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Home My WebLink About3284-zFORM NO, 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S O17FICE SOUTHOLD, N. Y. P. ERTIFIE:ATE: OF r"I~UPANEIY No. ~ 2~7 Date TtiIS CERTIFIES that the building located at · ~,/~ ~l:tetfO0~ ~ Street Map No. ~ Block No ~ Lot No. ~ (l~l~hcrglle~,..]~t~., ...... conforms substantially to the Application for Building Permit heretofore filed in this office dated (k~t~ 2~. 19. (:~ pursuant to which Building Permit No. dated . O~; . ~., 19 ~, was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is P~t%'a~;e one'-/~am£l'y'~i~e!l~rrl~ .................................... The certificate is ~ssued to . ~{l', ~- ik'S. DOD. Z~i~i- Oa~l~.l -.. Owrlel'~ ..... . ......... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . ...}~,I{.~ ...................... ~ '" Buildin~ Inspector / ! ]~OZ~ NO. ~ TOWN OF SOUTHOLD BUI[DII~G D£1~RTMENT TOWN G~LERK'S OFFIGE mUTHO~.D, bi. Y. ~ ._ ~*- ~ILDING PERMIT ~HIS PERMIT MUST BE KEPT ON,THE PREMISES UNTIL FULL. 'TH[ W,~OI~K AUTHORIZED) ~ _ C~MPLETION OF Building Inspector. FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTt~ENT TOV~N CLERK'S OFFICE SOUTHOLD, No Y. ~p~ro~ed ........................................ , ~ ........ ~J~ ~o ..... ~..~.......~ .... 5Z.. ~ Disapproved a/c ............................................................................................. ....................... ........................... APPLICATION FOR BUILDING PERMIT Date ...~..~ ............. .~./.. ............ ,9.~...~ INSTRUCTIONS o. This application must be completely filled in by typewriter or In ink and submitted in duplicate to the Buildif Inspector. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or pubhc streets areas, and giving a detailed description of layout of property must be drown on the diagram which is part of this applicatlc c. The work covered by this application may not be commenced before issuence of Building Permit. d. Upon approval of this application, the Building Inspector wdl issue o Building Permit to the applicant. Such pern 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 Occupan shell have been'granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Deportment for the issuance of a Building Permit pursuant to t Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances Regulations, for the construction of buildings, additions or alterations or for removal or demolition, as herein describ The apphcant agrees to comply with all applicable laws, ordinances, buildilqg code and regulations. ........ ......................... (Signature of applicant, or name, if a corporation) / ' ~ z- .... T ................................. ~ ...... ~ ....... (Address of applmcon~ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or bull. Name of owner of premises ..... /~..~.~..~..&.S. ...... R.e.~.~.~.~.. C,4.~..,..L.~ ........ 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 ................ Street and Number · ...~...(..~/.,i~ ,. L~!.~..o....c[..~..~..¢...~.:..~ ...... .~..~Z.~.~..¢~.~..~.~..~, ....... ~.,.~..... ...................... ~ Municipality / State existing use and occupancy of premises and intended use and occupancy of proposed construction' a Existing use and occupancy ........... ~..:.~' ,.../~.~.....i~..~-. A.~,...~.~..~,.~ ...................................................... b Intended use and occupancy .................. J~.~.~ ..... R.o.O ~..~ ................................................................. 3. Nature of work (check which applicable)' New Budding .................. Addition .....~... Alteration ................ Repair .................. Removal .................. Demohtion .................. Other Work (Describe) ..................................... 4. Estimated Cost ...~.~..~...~...~..,...~.~ ............................... Fee ........................................................................................ (to be pa~d on fihng thru application) 5 If dwelling, number of dwelling units ...... ~ ..............Number of dwelling umts on each floor If garage, number of cars .......................................................................................................................................... 6 If business, commercial or m~xed occupancy, specify nature and extent of each type of use 7. Dimenmons of existing structures, if any' Front .... ~. F...rT.. ....... Rear ....~.~.Tf...~'. ................ Depth .....~.*.'..~.~..~. Height ...../..~....~.~ ..... Number of Stories ....2~..~'.P2~: ............................................................................................ Dimenmons of same structure with alterat,ons or addmons: Front ....... ..~..C...?....~'.. ............ Rear ....~..?...~.....'~.. ....... Depth ....,~.&.~....?..../['... .......... Height ...... ~'.~...~..../~. · .... Number of Stones .../ .......................... 8. D~mensions of entire new construction Front .... Z~. ~..~..: ................ Rear ..... t.~,~....~.. ,~',,.. ..... Depth .~...z.~..~.,. ..... Height ...~'..~.....f./.'~.. Number of Stories ..... ./. .................................................................. ; .............................. 9. S,ze of lot' Front .Z..~.F?.:..~....~....~../.~.'. Rear ./.~.f~ ...f ~ ........... Depth A.~...z.~.z..~.¢ ..... /..~.~..~.. 10 Date of Purchase ..... ~...~..~..~.~..~..i~..Z:3. p/.~. ~'..~./. ..... Name of Former Owner ~'~.~..'...~..f....~'.~.~.i~.~£..A/z....~.~..~ 11. Zone or use dmtnct in which premmes are s~tuated ................................................... :"i[-' ..................................... 12 Does proposed construchon violate any zomng Iow, ordinance or regulot~on~ ....~..¢.~.'.~'. ....................................... 13. Name of Owner of premises/~.~.~.$.~.../).....</t./~.~.4..&..Address ..~..v~.T.G~..~.~...~.I~. ............. Phone No. 7.,~.~.?.:~.~.' Name of Architect ............................................. Address .................................... Phone No. Name of Contractor .~..&.3/.~..$.~....~..:....~..a..~/..~.....Address ..2~N.T..~..,i.17.~..¢....~. ........... Phone No .~.,3.,..?~...~.~ PLOT DIAGRAM Locate clearly and distinctly all buddings, whether existing or proposed, and red,cate all set-back d~menmons frorr property hnes. G~ve street and black number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF N~JG'",~ i,¢ ¢ ...... .................... ~~....f.....! ....................... being duly sworn, deposes and says that he ~s the apphcant (Name of individual sigm n~p/~)ho~o~n) /~ above named. He ~s the ......................~...~...~ ............................................................................. (Contractor, agent, corporate officer, etc.) of sa~d owner or owners, and is duly authorized to perform or have performed the said work and to make and this apphcahon; that all statements contained m th~s apphcahon are true to the best of his knowledge and behef, ant that the work wdl be performed m the manner set forth m the apphcation filed therewith Sworn to before me this n~ -- z ............ ~4....~da]~f .~ ............ , 19.~.~.. ~ ~ .... ~ ~ ~ .... ?.~ .... ~_M~...~ .................................................... Nota~ Public, ~~.~ounty ~ (Si~n~tur~~;~ " Comm~ss~o~ Expires ~arch 30, Z~