HomeMy WebLinkAbout3643-zFOI~M NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
CERTIFICATE OF OCCUPANCY
No. ~...~.0.'/.S ............. Dote ............................ ~l,a~. ....... ~.3., ...... , 19..~.~..
THIS CERTIFIES that the building located at .~,~t~tl..~,.~.~.~. .............................................. Street
Map No ....................... Block NO ....................... Lot No..~,M~O.c~tl.e,,...~^.~a....~.~.~...~..~.~; .........
conforms substantially to the Application for Building Permit heretofore filed in this office dated
............................. .(1..e.~.~.~....,..2...6. ............... , 19..6.7.... pursuant to which Building Permit No.
dated ................... ~.~.....,~1~ .............. , 19..~'~.., was issued, and conforms to all of the requirements
of the appUcable provisions af the law. The occupancy .for which this certificate is issued is ........
~.~ ~a..~.e.....e. ~.u.~. ..........................................................................................
The certificate is issued to ....'~"'O'~.~.}.),..~..~.~;...~.~.l;i~t,~'~...~l'tt~...~ ........................................
(owner, lessee or tenant)
of the aforesaid building.
Building Inspector
· TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
$OUTHOLD, N. Y.
BUILDING P£R~IT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
36~3
N? z -
Permission iS hereby granted tO: . ' -
.... ~.t.e~:.e. ..............
/ . dale'~ ~e~ r~ 1 9..~..?,..,
pursuc~r~ to application x o; ........................................................... , and approved by the
Building Inspector.
~,vO ...
Fee $.~..' .................
NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Approved ........................................ , 19../..*...Permit No. ~..~.~./....~./..'.u~....~..'..~.
Disapproved e/c ....;.~¢...~ ...........
.................. '/'"'?' "("::'~;~(Buildin~ector) ........................................................
Application No. '~ ~4/~
APPLICATION FOR BUILDING PERMIT
Date ......................... ~,~.,.~ ............ ~J~. ........ , 19..6.~. .....
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 punic 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 ~he
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.
c~ntr~ctor
If applicant i~ 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.: ........................
Street and Number )¥~nln Rd ~utchogue
Municipality
2. S%ate existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy D.i~t.b..~.O~,I. Sf~ ...........................................................................................................
b. Intended use and occupancy ss. ma with an adc~..t%ion
3. NatUre of work (check which applicable): New Building .................. Addition ..~ ......... Alteration
Rep~air .................. Removal .................. Demolition .................. Other Work (Describe)
4. Esti~nated Cost ....~...O.~.Q...0..O......~..~.~. ............................. Fee ...~...
!
(to be paid on filing this application)
/
5. If c[welling, number of dwelling units~...O.~,e. .................... Number of dwelling units on each floor .......................
If g'arage, number of cars
6. If lbusiness, commercial or mixed occupancy, specify nature and extent of each type of use
7. Dimensions of existing structures, if any: Front ............................ Rear ................................ Depth
Heij2ht ........................ Number of Stories
Din'~ensions of same structure with alterations or additions: Front .................................... Rear
i..
Del~th ................................ Height ............................ Number of Stories ................................
8. Dimensions/ of entire new construction: Front ......... ,~ ....................... Rear ....... .."~ ................ Depth ...~.~(~ ......
Hei.'ght .................... Number of Stories ....... .O.~.~. .......
9. Siz~ of lot: Front ............................ Rear .................................... Depth ................................
10. Date of Purchase .................. ...................................... Name of Former Owner
1.
Zor~e or use &strict ~n which IPrem~ses are s~tuated
Does·r proposed construction violate any zoning law, ordinance or regulation? .......................
12.
]3. Na!ne of Owner of premise~,.~.~.,.C.,...C.~,U.b. ............... Address ....... (~,l;~..?~.O~t~" ............... Phone No.
Nar}ne of Architect ..,~..~;~.I~G~J.O ........................... Address ..G~.~,~...~e~c ................. Phone No.
PLOT DIAGRAM
Locat,e clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions
property I)nes. Give street and bl.'ock number or description according to deed, and show street names and
whether in lerior or corner lot.
STATE al
COUNTY
NEW YORK, I. c ~
OF ~t.:£.~:J.~- ............... ~ ~'~'
................................... ~'~.~e~}~....JS~;~'~C)~.~,~J, ....................... being duly sworn, deposes and says that he is the applk
' Name of individual signing app ica,ion)
above named. He is the .......................... (]O~;~.~e.~;O~. .......
i (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
this appIi~,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 Jn the application filed therewith.
Sworn to I~efore me this
~I ~(~ day of ~e.~1~ 19 ~. ×, 'J ~"~, .' /~ / ,' ~
I --~ .~ .~ ~-- .....~..,. ............. ~ ............ l .................... 7. .........
Notary Pqblic, ~.]..~ .~...~..?.(.:.!...~.~.. ......... County· / /' (Signoture of applicont)
Term ,Ex/)res M~arch 30, 19/~.~