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HomeMy WebLinkAbout4190-zFORM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte Of Occupnncy No..Z%~t~2 ..... Date ......... October' 'lTi ...... , THIS CERTIFIES that the building located at ... l~nnehaha. Bird. ....... Street Map No.. X~ ........ Block No..XX ....... Lot No...2 ..... $outhotd .............. conforms substantially to the Application for Building Permit heretofore filed in this office ~~~t[~ ......... 'Feb;' '21% TM 19-69 pursuant to which Building Permit No...~t .......... Feb'.' '2~ .... , 1969., 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 . Pr~vat~ 'one 'fam.~'~'y' dwelling ....................................... The certificate is issued to .. ~/i']:ta;'d · Van~erb'e~k ....... owner ................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .. N.,R o ............................. UNDERWRITERS CERTIFICATE Ho....N...R. e ...................... ' ............... HOUSE NUMBER 2.21~ .... Street 1.ii.n~.enaha Blvd, ................................................. ,S.o.u.t..h.o.Z.d. ..................... ................. ..... Building Insp~t'o'r'~ ......... FOII~ NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE $OUTHOLD, N. Y. BUILDING PERMIT CT'HIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 4190 Z Permission is hereby granted to: at premises located at ............ ~d~... ~*~....~Jt~n~l~&..~l,~l~ ........................................................ ..................................................... l~outhel& ....... 1I.~, ....................................................................... pursuon~ to applicotion doted ............................. ~..Q~ ..........~t: ........., 19.~.., ond opproved by the Building Inspector. Fee $.,~,~:~ ............. Building Inspector IFORM ,NO, TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. .'Examined ...~.,ff:~'. ........ ' ..... Approved .......... I., ..........19 . :.. Permit No../~:~. ~...c~.i.). [~:~... Application No...4-I i. ~ .~,!, ~:,~. · · Disapproved a/c ............................ ~ .~.~..~.~. ............. ........................ (Build~g ~C~) APPLICATIQN FOR BUILDING PERMIT INSTRUCTIONS a. This applieati.on must be c.ompletely filled in by typewriter or in ink and .submitted in duplicate to the Building Inspecbor. b. Pl, ot plan showing location of t~t and ~of buildings on premises, relationship t.o adj,o.ining premises or public streets ~m' areas, and giving a deiailed description of layout of property must be drawn .on the diagram which is part of this application. c. The work covered by this applicatkm may n,ot be commenced before issuance of Building Per, nit. .d. Upon approval ,of this application, the Building InspeS~or will issue a Building Pe~rnit ~o the applicant. Such permit shall be kept t~n the premises available for inspecti'nn throughout the progress of the w~ork. e. No building shall be occupied or used in whole o~ in part t}o~ any purpose whatever until a Certificate ~f Occupancy shall have been granted by the Building Inspect~r. APPLICATION IS ~Y MAI)E to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of S,~uthold, Suffolk ©dur~iy~ New Y.ork, and other applicable Law, s, Ordinances ~or Regulations, for the construction <ff build ings, additions or .alterations, or f, or removal or demo- lition, as herein described. The applicant agrees to comply with .all applicable laws, ,ordinances, building code, h.~using code, a~d regulations. .... ............ (Signature ,of .applicant, o~ name if a corporation) (Address of applica~nt)// State whether applicant i,s owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder .. ~../) z'...~ .~..,~..~ .............................................................................. Name ,of ,owner of premises /~../.~..~..~../~g~[... (~.~.A./.Yp.~./~..~.~..~..~ .......................................... If applicant is a corporate, sig?ature of duly authorize d ,~ficer. ... ).... (Name and title of corporate officer) 1. Location ,of land o,n which prop(~sed work will be done. Map No ................. Lot No .............. Street and Number ,/~.1 ~,/z-'.,~,,~ ................................... 2. State existing use and occupancy ,o'f premises and intended use and ,occupancy of p~oposed construction. ' a. Existing use and occupancy .................... .5..,i..~..< ~. ~ ............................. b. Intended u.se and qccupancy ............ ..~. ~7.4~.~. ~ .............................................. 10. 11. 13. Nature of work (check which applicable): New BuiIdiug ........ Addition ...t~..... Alteration ........ Repair ......... Removal ........ Demolition ........ Other Work (Describe)~.~.~.~...'.~?..N.~..~ ...... Estimated Cast ...~...'-~.. ~ ....................... Fee ................................................. (to be paid ~n filing this application) If dwelling, number ,of dwelling units .......... Number af dwelling units on each floor .............. If garage, number .o{ cars .......................................................................... fi' busin6ss, commercial o~r mixed occupancy, specify nature and extent of each type of use .............. Dimensions of existing structures, if any'. Fro~nt ~.~.~ ....... Rear . .~ .......... Depth ~.~.~. ....... Height .../.~. ......... Number of Stories ../. ................................................... Dimensions .of same structure with alterations .or additions: Front ....~..~ ........ Rear ./.?. ......... Depth . .$.~. z. .......... Height ../. ~ ........... Number of S~ories ../. ................. Dimensions ,of entire new construction: F~3nt ................. Rear .............. Depth ............ Height ............ Number ,~f S~ories ............................................................. Size of }at: Front ................ Rear ............... Depth ............... Date of Purchase ............................... Name <Yf Former Owner ............................. Zone .or use district in which premises are situated. ~.~.~.~?..~..~. ?T.~. .~...~. ............................. Does proposed construction vi.elate any z,3ning law, .ordinance or regulati,3n? ./q..~. ..................... Name .of Owner ~of premises/~././..z.~.~.~. .~.~.~P..i~'~..~. ~dress . A..~.¥ ;~.~..~.~. ~..~. '.~.,.. Ph,(me No ............ / Name of Architect .............................. A'ddress ...................... Ph,sne No ............ N. ame .of ContracVor .~.,¢~/~A~.Y..X='g~ ./<4.¢.~?.~..~... Address . .,F..o..~..2q..~t~. ~ ~ ..~..a.~¢.. Ph,sne No.~.~...~..~.~. y PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing .or 'proposed, and indicate all set-back dimens$ons from pr~o.perty lines. Give street an,d block number ,~r descripti.on ac¢ording to deed, and show street names and indicate wheiher interior .or corner lot. STATE OF NEW YORK, )S.S. COUNTY OF .............. ) .... .-.~'-..~.?¢.3..~....Y~.( .¢...~.d:/?..~..~..~. ................. being duly sworn, ,deposes and sa~s that he is the appli- (Name ,of individual signing application) cant above named. He is the ...~.~ 7. ¥.~..~..~-.../-~... ....................................................... (©ontractor, agent, corporate officer, etc.) of said owner ,or ,owners, and is duly auth,orized to perf~3rm or have per~ovmed the said w~rk and ~o, 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 ;v,m'k will be perf,ormed in the mann er set forth~ in the application filed therewith. Sworn ~o before me this (Signture of applicant) APPLICATION FOR BUILDING P~RMIT Date .................... .~. (.Z..~. ......' :9.~. INSTRU(;riONS a. This application must be completely filled in by typewriter or in ink and ~ubmitted in duplicate to the Building Inspector. b. Plot plan showing location of lot and of buildings o n premises, relatimmhip to adjoining premises or public streets or area~ and giving a detailed description of layout of property must be drawn On the diagram which is part o.f this application. C. The work covered by this application may not be commenced before issuance of Building Permit. d. Uptm 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 o~ in part for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS l-~a~.~Ry MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk Oounty, New York, and other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demo- lition, as herein described. The applicant agrees to eom ply with all .applicable laws, ordinances, buliding housing code, and regulations. (Signature of applicant, or, name if a corporation) / .............. ........... ~),~,~ ~ ~~_ ~ (Address of applicli~t) / State whether applicant i~ owner, legsee~ agent, architect, engineer, general contractor, electrician, plumber or builder.. ~. ~../...,4 .~1)..,i~.,~, ......... ~t/ ...... ................................ ; ....; .................... ¥ Name of owner of premises ./~./.z..R .~,~/... ~/..~..~..i~.~'~AT.~..A~ ...................... ~ .................. If applicant is a corporate, signature..of_ duly authorized officer. (Name and title of corporate officer) 1. Location of land' on which propesed work will be done. Map No ................. Lot No .............. Street and Number ff.~/A~/.~.~..~1 .k/..~..~..g..~. ~) ...... .~.p..o.T' .~..a..L..(~)~ .~...~.. ~ / ~ ~ ~/~ ' Murli~i~'a~ .................... 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction. a. Existing use and occupancy ../....~.-~'ff..'~/..,!.,~....,~...~...~..~..~./.'.~..~. ............................. b. Intended use and occupancy ................................ -. ......................... Be 9. 10. 11. 12. 13., Nature of work (check which applicable): New Building ; ....... Addition ~. ...... Alteration ........ Repair ......... Removal ........ Dem01~ti.0n.. ....... ~)ther Work (Describe)o..ff./..~.. ~.~.~.c.'~. ...... Estimated Cost ...~'~... ] ................ ~. ......Fee'. ................................................ . . (to be paid ~n filing this application) If ,dwelling, number of dwelling'units .......... Number .of dwelling units on each floor .............. If garage, number ~f cars .......................................................................... If business commercial or mixed occupancy, specify nature and extent of each type of use .............. Dimensions of existing structures, ff any: Front . ~.: ........ Rear ~.~.~. ........ Depth J.~.' .......... Height ...~.~ ......... Number of StOries .ff ...................................................... Dimensions of same structure with,~ alterations o~ additions: Fpont .. ~. ~ ........ Rear ~..~ ............ Depth . ~.¢ ........... Height . .¢~ ........... Number of Steries .'.] .................. Dimensions of entire new construction: Fro~t ................. Rear .............. Depth ............ Height ............ Number of Stories ............................................................. Size of lot: Front ................ Rear " Depth ............... Date of Purch.ase ............................... Name <~ Former Owner ............................. Zone or t~se district in which premises are situated, f..~.q .~.Z?.~..~..~..~..~..4. ............................. Does proposed construction violate any z~ning law, .ordinance or regulation? . ~4.~ ..................... Name ~f OWher.~ premises~/~.~..~..~)./~&~.~k'~.~c.~Idress . ~.~. ~.~. 9~.~. ~..~.... Phone No ............ Name of Architect ............... ' ....... ; ...... Address ......................! Phone No ............ l~ame of Contractor ~'&'AL~..~'t,.~ff.~..~.s./.~... Address . A~.,~...~..~'. P..~...~..~.')( 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 de scriptJon acoording to deed, and show street names and indicate whether- interi°r or co~ner tot. STAT~ OF N~W YOR~, )S.S. /~'~ COUNTY OF .............. ) ' ' · ... ~ ~.4~. ~ ~ .~ ~/.~ · ~ ................. bein~ duly ~ : .... swo~, ~e'i~ ~e~ppli- (Name of ~dividual signing application) c~t a~ve n~ed. He is the ...~ .~. ~. ~. ~.., ...................................................... (~on~a~r, a~t, ~r~ate ~icer, etc.)  .o~e~, ~nd ~ly~aU~z~ to P~dr~ ~a~ ~~k~d ~k ~d ~ m~e ~d cation, ~ ~1 ~tateme~s ~ntain~ in ~is application ~ ~e to the best of his knowl~ge ~d t ~e ~k will be p~ in the mann er set fo~ in the application filed the~with. ~ me ~is , ' , ........... .... .. . · NOTARY PUBLIC, Stete of New Yorl( No. 52-3233120 Suffolk Count~ Term Expires ~rch 30,