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TOW~]~ ' OF $OUTHOLD
BUILDING DEPARTMENT
Town Cler~:'s
Southol~, N. Y.
Certificate Of' Occupancy
Date ............ ~T.~.e...~.~ ...... , 19~...
THIS CERTIFIES that the building located at . ~/~. ~ .P&~ ........ Street
Map No. ~ ......... Block No..~ ....... Lot No~..l~a~t .NaI~,Oll .... I~oY, ........
conforms substantially to the Application for Building Permit heretofore filed in this office
dated .......... 8et0t ... 9..., 19~.. pursuant to which Building Permit No.
dated ......... ilel~t ... 9 ...., 19~.., 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 PrinCe..olle. f. am~lV. .d~teZl~-~g ........................................
The certificate is issued to .. 6eorg®. ~c1~1,~;1~ ..... 0~mr ...........................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval . .1~...2.~...19~ ..................
UNDERWRITERS CERTIFICATE No ..................................................
HOUSE NUMBER..~.~;00 ....... Street ....~'~11~4~ .P&~ ..............................
Building Inspector /
FORM 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? 5497 Z
Permission is hereby grante~l to:
........... ;...~r.m~;.-z::~; ............................................
~/ ,
at premises located at ............. ~J.....~i~1~..i.&l~r,~ ..........................................................................
...................................................... ~.~.%..t:.~.L~ ......... Ii~le ............................................................
pursuontc to application dated .............................. ..~..e.~.~. ....... ~. .......... , 19..~.~1.., and approved by the
Building Inspector,
Fee $....~..0..?.~ ?. .........
S-9
SCHD
SUFFOLK COUNTY
DEPARTMENT OF HEALTH
~ 4 1972
Date
Bldg. Permit No.
TO WHOM IT MAY CONCERN:
The sew.~,~e disposal facilities for a structure
(Give~ deed locat tc~)
located
have been inspected by this department and found to be satisfactory.
MAY 2 4 1972
Chief of General 2T¥£ineer~ ~:~ ?,~?:~ eo~
,~oproved ........................................ , 19 ........ Pemit No .........
Disapproved a/c .............................................................................................
TOWN OF SOUT.OLD
BUI. LDING DEPARTMENT
~ CLERKS OFFICE..
,icat,on .......
APPLICATION FOR BUILDING FERMIT
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 o~ premises, relationship to adjoining premises or public streets or
areas, and giving a detailed description of layout ofproparty 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 (3 Building Permit te 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 /V~,DE 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, Ordinonc.e.s 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 cede, end regulotions~
Jos Diaz
(Signature of applicant, or name, if a corporation)
Gree.n. Dort
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Contractor
Name of owner of premises ...... G~.er~e..~bm~ t;.t ............................................................................................................
If applicant is a corporate, signature of duly authorized officer. ~
.................. .........
1. Location of land on which proposed work will be done. /v~ap No.: ..... .B...a.~....L...a..~..e....?..~ ........ Lot No .........................
Street and Number ................. ~/~.....ztl~azL.P~,.f~ ...........,~&la~..~,z~Lo~ ....................................................... _~
/ ~00 ~ Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
o. Exisiting use and occupancy ..... .Y..B:.~...~...~....~.9.~ ..................................... ;. ............................................................
one famil~ dwellin~
b. Intended use and occupancy .................................................. ~ ...........................................................................
3. Nature of work (check which applicable): New Building .~ .......... Addition .................. Alteration .......... .~
Repair .................. Removal .................. Demolition ............... ... Other Work (Describe) ................................. .~.....
4. Estimated Cost ...........,~.....~,.....,~...o~... ............................ Fee ...1...0..~.~.0.. ...........................................................................
(to be paid on filing this application)
5. If dwelling, number of dwelling units .....o.b.e. ................. Number of dwelling units on each floor
If garage, number of cars 0
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 ....... .2...~. ........................ Rear .......... .2...~. ............. Depth ......~..0..-...6. ..........
Height .................... Number of Stories .......... D~ ...............................
9. Size of lot: Front ......... ~..(~ .............. Rear .................................... Depth ......... ~.~..~. ................
10. Date of Purchase ........................................................ Name of Former Owner ........................................................
11. Zone or use district in which premises are situated "A" (].i$~;
12. Does proposed construction violate any zoning law, ordinance or regulation? ....~(~ ............................
13. Name of Owner of premises .G.,..~cZ~:t,'Lt;.t, .............. Address ~,. M&~'±OT~ Phone No .....................
Name of Architect ........................................... ~. ......... Address ............................................ Phone No .....................
Name of Contractor ....~.,...~J,~,~. ............................... Address ...... c~.e~e=[0.o.~.~. ................ Phone No .....................
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimension
property lines. Give street and block number or description according to deed, and show street names and
whether interior or comer lot.
from
dicate
STATE OF NEW YORK, tS S
COUNTY Of ....~I~'.Q~. ........... $ ·
............................................ ~O,~..~a.~ ................................. being duly sworn, deposes and says that he is the applicant
(Name of individual signing application)
above named~ He is the ...................... ~o~c.~o~ ...........................................................................................................
(Contractor, agar, co~orate officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to ~ke a~d file
this application; that all statements contained in this application are true to the best of his knowledge and belief; and
~at the ~o~ will be. performed Jn the manner ~t fodh Jn the app~cation filed therewit~
om to before me this /
...................... o, ........... ......
[I ..........
~o ~ 'c~~...~..~.. Coun~~ (S~gnatu~ of applicant) / ......
ELIZA~H ANN NEVtLLEI
NOTARY PUBLIC, State of
Term Expires ~