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HomeMy WebLinkAbout5079-zI~ORM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office $ou~old, N. Y. Certificete Of Occupancy No. ;~b~3J~ ..... Date ............. .Oct...21 ...... ,19..7.1 THIS CERTIFIES that the building located at G3~oYe. D. rilr.e ............... Street Map No~eydon. Shorel~lock No .... H ...... Lot No.9.,.%0 ~ ~.1 ..... Southolcl ........... conforms substantially to the Application for Building Permit heretofore filed in this office dated ...........l~ov...2~..., 19.70. pursuant to which Building Permit No..~079~. dated ...........Nov-. '30 .... , 19.75, 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 ... D.,~e ll&ng .... p ~.lv~.te. c~e. £am~&y .................................. The certificate is issued to . .&r.t, hur..T.~ucken]~rol, t ....... 0wne.x, .................. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .t~ ,R..- .............................. House ,~ ~O0 Grove Dr ~/~, TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PER~IT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF: THE WORK AUTHORIZED) 5079 Z Building Inspector. ,Fee $ ..... Building Inspector %~v'N OF ~OUTHOLD Bg~4/I)ING DEPARTMENT ~ TOWN CLERK'S ~FICE ~ S~THOLD, N.Y. ~- ................. ~oved .................... -'~'~.~.....~ ,~.~........~ ~,~ ,o....~..~.~ ~ ~i~pproved ~/~ ...................... ~ ...................................~ ............ .................. {Buil~m~nspector) INSTRUCTIONS '~ a. 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 pu. blic streets or areas, c~nd giving a detailed description of layout of property must be drawn on the diagram which is port of th~s 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 c~pplicant~. 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 hove 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 demoli~en, as herein described. The applicant agrees to comply with all applicable laws, ord '~"~~"'"'~-~'~('~Sil ,natu'g of al ' '~l'i~'; ~ '"~'~/'~'pp 'c , o ome, .......................................... 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 of Rcer. · ~ ~ 3/ ~-/~-// 1. Location of land on which proposed work will be done. ,Mop No.: ........................................ Lot NO.: ........................ ~/~...?.~ ~/vA, ..2...(~e~.£g.,...¢.~.4.,.~ r...~o..~.e.. 5:./... /~, ~', Street and Number ..................................................................................................... ~unicipality 2. State existing use and occupancy of p~emises and intended use and occupancy of proposed construction: a. ~is,,ng.seondoccuponcy ...... ~..'..~..<. ....... ~...*..'~ .............................................................................. b. Intended use and occupancy ................................................................................................................... ~ ......... 3. Nature of work (check which applicable): New BUilding ..~ ............... Addition ................. Alteration .................. Repair .................. Removal .................. DemolltlOn.,~.;...~;.....~r Work (Describe) ~, .................................... 4. Estimated Cost ........ :.~...~...~.:. .................. ' .................... Fee ...... ,.~:/: .......................................................................... "(to be paid on filing this application) 5. If dwelling, number of dwelling units ............................ Number of dwelling units on each floor ............................ If garage, number of cars .............. .~..../~....~:... .......................................................... ......................................................... 6. f business, commercial or mixed occupancy, speci~ nature and extent of e~.c~ type of use ..................... . ...... .... . 7. D~mens~ons of ex~stmg structures, ,f any. Front ............................ Rear ................................ Depth .................... Height. ....................... Number of Stories ............................................... :~.~.~.~. ....................................... ~ ......... Dimensions of same structure with alterations or additions: Front .................................... Rear Depth ......?'..~':....~...~.. ............. Height ............................ Number of Stories ................................ 8. Dimensions of entire new construction: Front .................................... Rear ............................ Depth ........................ Height .................... Number of Stories ...................................................................................................................... 9. Size of lot: Front ..... .~..,~..../~....'~'.. ....... Rear ......... /...~ ..~..~ ......... Depth .~..~..~../~./..~/.~...../:...~'...~- ~ ~'/~'//'7~. ...... 10. Date of Purchase ........~.....~.~.~...../...~..-~...~... .......... Nome of Former Owner .............. ./.~: ..................................... 1 1. Zone or use district in which premises are situated ......................................................... .~ ................................. 12. Does proposed construction yJolgte any zoning law, ordinance or-regulation?/~ .......... ~ ...... ~/. ........................... ,~/ ,,~ /f'~ ~,~20~' ~ .... 13. Name of Owner of prem~Z' ........................~..~.......~...Address ...................... ~.¢: ...... :...o~q...... Phone N .~.~......~ .......... Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor .~.'.~.Z:..~..:....gL~.~.~//..~...../~....x~.:Z~'/~.f..~../...Address .~....~../......~....~..~../...~.~..z....~.. Phone No?~..-~..:..~..~..?..~' PLOT DIAGRAM Loco.t.e clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property hnes. Give street and block number or description according to deed, and show street names and indicate whether interior or carter lot. //~ ~ f/ STATE OF NE~Y~RI(,~ tSS COUNTY ............... · · . .......................................................................................... being duly sworn, deposes and says that he is the opplicant (Name of individual signing application) above named. He is the -,~///J-~/: 7'~ ................................................................................ ........................................................... '~: ....... (Co;:~tract;r, 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 file this application; that all statements contained in this application are true to the best of his knowledge and belief; and that the work will be performed in the manner set forth in the application, filed therewith. Swam to before me this ................ of .................................... Public,,~9..: ............... 7,,~.......~,.~ ................