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FORM NO. 4
TOWN OF SOUTHOLD .
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No. .Z. 3455....
Date......... .Ap.xil... .15,.....,19.69.
THIS CERTIFIES that the building located at Pvt....Rd. 0.££ . Vanston .Rd.. Street
Map No. NaasQu. .P.t. Block No. ......... .Lot No. .Cutchogua,. .N.Y...............
prop.
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ... NOVßIMe:¡:. . .n, . . ., 19.613. pursuant to which Building Permit No. . .41:3.6. .3
dated ... NovßIMer. . .21,. . . ., 19.6.8, 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 . . px:ivat.e .one. .family. dwelling. . . . . . . . .. " .. . . . . . . . . . . .. . . .' . . . . . . .
The certificate is issued to . .E. R.. . HP~land. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval
.............................,..,.. .
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. . . ,J/j¿;N/?m?<.:. .tA'./v.~. 8.í¡< ., . . . .. ..
Building Insptf!tor
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FORM 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)
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4136
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Permission is hereby granted to:
...... .... !.~.. J~~.':!r !::ç;j'; ]S;,.. .~If... 7.~.~i.~ .~"-Q:Ulmd..
...................... ){.¡.t.:t. t1.t'w:Ik....................................
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to ..IJ.,;'..1.i'!...~r....fi~\~i.t~!.':;'..LIiQJ:¡¡¡cr."'..r.:r... s.n...ex.1s:t;;,I.4;..dvelUna..............................
..............................................................~?·ï..·:.:.:·:3·;¿;:V'..··..··..··..·..··...··..·.....··..········..··..······.........
at premises located at .............. X..ç¡1;.. .ft.... .'II.:;';. .;.~).;..1: ¡;,in t.. ,,~.. .r.rgp........ .....................................
.......... ............... .... ......~º.~.!f.~.. .~f.r... .y~.p..~.Ki~..)1Q.Ç:.a.. ........c.w:.alMa................................... .......
................................................................................................................................................................
pursuant to application dated ...............................;:r.9..,........~t........., 19...<..~·.. and approved by the
Building Inspector.
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Fee $..t..,.,..~..............
. ....../rk:.:4G.~..~...L~:\1.:~~t.....................
Building Inspector ,
¡FORM :NO. 1
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TOWN OF SOUTHOLD'
BUILD"ING DEPARTMENIf
TOWN CL!E.RK'S OFFICE
SOUTHOLD, N. Y.
Examined... /'VtÝ...~.\.., 19.G.I~
ApprJVed . . . . . . . . . . . '. ~. . . . . ., 19 . . . . Permit No. ~ 1.3.. ~ .~. . . .
., L-( (j 6
ApplIcatIOn No. ................
Disapproved alc .......
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. . . . . . . . . . .
......................................\j/..........~.........
.............!.. .... '(B~¡;;;:~""" ..............
APPLICATIO.:: FOR BUILDING PERMIT
Date..... ....... ~.qy!'J:uJ.'9!'J.~.. .. .. .41.. 19..68
INSTRUCTIONS
a. This applicati.on must be c.ompletely filled in by typewriter or in ink and submitted in duplicate to the
Building Inspector. .
b. Plot plan showing l.ocation .of ¡,at and ,of buildings 0 n premises, Ì'elatÌiCmship to adjoining premises or public
streets O'r areas, and giving a detailed description of layout of pI'operty must be drawn.on the diagram which is
p8.rt of this application.
c. The work covered by this applicaHan may Dc>t be commenced before is¡m,ance of Building Permit.
d. Upon approval of this applicatk,:¡, the Building In spectc>r will, issue a Buildiug Permit to the applicant.
Such permit shall be kept ,an the premises available for inspection throughout the progress .of the work.
e. No buildiug shall be occupied or used in whole CIJ in part Dor'any purp:ose whatever until a Certificate ,af
Occupancy shall have been granted by the Building Ins pec1100'.
APPLICATION IS HEREBY MADE to the Building Department fo:r the issuance of a Bui1ding Permit pursuant
ûO the Building Zone Ordinance of the 'Down of SO.ltho Id, Suffolk Oóunty, New Y,ark, and other applicable Laws,
Ordinances or RegulaÜons, for the oonstruction of build ings, additid:ns or aliel;'ations, or f.or removal or demo-
lition, as .herein described. The applicant agrees to com ply with all applicable laws, ordinances, building oode,
hausing code, and regulations.
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. .... .. .~o.~t;P? J?~~f~O~~~... ...... ...... .........
(Signature .of .applicant, or name if a oorporation)
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. .. .. . Me. t.tituck· . .. . .. . . .. . .. . .. .. .. .. .. .. .. .. .. .
(Address of applicant)
State whether applicant is owner, lessee, agent, arch it eel, engineer, general contl'actar, electrician, plumber or
builder. . . ... ......... . . . .Contra.ctor.. .... .' .. .. .. .. .. .. .. .. .. ...... ., '" . . .. .. .... .. .... .. .... .........
Name >of ,Owner of premise¡; ....E. K.Holland. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..........................
If applicant is a oorporate, signature of duly authorize d .officer.
. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name and title of corpo'rate officer)
1. Location.of land on which prO'posed work will be done. Map:No. .~i'I:~~"-.~. pq:j.:t. ~o. .............
Street and Number ........... Pv.t . Road. .off . Vans ton. Road. . Nassau. Point. Cutchogue . . . . .
. Municipality
2. State existing use and ,occupancy <of premises an d intended use and >occupancy of proposed oonstruction.
a. Existing use and occupancy .... P:v.t. .ane. .fam. .dwe.lli;ng. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Intended ttseaml üCcupancy .... Same .with. a.ddition..(. .Dormer) ..........................
. ' ,. "¡ .. ,Ii"
'-",' .. ~",._,.__"". *<.,l. ~-¡ft ~.'
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9.
10.
11.
12.
13.
(check which applicable): New Building ........ Addition .. ~ . .. Alteration .. .~. . .
Removal ........ DemoJition .. . . . . .. Other Work (Describe) ......................
..9.9P ...t.... . .. .. .. .. .. . . . . .. . Fee .5 ~ qq. .... . .. . .. .. . .. . . .. .. .. .. .. . .. . .. .. .. .. .. .
(to be paid on filing this application)
5. If dwelling, number ,of dwelling units . .Q~.~ . ... Number of dwelling units on each floor. .... ...... .. .
If g.arage, number 'of cars ...................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If business, commerdal ,ar mixed occupancy, specify nature and extent of each type of use..... ...... .. .
Dimensilons of existing structures, if any: Fl'(ynt . . . . .... . . . . " Rear ............. Depth .............
Height ................ Number of Stories .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dimensions of same structure with alterations or additions: Fl'ont .............. Rear ...............
Depth ................ Height ................ Number of StOTies .....................
8. Dimensions .of entire new construction: Front. . . .18. ., ... . . ... Rear.... .18.... '" Depth............
Height ............ Number {If Stories .. + . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Size of 10t: Front ................ Rear ......... . . . . .. Depth ...............
Date of Purchase. . .... . . . . . . . . . . . . . . . . . . . . . . . . . Name af Former Owner .............................
ZOne or use district in which premises are situated. .. .'~~~'. .41.:!it. .. " .. .... . . .. .... .................. .
Does proposed construction violate any :¡¡oning law, ordinance or regulation? .. ...... no................
Name of Owner'of premises .?..~.ß:.q¡¡~l,lÇl.. . .. . Address '" 9:t!"!;ÇÀ9g:qf,1.... ... Phone No. ...........
Name of Architect ............................. kddress ...................... Phone No. ...........
Name ·of Contrac1Jû'r ..J.. De.e.~ko.sk1.......... Address..... .Ma..tti:t.uck.... Phone No. ...........
3. Nature of work
Repair ... . . . . . .
4. :Estimated Cost
6.
7.
PLOT DIAGRAM
Locate dearly and distinctly aU buildings, whether existing or proposed, and indicate aU set-back dimensions
from property lines. Give stTeet and block number 000' de scription according to deed, and show street names and
indicate whether interior or corner 10t.
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STATE; OF NEW YORK, )S.S.
COUNTY OF .fJ'\l.:t::fplk....)
. . . .... .. .... . . .. . .J.oã.eph. Deer.ko.sk1.. .. .. .. " .. . being duly sworn, deposes and says that he is the appli-
(Name IOf individual signing application)
cant above named. He is the .... ,C on tra.c tar. .. .. . .. . .. . .. . .. .. .. .. .. .. .. .. . .... .. .. .. .. .. .. .. .. . .. . ..
(Oontractor, agent, oorporate officer, etc.)
of said owner ,or lowners, and is duly authorized to perf,orm or have perflormed the said w JJ:'k and to make and
file thl,s applicati'Ûu; that all statements oontalned In th is appJicaUon we true to the best of his knowledge and
belie:ê; and that the wtork will be perfocmed in the mann er set [,orth! in the application filed therewith.
Sworn to before me this
.......... ..2:1.. ~ay of ....... No:vember. 19.6.8 0 ~ ~-
No1ary Public7J?çÇd:l..ut.f':. {'-l.~. ~;¡;'ty J..._..J!Þ n .. . t. '(. . (Signtu~e' ¿f' ~p~iid~~Ù' .. .. .. .. . .. .. ..
MILDRED Ctl~PM eW Vork y-- IT'
NOTARY 5i~~il~io~"t~U:lf k GOU~~
com~~·s\On ExpIres March 30.. 19 I