HomeMy WebLinkAbout3580-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
DERTIFIDATE BF EIP. BUPANCY
No. ~ .~30 .... Date ............. ~c~velllbe~¢., 9., 19..67
TEl]ES CERTIFIES that the building located at 8¢48.8~1~¢1r~. ,!~.teI¢' A~t~ ....... Street
Map ~o.;~ ........ Block ~To ..... ~ ...... Lot No. ~ .... lk~-%i%~t~- .............
cor~forms substantially to the Application for Building Permit heretofore filed in this office
dated ......... ,~llg ...... :~'!, 19 .~. pursuant to which Building Permit No...3.~8,0 .Z
dated .......... ~111~ ...... ~.., 19 '(~7" 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~.%Va~;e..olrte. ~.~i~4~ · ~.~4~.~f~lg ......................................
The certificate is issued to .~.Tr'b:~a. };¥,:~.l~rf[~. .... O~31, ...........................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ........ ~2.,i~, ......................
Building Inspector
FOI~M NO. 2
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, hi. Y.
BUILDING PERMIT
(THIS ,PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
Permission is hereby granted to.~.. _ .~ '
......... :.~:~.~ ~.~..~.~..~.~.!.~ .............
........ L~..~..~-~...~.(~.q..~.~.~.-.. ...................
............. ........................
to ....d...q..~.~...o...a~..&.~...~:.,..~.~,..~.~.~..~'..~.~.Z.c~.~ ....................
...~..~.....~.~.~m~:~.~ ....... .o....~....~.~.~.:..~.......~...~...~.~.,.,.~...~ ............
at premises located at ...?,,.~..,,~,,....,~,..~,.-,,q,.,~,.,u~,,~,,....~,.~..~..~,,~.-,i..-,~, ,~ ......................................
.............................. ~ .......... ~L~..~.~:...~..~.. ~ ............................................... ~. ........................
pursuan¢ ,o application dated ................... ~..:..,. ............... ;.,, .......... , 19..(~.~ and approved by the
Building Inspector.
Fee $ ...........
FO~M ~0.1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
~._..,~ ~ ~..~ '~ SOUTHOLD, N. Y.
Examined ........... ~ 9..~..~..
Approved ........................................ , 19. .. Permit No ..........................
Disapproved a/c .................... ~ .................. :,..,.~.r....~;;~ ...........
............. ........................................
(Building I~c~pector)
Application No.
APPLICATION FOR BUILDING PERMIT
Date ...... ..~. ·. · .~..~-~/~2~.~...~... ...... ~./ ........... , 19....'.~.Z.
INSTRUCTIONS
a. This application must be completfly 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 property must be drawn on the diagram which is part of this application.
c. The work covered by this application may not be commenced before issuonce of Building Permit.
d. Upon approval of this application, the Building Inspector will issue a Buffding 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 ncfmeM'f a corporation)
(Address or appficant)
State whether applicant is owner, lessee, agent, architect, engi'neer, general contractor, electrician, plumber or builder.
..............................................................................................................
Name of owner of premises .....................
If applica¢is a corporate, signature of duly authorized officer.
(Name and title of corporate o~cer)
1. Location of land on which proposed work will be done. Map No.: .......... .x ................... ~.... Lot No.: ........................
Street and Number ~~.~/.~..~.~ ....... ~..~Z.~¢ .........................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
,xis,., o.=,.,c, ......................................
b. Intended use and occupancy ...~ ............. ~ ............................................. ~. ..........................................................
3. Natbre of work (check which applicable): New Building .................. Addition ....... ~.. Alteration ..............
Repgir .................. Removal .................. Demolition .................. Other Work (Describe) ....................................
4. Esti~nated Cost .................... ,~..~/~?[2.~ ................... Fee
j (to be paid on filing this application)
5, If d~welling, number of dwelling units .............Z. .......... Number of dwelling units on each floor .......................
If g?age, number of cars ........ T. ......... ;..".....~ ............................................................................................................
6. If 6usiness, 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 a,lterations or additions: Front ....... ~4~..._...~ .............. Rear ..... ,.~'..~..~.~..
Dep,lth ...~,e~...:.'~...J(.o. ...... Height ..... ,~./.m-x ........... Number of Stories ...........
8. Di4ensions of entire new construction:
9. Siz~ of lot: Front ........ ,~,~..~..~ ....... Rear ...... ~,.~.~..: ................ Depth ........ ,~,,.~'~..~...~ .........
10. Date of Purchase ........................................................ Name of Former Owner .,~.~...Zz'.~/J¢'.~'~.~./. .......
11. Zor{e or use district in which premises are situated ..... ~.. ........
12. Doe]s proposed construction violate any zoning law, ordinance or regulation? ..~.~,
i of premises~.4C~/~cC.x~..l~..../-r~res~~.~.~.. Phone No.~
]3. Na~ne of Owner
Na~ne of Architect ...................................................... Address ................ m ........................ Phone No ...... ..~. ......
PLOT DIAGRAM
_ocot~ clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions fr
property lines. Give street and block number or description according to deed, and show street names and indic
whether in~erior or corner tot.
Notary Pt
blic, , County of apF
NOTARY PUlL!C, ,~r*i'e of New ~'
No. ~Z -69056~0
Qualified in ~uffolk County
Term Expires March ~0, Ig~
~eforeme this
}..~..... day
STATE O~ NEW,YO~P,,K, , } c
COUNTY OF ...~..q..P..~..~..¥.(5 ...........
....... !:~..~.....~. ........ : ....... (~.U..~,.....~.: .................................... being duly sworn, deposes and says thqt he is the applic
i(Name of md~wdual s~gnmg apphcat~on)
above narhed. He is the ..............................................
(Contractor, agent, corporate officer, etc.)
of said o.~ner or owners, and is duly authorized to perfarm or have perfarmed the said work and to make and
this applic;ation; that all statements contained in this application are true to the best of his knowledge and belief;
that the ¥ork will be performed in the manner set forth in the application filed therewith.