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Home My WebLink About3786-zFORM l~O. 4 TOWN OF SOU?HOLD BUILDIN~ DEPARTMENT 'I"OWI~ CLERK'S OFFICE SOUTHOLD, N. Y. EERTIFII~AT£ DF r~U~AN~Y THIS CERTIFIES that the building located at .B./.~....~.l~.lt' .~.~.~ ........... Street conforms substantially ~o the Applicati, on flor Building Permit heretofore filed in this office dated ......... ~ .... ~ ........ 196.~. pu.rsuant to which Building Permit No.. ~.~. dated ........... ~ ..... ~ .... 19.6~, was issued, and conforms to all of the require- merits .of the .applicable provisions of the law. The .occupancy ~or which this certificate is (owner, lessee or tenant) of the aforesaid building. ,Suffolk County Depar~men~ of ~ealth Approval ............ ~ ............................ Building Insb'~ctor FOEM NO. ~ 'TOWN OF $OUTHOLD 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? 3786 Z Permission is hereby granted to: .................. ~qS~:l.~m~ ....................................... et premises ~ocoted at ..~.~..~ .......................... ,......~ ..................... ~ ............................... ......................................... ~..~r~ ...... ~_~, ................................ i .......................................... pursuen¢ to application dated ........... i.,...i ...... ~Jt,~l ............ .~. ........ , 19....(~ and approved by the Building Inspector. ~ .Fee $..~0, ............ FO~M NO. 1 TOWN OF SouTHoLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Approved ........................................ , Permit ...... Disapproved a/c ............. ~::..; ........ -~:~. ....... L': :.'~ ........ *~:':: '-: '%%~' "L':.u~~'' '~'''~' ' ....... (Building InspCtor) Application No. ~ '~ ~''~ APPLICATION FOR BUILDING PERMIT Dote ...... .................... , 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, relotionshlp 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 o{ 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 Deportment 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 to comply with alt applicable laws, ordinances, building cod, e, housing, code, and regulations. .................................... (Signotu..~e o~ applicant, or name, if o corpor~;i~) State whether applicant is owner, lessee, agent, archi/t/act, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ................... . ..~...~.~.~.' ............................................................. If applicant is a corporate, sig'Kature of duly authorized officer. (Name and title of corporate officer) 1. Location of land on which proposed work wilt be done. Map No.: ........................................ Lot No.: ........................ Street and Number .................... ~- v -'~GC~r')C'~)'""D~'~ .......... ~..Z~,.r.~.......;.~'.,~.~, ................... ~ Municipalyy/ 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: o. Existing use and occupancy ............... , ................ .~.M~.. ........................................................... b. Intended use and occupancy ................................................................................................................................. 3. Nature of work (check which applicable): New Building Addition ..~- ....... Alteration .................. Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................ 4. Estimated Cost ...... ,~..~..;:~ ............................ Fee .......................................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ....... ~..~¢7~(,.~ ...... 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 ....~..z.(. .............Height .....~.. ................. Number of Stories ....... ~ ............ 8. Dimensions of entire new construction: Front ..... ~../...O.../~ .................... Rear ............................ Depth .~....(...~..../.~ ..... Height ..~)..r. .......... Number of Stories ........ ~.fz!~,.:. ..................................................................................... . ........... 9. Size of lot: Front ............................ Rear .................................... Depth ................................ 10. Date of Purchase ........................................................ Name of Former Owner ........................................................ 11. Zone or use district Jn which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning Iow, ordinance or regulation? ............................................................ 13. Name of Owner of premises ........................................ Address ............................................ Phone No ..................... Nome of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor .................................................... Address ............................................ 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 number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEWV'~'~_.~ COUNTY OF .~,~'.,g..~ ......... f~'~' .......................... · .~....~.~....~..~...~ ................... being duly sworn, deposes and soys that he is the applicant (Nome of individual signing application) (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 file this application; that all s~atements 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 application filed therewith. Sworntobefprezr methis~,,. _~ .................. .~.. day of ..... ~.~.~ ........... , ' ............ ............. ................... ........... ............. :[emi Exl)ire~ ~a crt 30, 19_~