HomeMy WebLinkAbout4796-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupnncy
THIS CERTIFIES that the building located at ~..l~.e..m~..a.y...F~..z.t ............ Street
Map No. 6r.e.~.~t. ~el~lock No ........... Lot No. 3.1 ....... (~_r$.~;..)I.o~ ..........
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ............ ~Y...2.~.., 19.70. pursuant to which Building Permit No..
dated ............. J'lll~e...~., 19.70, was issued, and conforms to all of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is . Pti. rata .sw~un~a~8~ .pool ff~. lena& .... .(Appr~ed. b~ .Bd. Appo~18)...
The certificate is issued to .Dar~e~. ~..l~.t~ .Al~cl~er ...... ( era ..................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval .~..,.R., ...............................
UNDERWRITERS CERTIFICATE No... ~,lt~ ..........................................
HOUSE NUMBER .... ~.0 ...... Street ...... ~.~.$.e~.W.~.~'..E.a.~.~; ............................
FO~ NO. 2
TOWN OF $OUTHOLD
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? 796 Z
Permission is hereby granted to:
.................. ~)~.e~t ...............................................
at premises located at .......... J~'~'"",lJ:J ....... ~Fetl~.~Fe.~..&~l,..(iJ',[~l~Jl .......................................
......................................... ~i/a.. ~ar~..~:Lev..&..E~8...Q=~e~v~..~t ..........
pursuan¢ to application dated ........................ ~ ......... ~J .............. , 19..~1~., and approved by the
Building Inspector.
Fee $....,~,J~ ..........
Building Inspector
lX)WN OF souTHoLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFIC:!
SOUTHOLD, No ¥.
~m,r~ ..... :./.~..%...~..f ....... ,"
^~,ro~d .......... J ~.?...0.. perm,t No. ~..7..Z ~ ~
.............. Cr~/ ................ ,.....~ ..................................... ~ .........................
....
r~ ...... ...~,-::..,: -. -:. ~ ..........................................
)q~l:)licotion No. /~ ~ ~' ~0
APPLICATION FOR BUILDING PERMII'
,te ............. ...... ............. ....
INSTRUCTIONS
o. This application must be completely filled in by typewriter or in ink und submitted in duplicate to the Building
Inspector.
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining prem Mm or public streets or
areas, and giving a detailed description of layout of property must be drown on the diagram wh]ch is part of this application.
c. The work covered by this application may not be commenced before issuance of Building I~rmlt.
d. Upon approval of this application, the Building Inspector will issue a Building Permit to fhe apMk:ant Such permit
shall be kept on the premises available for nspect on throughout the prOgress of the work.
e. No building shall be OCCUpied or used in whole or in part for any purpose whatever until a Certificate of Occupancy
shall hove been granted by the Building Inspector.
B i'~'~iPLI'CA'rIO~N'!S HERE~Y.,MA_DE to t.h.e B.u, lld, i.ng.D.el~,.rtm_ent.for. ,the .Issu, ance .of .a B~i .Idl~_ _ ~l~lJ~..~mtmM to the
Ru ,~i~tgi Lone. w.m, mance o, r.ne .o.w,n .o,t ~oumo,a, .~urro,. ~.oun.~., .*w .or., ona other ap~l.."~_~Mi: IJM~. ~ m '
TN .o.,s, .tar the co. nstruct,.on OT..bu!~dings/ad.d. it,.ons or a!terat,ons, or for removal or clemoflttan,' ai:IMMfl dill:ribed.
neappncan~agrees~c~mp~yw`I~"auap~ica~e~av~raInanc~bui~di~h~u~lng~de~reg~at~$~.
· .................... ...................
~ignature of applicant, or ngzneo If a corparatlofl)
(Addre~of o~pllcant) 0'
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner of premises ....... ~.....~....~...~,...iiiiiiiiiiiii iiiiiii iii iiiiiiiiiiii
If applicant is a corporate, signature of duly authorized officer.
(Name and title 'of corporate officer)
Location of land on which posed work will be done J~No' ..'~.....~.2 .~..(~. ....... Lo Fun -~ (
1. n pr~osea work wmDe aon~ ,..- .................... ~ ....... t .............................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
' ~.
o. ~lsting use and occupancy ...................................................................................
b. Intended use and occupongy . ............................................................. .~ .......... ~-,~,..~..-_'~5.~ ~ :. ~_.,.i...¥.....-~;~m..
/ (to be paid on fi!lng 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 construction: Front .................................... Pear ............................ Depth ........................
Height .................... Nurpbe~; of Stories ................. ....................................... ..................................................
9. Size at: lot: Front ......1~..~.~.'! ........... Rear~.....~..~.~ .................. 7 Depth. ~'.~'"'/~ I, .... /'/' /7
10. Date of Purchase ............. ..~...~..~.....'~....~'.. .................... Name o;'Former ~e~"...i~.~ ..........
11. Zone or use district in which premises are situated ............................................... 1~/"~ ...........................................
12. Does proposed construction violate any zg~ing Jaw, ordinance or regulation.> ...~Tf~.~) ..........................................
13. Name of Owner of premises ...~...~'..~...(,~....~Address ..~ ......................... Phone No .....................
Name of Architect ...................................................... Address ............................................ Phone No .....................
Name of Contractor .................................................... Address ............................................ Phone No .....................
PLOT DIAGRAM
Locate 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 interior or comer lot.
COUNTY OF ..~~.~.J'~.- '
................................................ 5~.%..~/,~-~....~.~..being duly sworn, deposes and says thor he is the Opplicant
(Name of individual signing applico~
above named. He is the ................................................................................................C~ [[ .......................................................
(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 all statements contained in this application are 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 t~erewith.
Sworn to before me this /I
............... ........... ..............
h to Pubh ..................................................... ~' ..................
o ry 'c, . ........................................................... County -/(~l~nature of applicant) "