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Home My WebLink About5086-zFORM NO. d TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office $outhold, N. Y. Certificate Occupancy No.~'.~.~...7.~.. Date (~ ~, *~t~ , 19 '~ ~ TI'IIS CERTIFIES that the building located at' i'~i~.'.'~" i~i'.'.i. Si~e~i conforms substantially to the Application for Building Permit heretofore filed in this office dated ....... ~'...~, ..... , 19~.a pursuant to which Building Permit No ......... dated ......... !' ..... ~ ...... , 19.~..D., was issued, and conforms to all of the require- ments of the applicable provisions of the law. The occupancy for which this certificate is (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval 7J-, ' UNDERWRITERS CERTIFICATE No :~ HOUSE NUMBER.....,~.. ~ .... Street .... ~...?~..t. ~... ~.' ............. Building Inspector FOR~Z NO. B TOWN OF $OIJTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT CTHIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N°. 5086 Z Permission is hereby gronted to: pursuc~ to application dated ........................... JJJJ~t~.: ..... JJ ............... , 19..~t~JL, and approved by the Building Inspector. Fee $...~ ......... ........... Buildin~"J~ ............... Approved ........................................ , Oi~pproved a/c ............................ ~..~,~-..... ..... BUILDING ~PARTMENT ~,.,. ' ~ ~ ~~ TOWN CLERK'S OFFICE ~1 ~ ~../~ ~, N.Y. ~ ~ APPLICATION FOR BUILDING PERMrT g_~J D,t, ...... INSTRUCTIONS e- a. ~is app icati~ must be c~pletely flll~ in by ~ewriter or in ink und ~ubmitt~ In ~pllc~e ~ the Buildi~~ In--mr. b. PI~ plan s~wi~ I~ation of lot a~ of bu~lding~ ~ premix, mlatlon~hip to adjolnl~ pmmlm or public atmets or ~ a~, a~ glvl~ a d~afled ~ri~l~ of I~t of p~ must ~ drown ~ t~ dl~mm ~l¢h I~ ~ ef ~ ~llcati~. ~ c. ~e ~rk c~ by this appllcatl~ ~ ~t ~ commenc~ before i~ua~e of Bulldl~ Permit. ~1 ~.., U~ ~al of ~is a~licati~, the Building In~ctor will I~e a Bulldl~ Pe~lt ~ t~ ~pll~nt. ~h ~it ~a ~ k~t on the premiss ~llable for In~ection throughout the p~ of the wo~. e. No building s~ll ~ ~cupi~ or u~d in whole or In pa~ for any pu~e ~ate~r until a ~lfl~ of ~c~y~ shall h~ ~en gmnt~ by the Building In~r. APPLICATION IS HEREBY MADE to the Building Deaartment for the issuance of a Building Permit pumuant to the , Building Zone Ordinance of the Town of.Southold, Suffolk County, New York, and other applicable Laws, Ordinances or~ TR~geeulations, for the construction of bulld,ngs, additions or alterations, or for removal or demollti~, al heroin dmcrlbed. ,.2,/ · applicant agrees to comply with all applicable laws, ordinances, ~l~llding code, housing code, and regulations. /u (Signature cf applicant,--or name, If a corppratlon) ............... ........ ..................... (Addre~J of applicant) / State whether applicant is owner, lessee, agent, architect, ~eneral contractor, electrician, plumber ar builder. Name of owner of premises ...~..L.~...~.:......~.~ ........................................................................... If applicant Is a corporate, signature of duly authorized officer. (Name and title 'of corporate officer) 1. Location of land on which p~roposed work will be done. Map No.: ~ NO.L.....~.. .............. Street and Number ..... ~..~....~.~.~ .............. ~ ........................ ~'~ .~0 ~ Municipality 2. State existing use and occupancy of premises and Intended use and occupancy of proposed construction: C~ 3. Nature of work (check which applicable): New Building ~....~ ........ Addition .................. Alteration ............... Repair .................. Removal .................. Demolition .................. Other Work (Describe) ...................................... 4. Estimated Cost ..... -- ~..O..~..O'JTt/ ................................ Fee ......... (...O.......~..~ ............................................................ (to be paid on filing this application) §. If dwelling, number of dwelling units ............................ Number of dwelling units on each floor ............................ If garage, number of cars ............................................................................................................................................. 6. If business, 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 alterations or additions: Front ....................................Rear ............................ Depth ................................ Height ............................ Number of Stories ................................ 8. Dimensions of entire new construction: Front .....~.......~. ...................Renr ..... ~1--'....~. ............. Depth ..s~.J. ............... Height ..~Z....~ ........ Number of Stories ...... ,~......-~,~ ................................................ ~, .......................................... 9. Size of lot: Front ......~../~....~. ......... Rear ....... ~/..~...(~ ................. Depth ..... :/...~....~. ........... )0. Date of Purchase ........ ~/....~...~.....~.., ......................... Name~ ~°f Fo~rmer Owner ...... ~....~....C~.~(~... 11. Zone or use district in whlc~h premises are situated ........ I..~....-f,-~c~,dZ. .......................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation? ...... ~....7. ....................................... )3. Name of Owner of premises .~Rv~.t.~.[~~ress ............................................ Phone No ..................... Name of Architect ....~...~...~...~....Address t.2~..~ ~ .................... Name of Contractor ~..~'Address ..~.".~..'..~l~e No.~..~.~.~.~,~. PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate ail set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or comer lot. ! STATE OF~ NEW' Y~II[K,.~Z,~~' tee COUNTY ................... , .................................... being duly sworn, deposes ond says that he is the applican~ (Name of i~dividuol signing opplication) ' above named. He is the ...................................................... ~r;~......-t.. .................. ~ ........................................................ (Contractor, agent, comorate 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 am true to the best of his knowledge and belief; and tha~ the work will be performed in the manner set forth in the application filed therewith. Swam to before me this ~ ..... ....... ............ ...., 1,.7/-2.. ('.,-)(')._ "(=)' ((' )( / (0 ' · t P '1 ,~'~/'~._-/Z.~/ j/l .... 7 ~ · ,~/) .... '_'~..-~ .................... mo ary ua i~~/~'~ ..... County~'~ (Signature of applicant) v .... ' ~, A~i~el~f'l~{v Yorl~ Nnr~ ~.[~~r*a .~ ~N~ /~EWLLE ~r~? r;~.rLr ~,rch :~ 19~_ ~,,,, ~p~res March 30. 19~'~ '