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Home My WebLink About4576-zFORM NO. 4 TOWN OF $OUTHOLD BUff,BING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No.. ~.2.7 ..... Date . .J...u~...27. ................. , 19.. 7~ THIS CERTIFIES that the building located at .~..0.0.0..l.,l.a~.n...Ro.a.d. ......... Street Map No ............. Block No ...........Lot No .................................. conforms substantially to the Application for Building Permit heretofore filed in this office dated . p. qqe.~.b, ql,...~. ........ , 19..6.~. pursuant to which Building Permit No. ~?.6.~.. dated . .9.e.c..e.m.b.e.r.. 3. ......... , 19.6.~.., 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.r.i.v.a.t..e..5..ar.ag~. ................................................... The certificate is issued to ..... .~..~..a~...G.]..oy.q .~ ..................................... (owner, lessee or tenant) of the a~oresaid building. Suffolk County Department of Health Approval .................................... UNDERWRITERS CERTIFICATE No ............................................. HOUSE NUMBER...~?..0~.. ...... Street...l~.i..~..R.o..~..,..? .u.t.c.h.o..~..e.~...N.e.~..¥.o.r.k. .... TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING FERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? t576 Z Permission is hereby granted to: to ........ ~t..tS.&..e~-.me~e-.~l~a.- ~l~l~m, te .. tl~'a~le- ...................................................................... at p~i~s ~d ~t ................... ~...~..~ ...................................................................... .......................................................... ~~ ......... ~,~, ............................................................. pursuit to application d~ed ................................ ~.~ .........~ ...... , 19....~ and appr~ by ~he Building insp~tor. TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE Approved ........................................ , 19 ........ Permit No ................................. [ 3- . Appficaflon No ............................. Dtsopproved o/c ...................... APPLICATION FOR BUILDING PERMIT INSTRUCTIONS o. 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 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 applicable laws, ordinances, building code and regulations. (Signature of applicant, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premises ...... ~ ........ ~.'. ............................................................................................... If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Location of land on which proposed work will be done. Mop No: ............................................ Lot No: .................... Street and Number ..... ~ ...... '~ ^.~....~ ........ '~ '~ ~~ ...... ...~..,.~....A .................................................... MunicipUity State existing use ~nd occupancy of premises and intended use and occupancy of proposed construction: o. Existing use and occupancy ..............~. ................... ~ .......................... ~ .......................................... / b. Intended use and 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration .................. Repair ....................//Re~n°val .................... Demolition ............ ~:~Other~ Work (Describe) ~..~1~..~',/.~, 4. Estimated Cost ..... ~rrf'Z,fdC. ....................................... Fee-~...... ................................................................................ ,.. (to be paid on filing this application) 5. If dwelling, number of dwelling units ............................ 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 ...... /.~...~.~...:.f. ..... Depth ...../..~.......~. .......... Height ....L~'..! ................ Number of Stories ....... ~. .................. 9. Size of lot: Front ...... ~../..~) ........... Rear ...../.~'.O. .............. Depth ..~..~..~. .......... 10. Date of Purchase ........................................................ Name of Former Owner ...... ~.4x, e~,e~s~......(~.~ ..... 11. Zone or use district in which premises are situated ................................................................................................. 12. Does proposed construction violate any zoning law, ordinance or regulation? ........... ~ .................................... 13. Name of Owner of premises ..~.L~..~.Address ..~.~ .............. Phone No.~..~..~..'...~..~..~..~ Name 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 numbers or description according to deed, and show street names and indicate whether interior or corner lot. //(~ ~ STATE OF NEW Y(~K,_J.~ ........................... ~...~{~'1~~ ........................ being duly sworn, deposes and says that he is the applicant (Name of individual signing above ~med. He is the ......................................................................................................................................................... (Contractor, agent, co~orate officer, ~c.) of said owner or owne~ and is du.ly authorized to perform or have performed the said work and to make and file this application; that a I statements contain~ in this application are tree to the ~st of his knowl~ge and belief; and that the work will be perfo~ed in the manner ~t fo~h in the application filed therewith. Sworn to bede me this .......................... day of ..... Nota~ Public, .~~.~4~un~~a~ew'~m~'y~S,gnature of apphcont)