HomeMy WebLinkAbout3616-zF~RM NO. 4
TOWN OF SOUTHOLD
BUILDING D~EPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
CERTIFICATE: OF OCCUPANCY
No. Z...,~li~5 ............. Date ............ ~Ug.U~.'I~...2..7... .................... , 19....6.~..
THIS CERTIFIES that the building located at ..lf. llo[l~oc~.Lane .................................. Street
Map No ....................... Block No ....................... Lot No..Ma.tt~ttt~.~]C.,...~..e.~....~...o.~. ......................
conforms substantially to the Application for Building Permit heretofore filed in this office dated
.................... E~J~te~ll];;~:~...].;[., ............... , 19.6.'Z.. pursuant,to wh ch Building Permit No..~1.63,.6....~..
dated .......... S~pt. IBF, lbtt;J'...1,J,t ............. , ] 9..6.~., was issued, and conforms to all of the requirements
of the applicable provisions of the Iow. The occupancy for which this certificate is issued is ........
..... pr :l,~a,te...one.. ,f, am~l.y.. ~elllnc~ .........................................................................................
The certificate is issued to ...gustaste...K~.tma~Lns...Jola~e,l:) ...........................................................
(owner, lessee or tenant)
of the aforesaid building.
Bui[ding Inspector J
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
~ SOUTHOLD, N. Y.
N?
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION oF'THE WORK'AUTHORIZED)
Permission, is
r-BuJldih~:lns~ctbr: ', '; : -
".Fi.e .., , ,,
approved by the
FORM NO, 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWF/CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined ...................................... ~"//'~ // , 19 ........ ~ ~
Approved ....................... h? .............. , 19 ........ Permit No ........
Application No, 3~/~/~'
APPLICATION FOR BUILDING PEP, MIT
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in init 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 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 rto comply with all applicable laws, ordinances, building code and regulations.
...................................
........ i~i~'~'r'~"~' app~ant, or name, if a corporation)
............. ..........
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
......................... ...........................................................................................................................................
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
1. Location of land on which proposed work will be done. Map No.: ........................................ Lot No.: ........................
Munici~ lity
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ........ ". ........ ~. ...... ~a..~..~..~.~.A .................................................................
b.
Intended
4.
5.
6.
11.
Nature of work (check which applicable): New Building .................. Addition .................. Alteration
Rep,lair .................. Removal .................. Demolition .................. Other Work (Describe)
Esti~nated Cost~/2 ~oo 0 ........................................................... ~ Fee ................................
j (to be paid on filing this application)
If c~well ng, number of dwelling units ................/. ........... Number of dwelling units on each floor
If ~arage, number of cars
If ~usJness, commercial or mixed occupancy, specify nature and extent of each type of use
· ..~. ........................... Depth
Dimensions of same structu~re with alterations or odc~itions: Front ....~..~?..~..~ .................... Rear ./~..~"~..~.
/
Dim, ensions of entire new construction: Front ........ ...-~. ....................... Rear ........ ~ ............... Depth
Hefght .................... Number of Stories
Zo~ or use district in which premises are situated
Do~ proposed construction violate any zoning law, ordinance or regulation? ../Z'.~¢.~....~. .........
Nah~e of Architect ...................................................... Address ............................................ Phone No.
PLOT DIAGRAM
e clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions
nes. Give street and block number or description according to deed, and show street names and
~erior or corner lot. ~
Local
property I
whether in
CZ
STATE 01~ NE O~R~, 1. c ¢
COUNTY|OF ................................ ~ ~"~'
................ i ................................................................................ being duly sworn, deposes and says that he is the appli~
: (Name of individual signing application)
above named. He is the
(Contractor, agent, corporate officer, etc.)
of said o~ner or owners, and is duly authorized to perform or have performed the said work and to make and
this application; that all statements contained in this application are true to the best of his knowledge and belief;
that the ~ork will be pe in the manner set forth in the application filed therewith.
Sworn to Before me this
.. day of
Notary P~ blic, :ture of applicant)
MILDRED ~HAP~AN
NOTARY PUBLIC, State of
No. 52-0618100 Suffolk Gount~.
gommmsion Expires March 30, 19~..~