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Home My WebLink About4650-zFORM NO. 4 TOWN OF SOUTHOLD · BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. ~,~'$0~ ...... Date ............. ~.,....l~. ..... , 19. THIS CERTIFIES that the building located at .Stl, lLtw&~,er. &Ye .......... Street Map No. t,~w= ........ Block No ........... Lot No..x~ ..... Cllt;ohogtle .... Ng.l[.. ...... conforms substantially to the Application for Building Permit heretofore filed in this office dated ......... i~h .... ¶8., 19 ~0. pursuant to which Building Permit No.. dated .......... 14~ .... $8--., 19..7/1 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 . .. Pl'~vata .olle. ~t,l~'. d¥.Q],~.l.l~ ..................................... The certificate is issued to . Adolph. ]~lis ...... (h~®F ............................. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .... ~.ul~r. · .7.-..1970...by. R, .Vii. la Building Inspector t ....... FOI~M NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN C:LERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK ^UTHORIZED) N? 650 Z Permission is hereby granted to: .................. J4m~...Peek- ......... I.,Zv .................. to .......... JJtl~ "J~ · ~lll~ "Jl~'~" ~JtelJ ~.' '~l~J ......................................................................... at premises located at ................. I~ ...... ~r~'~ '~J~T~ttJ~,~"A~r .............................................. ..................................................... ~l~l~j~J ............ ~-'~z'~' ............................................................... pursuan¢ to application dated ............................. Jl~ ....... JJJ ...... , 19...~j~ and approved by the Building Inspector. D,sapproved a/c .............................................................. (Building Inspector)/ APPLICATION FOR BUILDING PERMI'I' ........................... , INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in duplicate to the Building Inspector. b. Plot .pi.an showin.~ location of. lot and of buildings on premises, relationship to adjoining premises or public streets or areas, and g~vJng a detailed descriphon of layout at property must be drawn on the diagram which is port of this applicafie~; 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 shall 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 comply with all applicable laws, ordinances, building cede, housing code, and regulations. .... (Signature of applicant, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ...................................... ........................................................................................................................ Name of owner of premises .......'~...,~,..~)...~-....~'....~..........,/.,7~,.~.....~......~'... ...................................................................................... If appJj/',~nt is a ~ate, s[g,nature of duly authorized officer. (N(:l~ and title of corporate officer) 1. Location of land on which proposed work will be done. Map No.: ........................................ Lot No.: ~ Street and Number ............. : ...................................................... ..~.........~. .................................... ~ .......,, ....... ~ ~ '~l - ~,~, ~ Municipality % State exi~ing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~'//~ C/~/~- b. Intended use and occupancy ~.....~...~F' / ~......~.....,~... C/'~/"~- .... ~,1 I. 12. 13. Locate clearly and property lines. Give whether interior or corne~ Nature of work (check which applicable): New Building ~'~ Addition Alteration o..n. Repair .................. Removal .................. Demolition ........... : ...... Other Work (Describe) ........................................ Estimated Cost ..~.~...~...~.,..~..~. ............................... Fee ......................................................................................... (to be paid on filing this application) I -If dwelling, number of dwelling units ......... :.~ ................ Number of dwelling units on each floor ............................ · If garage, number of oars ............ ~ ................................................................................................... : ....................... If business, commercial or mixed occupancy, specify nature and extent of each type of use ...d ....................... ~ of existing structures, if any: Front .: .......................... Rear ................................ Depth!. .................. Height Number of Stories Dimen~ of same structure with alterations or additions: Front .................................... Rear ............................ Depth Height ............................ N. um,ber of Stories ......... . ....................... Dimensions : entire new construction' Front ~?'-~ ~.. . Rear "~-/(/~/~- D t Height Number of Stories ! .; ....................................... D~te of ........................................................ Nome of Former Owner . .~....- ........................................... Zone or use in which premises are situated ..................................................................................................... Does proposed ru :tion violate any zoning law, ordinance or regulation? ...... ...~....~.. ............................................. Name of Owne of premJses4~.~....~.....~..~.....~..~.../~....~..?.....Address ............................................ Phone No.?.~..~....~..~¢~' Name of Archi' ....Address ............................................ Phone No ..................... Name of · .~....~....~..~...~..~...-~'...~...~-.~...~..~...~...~'.Address .~....~.../~.../..~./...~....~.~.~.. Phone No~..~...-...~....~.? PLOT DIAGRAM listfnctly all buildings, whether existing or proposed, and indicate oil set-beck dimensions from and block number or description according to deed, and show street names and indicate STATE OF NEv~J"c~.Jg.k tee cOuNTY OF.~ .............. $ "'"'"' .................. ~.....~J,~. .............................. being duly sworn, deposes and says that he is the applicant (Name of ihdividual signing application) 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 oil 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. ELIZABETH ANN NEVILLE NOTARY PUBLIC, State of New York No. 52-8125850, Suffolk Coul]ly .Term Expires March 30, lg..Z~ S-9 SCHD SUFFOLK COUNTY DEPARTMENT OF HEALTH Date Bldg. Permit No. TO WHOM IT MAY CONCERN: at The sewage disposal facilities for a structure located (Give deed location) have been inspected by this department and found to be satisfactory. District Engineer District Engineer TC, w'N CF .:,.~.;u HOLD HEW VOF.4 ~ 2..5O N.58 40 oo w. 98.28