HomeMy WebLinkAbout4717-zFOB~M NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
CERTIFICATE OF OCCUPANCY
THIS CERTIFIES that the building located at ....~5.tzohsc~..P,o~d ................................... Street
Map No..;X~ ...............Block No...X~ ............... Lot No. ~, .........C,~L1..e. ......... ..N..~..Y..e. ............
conforms substantially to the Application for Building Permit heretofore filed in this office dated
................................... ~)r~. .......... 18..., 19.....~.0Pursuant to which Building Permit No. "~'1"7~..
dated ............................ Ajalt;L~ ....... ;~.'~..., 19...~70, was issued, and conforms to all of the requirements
of the applicable provisions of the law. The occupancy for which this certificate is issued is ........
............ p~.~a re.. ene .4'e,a.~.t~.....d~e.1..~ .~g. ....................................................................................
The certificate is issued to ...~h&.r.l,~a...t4a.llBeF. .......... ',~lel~e~ .......................................................
towner, lessee or tenant)
of the aforesaid building.
I~ouse ~ 1200
leORl~ NO. I
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? ~717 Z
Permission is hereby granted~.'
................... ~.~ .........................................
at premises located at ................ ~1~.....~..~.~...~. ................................................................
pursuon~ to application dated ............................... .~..~,,~-. ....... .~.~...., 19....~.,~.~ and approved by the
Building Inspector.
FORM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N, Y.
Examined .....~ ..................
,, ,,
Approved ........................................ , 19 ........ Permit No ............................
Disapproved a/c .................. ~..:.~~
................................ ......................
Application No ............................
APPLICATION FOR BUILDING PERMIT o
Date ........................ ~.../.....~.. ......... , 19.~..~. ..... O
V
INSTRUCTIONS ~
a. This application must be completel,j 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 p~rt 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 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 code and regulations.
State whe~er applicant is owj~er, lessee, agent, architect, engi.neer, general contractor, electrician, plumber or builder.
......... ............................. ............ ...........................................................
Name of owner of premises ~.,~-.--.....~-'.".. ......................................................................................................
If applicant is o corporote, signoture of duly outhorized officer.
(Name and title of corporate officer) . L t No
Location of land on which pTop, gsed wor~ will be done.,~ap,No.: ....... ~ ................ ~ LgT
1.
Street_g.nd Number .~~."~'J' ......... ~.... '"'~ .......
~/~ / e~O f.) Municipality
2. State existing use and occupancy of p,~ses and intended use and occupancy of proposed construction:
a~ Existing use and occupancy ...... ~....*....... ..................................................................................................
b. Intended use and occupancy ........ ~.~..~ ........................................................................................... ~ ..........
/
3. Nature of work (check which applicable): New 'Buil~iing .................. Addition ..... ' ............. Alteration
Repair .................. Removal .................. ' Demolition ........ ~ ...... :.. Other Work (Describe) ........................................
4. Estimated Cost ..... ./...~..~....O....~.O.. ........................... 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, 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 cqnstruction: Front ....~) ....................... Rear . Depth
Height ..../..~.. ......... Number of Stories ...............................................................
9. Size of lot: Front ....... ./.~. .......... Rear .......... .~...~...~. .............. Depth ..... ./......~...~.. ...............
10. Date of Purchase ....~...~.....~..O. .................................. Name~f Former Owner ....>.. .................................................
1 I. Zone or us~e district in w~hich premises are situated ...........~..~ ....................................... ~ ............................................
12- Does proposed construct On v o gte apy zon ng aw, ord nonce or regu at on? ...~.~...~. ............................................
13. Name of Owner of premise~..~..Addres~.~ ....... Phone No.~.~.~)'~.~..~..~.
Name of Architect ............................. ,~ ....... : ........ ~....Address ...... , .................................... Phone No .....................
Name of Contractor ~.l~..~...Addre~s ~ .......... Phone NJ(~..~....~......~
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indic~e all set,bock dimensions from
property lines. Give street and block number or description according to deed, and show street names and indicate
whether interior or corner lot.
I I
STATE OF NEW YORK,
COUNTY OF'. ...............................
.......... :: ........... r...:......~-..; .......... ;......~ ................................. ~ ....... being du~y Sworn, deposes and says that he is the applicant
(Name of individual 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 Perf~orrned the said work and to make and fife
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 apl~lication: filed therewith.
Sworn to before me this
........................ of ............................................ , 19 ........' ' ,'
Notary Public, . ........................................................... County (Signature of applicant)