HomeMy WebLinkAbout3648-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
DERTIFIBATE OF DDBLIPANBY
No. Z..29~. · - · Date ............ Dee,~ .......... , 19.6-~.
THIS CERTIFIES that the building located at E/8 · - ~/ells. -~oad .......... Street
Map No...X~. Block No.. ~:X ......... Lot No.xx .... Laurels..N,Y., .............
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ...... l]tep~; .... 28 .... , 196~. pursuant to which Building Permit No.
dated ...... Sept ..... 28 ...... ,1967 , was issued, and conforms to ali of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is . .Pr~.v¢2e. one- f~Itt¥, cl~¢e!h~ag .............................
· ' '0 ........ ,.'b 'i .....
The certificate is issued to . ~iat'ti.~uek..Buitd~g ~ ~p , (2fr~¢r ,~: '~der
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ....
Building Inspector
FOKM NO. e,
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 3648 Z
Permission is hereby granted to:
........... l~l~t,~.~mk.~..i~,p .............
.................. Jiei.1.e..~m~ .....................................
....................... ~.e.~. ..........................................
to l~i~tld..ne~..cu~...fm~kl~..A~ .~n§ .....................................................................................
at premises located at .l~.;.~....~..~.~..]..JJ.....~..1~. ..........................................................................................
............................................ ..~...~.~. ...... .~.,.~.~ .....................................................................................
pursuan* to application dated ........................... JJe~, ......... ~8 ......... , 19.6~.., and approved by the
Building Inspector.
Fee $.],D.-~ ..........
S-9
SCHD
SUFFOLK COUNTY DEPARTMENT
Date
Bldg.
TO WHOM IT MAY CONCERN:
The sewage
at ~-?4gT ~1~£' W~AS
OF HEALTH
Permit
disposal facilities for
(Give deed location)
structure located
have been inspected by this department and found to be satisfactory.
FORH NO.I
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Approved ........................................ , 19...].~ Permit No ...........................
Application No....~....~..~.('...~. ......
Disapproved a/c .................................................
APPLICATION FOR BUILDING PERMIT
Date ................... ~,,.....~.....,.~... ........ 19.~.7. .....
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 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 sh.all 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 Deportment for the issuance of a Building Permit pursuant to the
Building Zone Ordinance of the Town of Southoid, Suffolk County, New York, and other applicable Lows, 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 o 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 o corporate, s. Lqna~t~re ~ duly authorized officer.
(Name and o.icer)
I. Location of land on which proposed work will be done. Map No.: ........................................ Lot No.: ........................
Street and Numbe~l~.~T..~,~.~ ....... ~..~ ...... ~.~...../ZZ:...~...~.~....~.~.~..~.....~.~:¢ .........................................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ...................................................................................................................................
b. intended use and occupancy ..........
]~ocat
property I
whether in
3. Nat!ure of work (check which applicable): New Building ....... ~Addition .................. Alteration
Repgir .................. Removal .................. Demolition.: ................ Other Work (Describe)
4. Estiinated Cost ............... ./(~...,...~..~..~....~..f.~...o. ............... Fee ................... ,~..~. ...............
, (to be paid on filing this application)
5. If ~welling, number of dwelling units ....... ~'./.~..~.~ ......... Number of dwelling units on each floor ..... ~.~/..¢%~. ....
If ghrage, number of cars ......................... /.~..~..~..(~...c~.
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use
7. Dirfensions of existing structures, if. any: Front .......... ~ ...... Rear ................ ..--......~ ....... Depth
He t ........................ Number of Stories "
D~rr)ensions of same structure with a.lterations or additions: Front .................................... Rear
Del~th ........... ~i~. ......... Height .......... ..'~..~ ............ Number of Stories ...... i......~. .................
8. Dir~ensions of entire new construction: Front ....... .~...~...~ ................ Rear ...... .~...~. .............. Depth ...~..~g.'..zL.[
Heibht .../¢/Z~.. ......... Number o~f Stories ............... ~..Z~..fi.
9. Siz~ of lot: Front ....... ¢~..z~....~,. ........ Rear ...... ./..~....~.. ................ Depth ........ .,-ff'...~.:~...~.. ...........
10. Dat~ of Purchase .............. ..~....~.../.~....../...~.~.~.. ......... N~me of Former Owner ...... /...'~..¢~...../.~..~..../.~'.~-~ ........
1 1. Zorje or use district in which premises ore situated
12. Doe!s proposed construction violate any zoning Iow, ordinance or regulation? ............. /~...~ .........
t3. Na e of Owner of premises,ZC/~,f/./Z~.~..~..~..?J.~.~.lN..(r?Address .~..~..~./<,.JJ.,.~.~...~..I,/~.~./.?..°../~hone N.
Na~ne of Architect ...................................................... Address ............................................ Phone No.
Na~e of Contractor .................................................... Address ............................................ Phone No.
PLOT DIAGRAM
~ 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.
STATE OF[ NEV~ YC~,~./' ~ S S
COUNTY [OF ..~...~././....~.. ....... J'''
.......... .(..~...~..~.....~...~....~..~.~.' ....... ~../~.4'~...~...~..~.....~.. .................... being duly sworn, deposes and says that he is the applic
(Nome of individual signing application)
abow; nar~ed.-- He is the ................ ..~.'...~...~.....~..~..~....'~..'.~.....~'~.. .........
(Contractor, agent, corporate officer, etc.)
of said o~ her or owners, and is duly authorized to perform or have performed the said work and to make and
this appli, ~tion; that all statements contained in this application are true to the best of his knowledge and belief;
that the ~ >rk will be performed in the manner set forth in the application filed therewith.
Sworn to_[ e.fore me this
NMIFy Publi~, State of New
No, 30-5712500
Qualified in Suffolk County
Term Expires March 30, 198