HomeMy WebLinkAbout3347-zFORM HO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BERTIFIP. ATE OF E]CCUPANBY
No ...... Date ....
~i~ERTIFIES that the building located at .~.t.~.~.el, xg.. st~t
Map No. Block No. Lot No.~/~
conforms s~stantially to the Ap~catlon for Build--mit ~~9il~'~h'this office
dated ......... , 19~9~[ pursuant to which Building Permit No.
dated De~ ~]~... , 1 , was issued, and conforms to all of the
ments of the ap~able~ovisions o~e law. The occupancy for which this certificate is
issued is ....................................................
The certffic~-~e~ f, .~..].~r..~.,e..~.lJ.?g ..................................
Je~'~ , · ~ith (q~l, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval
Au~ 22~ 1966 by Re Yilla
FOEM 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? 3347 Z
December 22 19.,...6~...
Permission is hereby granted to:
.................. · 0~t~1 ..........................................
to ~r.e .. e~ ..exJ,~.tJ.~ .. ~1,1 ~r~...~.~....~b ~,.s... l.~..~.~.~.~..~...g~,~.t ~.~ ...~...9~.t .. ~.~.~zj
.......... ~e. ll~,ng ..................................................................................................................................
at premises located at .il/.S....-...~eaL.hre,t~...~...~..~l~.d, ...........................................
............................................... S~u~.J~ol~s..... ~ .~.o ..............................................................................
pursuan,t to opplicotion dated ......................... De~embe~. ....... 22..., 19..6~., and approved by the
Building Inspector.
Fee $..~LQ.°.Q~. .........
Building Inspector
TOWN OF SOUTHOLD
~ BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined .......~ .............................. , ........
"
Approved ........................................ , !9 ........ Permit No ................................
Application No ................... ..... .. ,..
D,sapproved a/c ~ ..............~ " ~ /~/&
'""" ' ' ' ' '~Du i'l*~i~' I rmpe~tq(r)
APPLICATION FOR BUILDING PERMIT
December 22 1-66~....
Date ............................................................
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 propertymust 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 Ce/tificate 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 Lows, Ordinances or
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, as herein described.
The applicant agrees t6 comply with all applicable laws, ordinances, building code and regulations.
(Signature of applicant, or name, if a corporation)
Southold
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor,' ~lectrician, plumber or builder.
g. ..................................................................................................................
Name of owner of premises ....~...e..~..r..~....~......~.~...~..~...~. ................................................................................................................
If applicant is a corporote~ signature of duly authorized officer.
(Name and title of corporate officer)
1. Location of land on which proposed work will be done. Map No: ...... 7~ ............................ Lot No: Z~ ............
Street and Number ~W/~.-.~W~ftS~]~Za~'Ch~.-.~`et?L~h~`~`~M.~1`e~u.t~'~~ ..............................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ......... .¥.~.0..~..~..~...~..~...~. ...............................................................................................
b. Intended use and occupancy ....... OZte...~e.rnJ 1 y...r1~zellJ_n&....-....~.g.V, fLqt...;[~,..~..[[~.9.~..e.~ ........................
3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration ..................
Repair .................... Removal .................... Demolition .................... Other Work (Describe) ...~Q~{tfJ...:L13. ...............
4. Estimated Cost ............................................................ Fee ....~...].Q, ..........................................................................
(to be paid on filing this application)
5. If dwelling, number of dwelling units ...~)Z~a ................. 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 ............................
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 ........ .~O ............... Rear ......... .~O .............. Depth ..~.?.~.(.a~..N,Z..3,ine
10. Date of Purchase .................. .3...~.6..~. ............................ Name of Former Owner .~.,...]~..~;.~ .....................................
l]. Zone or use district in which premises are situated....!!A.?...~,.o~e ..........................................................................
12. Does proposed construction violate any zoning law, ordinance or regulation? ...... ~ ..........................................
13. Name of Owner of premises .....[~,,-'2,~',~...~;L1;~ ........ Address ....~ec.oi::L~c ....................... Phone No .....................
Name of Architect ...................................................... Address ............................ ................ Phone No. ....................
Name of Contractor ....... ~....~.nl;:l; .......................... Address ....... Sott~;~;I.o;]~ .................. 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 an indicate
whether interior or corner lot.
STATE OF NEW YC~lJL~ ) I
COUNW OF: .......... ...... S.S.
................................ ~9.b~...L.,...H~.~tt ............................. being duly sworn, depos_e~s and says that he is the applicant
(Name of indivi(~ual signing application) j/~
above named He s the {;D, t3.1;,~a.c;I;D~ .................... Ik/~: ........................
(Contr&ctor, agent, corporate office~', ;tc.i' ..............................
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 al;t~ication filed therewith. ~
Sworn to before me this I' I K /x ~1 I' ~
2.2..dayof ................... 19.6 .. '
Notary Public,. ........................................................... County ......... (Signatur'"'"'"'"""""'"-e"~' a~l~1~i~:'~'~i ................