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Home My WebLink About4622-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office $outhold, N. Y. Certificate Of Occupancy No.~l~'~ ~ ...... Date ................ ~T~...~O. ·., 19..~ THIS CERTIFIES that the building locat~ at ~t~ .D~. ........... Street Map No. ~z,. ~.. Block No... ~ ...... Lot No..~ ...... ~O~.. ~.~e ....... co~orms subst~tially to the Application for B~ld~g Permit heretofore fil~ ~ ~s office dated ........... ~e~..2~..., 19. ~ p~su~t to which B~l~g Pe~it No..~. dated ........ ~b...~ ...... , 19~., was issued, and confo~s to ~1 of the r~uir~ ments of ~e applicable prov~ions of ~e law. The occup~cy for which this certificate is issu~ is . ~$~ .~ .f~. ~etl~ ....................................... The certificate ~ ~sued to .]~. ~$~. F~T~ ......... ~ ................... (owner, lessee or tenant) of ~e ~ores&d b~g. S~olk Co~ty Dep~ment of He~ Approval J~..$~ .~972..b~ ~.. ~1~ .... FO~ NO. ~ TOWN OF SOUTHOLD 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? ~622 Z Permission is hereby granted to: .~.,....~.~.,......~.~.....~.,.~.~..~..~. e ......... ~.~.....~..~ ........................................ pursucr~t to application dated .............................. ~Jj~ .......~1~ ........ , 19..~., and approved by the Bui~ing Inspector. Bul d~ng Inspector !/~/~ BUILDING DEPARTMENT * * m, Exa 'ned .........~ ....................... , ~9 ........ Application No...~....~.....~..~ ....... Approved '" " 19..?..~.. Permit No. A~ ~ ~. ,~. ~ ~ ~ b/~-- .............................................................................................. ......................................... i ....... ::::::::::::::::::::::::::::::::: ..................... APPLICATION FOR BUILDING PERMIT Date ............................... .~...~. ................... , 19..~..~ ..... 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 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 buildingshall 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 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, as herein described. The applicant agrees to comp y with a applicab · laws, 0rdinanc~es, bui ding code, ~nousing code, and regulations. (Signa~,~re of applicant, or name, if a corporation) ......................... .......................... State whether applicant is owner, lessee, agent, architect,~ ~engine?r, general contractor, electrician, plumber or builder. Name of owner of premises . ~ . If applicant is a corpo~gtp, signature of duly authorized officer. /')'. --(Name and title of corporate'"off*cer) 1. Location of land ~ which proposed work will be done. Map No.: ..... .~../...~'..~. ..................... ~. Lot No.: .....~.~... ............. Street and Number ....................... ~...~,,o ..................................................... ~,,~n-~.......,~n~....:.~ ...... Municlpalit~ 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: Existing use and occupancy .......................................... ~,~ ....................................................................... Intended use and occuponcy .................................. ..~...~ ..... .~.'.~ ........ i ................... i ........................... '~ ............. 3. Nature of work (check which applicable): New.Building ....... ~ ...... Addition .................. Alteration .................. Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................ 4. Estimated Cost ................. I.'~.~t..~.. ......................... 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. If business, commercial or mixed occupancy, specify nature and extent of each type of use ............................ 7. Dimensions of existing structures, Jf 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 ........ ~'1~. ....................... Rear ......... ~..~ ............. Depth ..... .3...~.~ ............. Height ....... J..~ ....... Number of Stories ............... /. ...................................................................................................... 9. Size of lot: Front ........ ~.~?.J~. ........... Rear ......... .~'.,~.~. .................... Depth ........ .~...~.. ............... 10. Date of Purchase ........................................................ Name of Former Owner .............. ~.~'.~.q< .............................. 11. Zone or use district in which premises are situated ....................... ~.. ......................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation? ....~ .................................................. 13. Name of Owner of premises ..'~....~.'~e~.....~...~.(.~# ......... Address .!J,~.....,~..~...~...~..~..~.KC .~.....~o~e~o.....~....~...~.O~.~ Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor ~..~9....~.~..~.(.~....~.(/..~..£...~.~/t~....Address ...~.~:~..~..~'...~.~,...~.~.~..~.: ..... Phone No...49..~..~....~."~/..~ PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-bock dimensions from property lines. Give street and block number or description according to d~ed, and show street names and indicate whether interior or corner lot. STATE OF NEW YORK, ......... ' ............. · ,~'~ ...................................................... being dbly sworn, deposes and says that he is the applicant (Narr~ of individual signing application) above named. He is the ......................................................... ~.~ ...................... ~ ................................................... (Contra~or, ag~t, comorate officer, etc.) of said owner or owners, and is duly authorized to perform or have perfo~ the said work and to ~ke and file this application; that all statements contained in this application are tree to ~e best of his knowledge and belief; and that the work will be performed in the manner ~t fo~h in the application filed therewith. Sworn t~ore me this ~ ~ ~ .............................. .............................. , ............... ............................. MARION A. REGENT NOTARY PUBLIC, 8~te of New YOFk No. 52-3233120 Suffolk County Term ~pires ~rch ~ 19~/ S-~ SCHD SUFFOLK COUNTY DEPARTMENT OF HEALTH Date JAN 10 1972 TO WHOM IT MAY CONCERN: The sewage disposal facilities for a structure located at / (Give deed ~cation)/f ' ) ' have been inspected by this department and found to be satisfactory. Chief of General E~gln~rtn~ 1972