or tenant)
of the afore.said building.
.Suffolk County Department of Health Approval ......... ~.~R~ ...........................
Building Inspector
FOI~M 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? 2916 Z Date ........................... jjo~eijbe/~.....~, ...... , 19..6~'
Permission is hereby granted to:
8 tanl e~r.. S apko .... ~/g.. l~t~,lt~a ..Eo tow~ ~ .........
.................. lJat~-i~uok ........................................
to t~u.t lcl.. an.. ~dcli i;~.o~ .. on.. ~,n..,o~ ~t lr~ .. civil, l.i. ng ..........................................................
at premises located at ...T,~o.t..l~. ................ .~0,],],~:~/oo¢1 .........................................................................
............................................ J~.~.....!~.¢1 ~... ~,~,..~..Co~ ..Na..1~ ..l~d ........... J~t f~t ~uek ...........
pursuant to application dated ............................. ..~..O.V. ............ .~.. .......... 19..6.1~...., and approved by the
Building Inspector
Fee $ .~...~...(~... .............
FORM NO. 1
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined ................ ,
Approved .......................... !: ............ , 19 ...... ~. Permit No. ~,~
...~:L,..~:~' ......
Disapproved a/c ..............................................................................................
.............. .........................................
/ i' (/"'~Bfilding In~l~ector)
Application No..?~:,~..:~2./.[:~ .............
APPLICATION FOR BUILDING PERMIT
Date .............................. Jio~embe~...:L....., 19...6.~. ....
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 drown 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 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 app icable aws, ordinances, building code .and regulations.
(Signature of dpplicant, or name, it a corporation)
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
................................................................... Con~Go.to~ ......................................................................................................
Name of owner of premises .l'.~'t].~...,~lt~l~W~k$ ............................................................................................................
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
t. Location of land on which proposed work will be done..Map No.: ...... .~e.~-~.~/T~ ............Lot No.: ........................
Stree¢ and Number ...J~/.J~.....I~&~..&..C~I~O~...J;J~ ............... J/~.~ts~.~1~ ............ ... ........................................
nnunicipa iry
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ...... ~t~e.~],~.~ .........................................................................................................
b. Intended use and occupancy ............ ~.~,~t.....~/~,.t*J~..~..&~.f]~l~Lol~. ...............................................................
3~ Nat,'ure of work (check which applicable): New Buil~ding .................. Addition ,.~r~--Jt',z~.. Alteration
Repair .................. Removal .................. Demolition .................. Other Work (Describe)
(to be paid on filing this application)
5. If d?elling, number of dwelling units ...... .~.JJ~. .............. Number of dwelling units on each floor ............
If g?oge, number of cars
6. If Business, commercial or mixed occupancy, specify nature and extent of each type of use
7. Dimensions of existing structures, Jf any: Front ............................ Rear ................................ Depth
Height ........................ Number of Stories
Dimensions of same structure with alterations or additions: Front ....................................Rear
Depth ................................ Height ............................ Number of Stories ................................
8. Dir~ensions of entire new construction: Front ........... ~1, .................... Rear ....... ~], ................ Depth ...1~. ...........
HeiClht .................... Number of Stories ....
9. Size of lot: Front ............................ Rear .................................... Depth ................................
10. Date of Purchase ........................................................ Name of Former Owner
1 1. Zone or use district Jn which premises are situated ......
12. Does proposed construction violate any zoning law, ordinance or regulation? ..................
13. Nanhe of Owner of premises, ~,.dL],,1.:J. al'l..[l~t.O~SJt~..Address ............................................ Phone No.
Nam[e of Architect ...................................................... Address ............................................ Phone No.
Nar~e of Contractor 8,~,.l~,ej)~lJ, ........................... Address .............. ~l~.~t&,t,~l~.k ........ Phone No,
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions fr,
property lihes. Give street and block number or description according to deed, and show street names and indic~
whether i,nterior or corner lot.
STATE OF ,NEW YORK, ~ e e
COUNTY ,,OF ...~'~ZlC ........... ~ ....
.................. '. ........ J~.~'.....~]~ .................................... being duly sworn, deposes and says that he is the
{Name of individual signing application)
obove'nomed. He is the ...................~g~O~O~ ...............
(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 f~le
filed therewith / aj,dto
this application; that all statements cont~:ined in this application are true the best of his knowledge and belief;
that the work will be performed in the manner set forth in the application .
................. v"'" day of ................... ......... ,
I - ~ ~ '
J , [ , ' ~ ............................... : ................... : ....................................
Notary Publ,c~,~..~[~x~-r~.~,/Cop~ty ~ .
i~otary Public Slate ol J~ew YOrK , '