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Home My WebLink About4886-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office $outhold, N. Y. Certi~icnte O~ Occupnncy No...~.~. ..... Date ............ ~'~e.. ~0 ...... , 19. ~1. THIS CERTIFIES that the building located at . ~. ~. ~a$ ........... Street Map No..~ ........ Block No. ~ ....... Lot No ..... ~ .... ~tit~ ... ~,~, .... conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ ~ .... ~., 19.~G. pursuant to which Building Permit No. dated ............ A~...~ .... , 19.70, was issued, and conforms to all of the require- merits of the applicable provisions of the law. The occupancy for which this certificate is issued is ... ~a~ .~e 'f~t7' ~l~l ..................................... The certificate is issued to ~$y. $1~i ..... ~$~ ........................ (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval -.J~ .-~ -~ .. ~ .R.. ~illa. · · .. b~ ~,~ .~. .. u~ .... ~:t ........... ' B~lding Inspector [ Disapproved ale .............................................................................................. APPLICATION FOR BUILDING PERMIT INSTRUCTIONS This application must be completely filled in by typewriter or in ink und submitted in duplicate to the Building~ Inspector. b. Plot plan showing location of lot and of buildings on premises relationship to adjoining premi~ee or public streets or areas, and giving a detailed description of layout of property must be drawn on the diagram which Ii part of thie app ication. 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. A e. No building shall be occupied or used in whole or in part for any purpose whatever until a Certificate,,f Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pureuant 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, al herein described. The applicant agrees to comply with oli applicable laws, ordinances, building cod, e, housing code, and ragu,lOtions. ..... (Signature ~f applicant, or name, if a cooperation) (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 aufhorJzed officer. (Name and title 'of corporate officer) 1. Location of land on which proposed work will be done. Map No~.....~... Lot No.: ... ................... Street ~.~N u.~mbe,~...~-~ ...~.........~....: ............. ~.~t~.ii..t~ ..................................... 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 occupon? .................................................................... 3. Nature of walk (check whicl~ applicable): New Building Z'"'"'"~'Addition AIterntion Repair .................. Remora! ................. Demolition .................. Other Work (Describe) .................................. 4. Estimated Cost ........................................................... Fee ..................................................................................... (to be paid on fi!lng this application) 5. If dwelling, number of dwelling umts ........ ./. ................. Number of dwelling units on each floor ....... ..,~.. ................ 6. If business, comme-cial or mixed occupancy, specify nature and extent of each type of use ............................ 7. Dimensions of exist!ng structures, if any: Front. ........................... Rear ............................... Depth ................... Height ....................... Number of S[ories ................................................................................................................. Dimensions of some structure with alterations or additions: Front .................................... Rear ............................ Depth ................................Height ......................... Number of Stories ................................ 8. Dimensions of entire new construction: Front ....~.~.O..~ .................... Rear .....-~ .................... Depth . .~.....~.. ............. Height ..... /.,...~.. ...... Number of Stories .......... /. ......................................................................................................... 9. Size of lot: Front ....... .~...~. ...........Rear ......... .~.,.C:~ .................. Depth ....... ~...C).C) .......... 10. Date of Purchase ........................................................Nome of Former Owner ....................................................... 11. Zone or use district in which premises are situated ..................................................................................................... 12, Does proposed construct;on ~iolate ar]y zoning law, ordinance or regulation? ....... ~ ............................................ premises ..~,.~Address~' ~x ~ , ~ . ..... ~ ........ Phone No ..................... Nome of Owner of Name of Architect ...................................................... Address ............................................ Phone No .................... Name of Contractor .................................................... Address ............................................ Phone No .................... PLOT DIAGRAM i-oco[e clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether ;nterior or ccrner Jot. 7e / 3o STATE OF NDA(~O~_ ~ )SS COUNTY Of. fw) x~.~. ~ ~ ' ~/.~'_'~ ......... )' ~' .................... ~..I...~.'...,.~r:ec'~s~. ............................ being duly sworn, deposes and says that he is the app,icant (No'ne of individual signing a~ication) above named. He is the ........... -_....'..-~ ......................................... .................... (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 file this application; that alt statements contained in this application are true to the best of his knowledge and bel el' and thor the work will be performed in the manner set forth in the application filed therewith. 19~.~ ....... d :of Notor', Public,~.~.~.~,~,~.... Cou~lt¥' '-~"~ ....... (Signature Of ,~ ELIZABETH ANN N/EVILLE NOTARY PUBLIC. State'of New York No. 52-8]25850, Suffolk C0~ Term Expires March 30. 19 $-9 SCHD TO WHOM IT MAY SUFFOLK COUNTY DEPARTMENT OF HEALTH Bldg. Permit NO. CONCERN: The sewage disposal facilities (Give deed location) for a structure located have been inspected by this department and found to be satisfactory. hT j'+' tJ.L t, +.,- L t',v* 2 '7Lo"