HomeMy WebLinkAbout5541-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupnncy
No. J%%~.3 ...... Date ........ 0c.~;ober..17, ....... ,19.73.
THIS CERTIFIES that the building located at .. S,;nrisa .9/alt ............. Street
Map No...~Q ........ Block No.. ~ ...... Lot No..177. .... ~uth~d ..............
conforms subst~ti~ly to ~e Application for Bulling Pemit heretofore filed ~ ~s office
-~~ ...... Se~t,. ~O, ..... , 19. Fl p~su~t to which Building Pemit No.
dated ...... 8.e~,. ~Q, ...... , 197~., was issued, ~d co~orms to ~1 of the req~
ments of the applicable pro~sions of ~e law. The occup~cy for which this certificate is
The certificate is issued to ... ~raCe..~,. ~ls ....................................
(owner, lessee or ten~t)
of ~e Mores~d b~ld~g.
S~o~ Co~ty Dep~tment of He~th Approval .. ~ ...............................
UNDER~ITERS CERTIFICATE No.. ~. ........................................
8ou~old
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)
~'' ~ '"~ 19 ~¶
N°. 55Zll Z ~o~e ........................................................ , ........
Permission is hereby granted to:
................ ~...~l,~l,~. .....................................
to .~..a...~....~...~...~.~v~...l~s~:l~...( ~'.e~ ..~1,). ........................................................
at premises located at ...~...l~l~.....~,~..~al~..~.ll, ll~ ............................................................
.............................................. ~mz~..~&X .............. ~e~ti~e3~ ................................ ' .....................
pursuantc to application dated ................................ ~l.ql~ ....... ~ ...... , 19.~..~.., and approved by the
Building Inspector.
~ee $..~.,.00. ............
FORM NO. !
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN' CLERK'S OFFICE
SOUTHOLD, N. Y.
INSTRUCTIONS
This application must be completely filial 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 r't
areas, and giving a detailed description of layout ofproperb/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 tothe 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 dlterations, or for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, building code, 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 ...... ..~....~....'~..~..~'........~...:.....~.../.'~..~.. .............................................................................................. ..~
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer) .
]. Location of land on which proposed work will be done. Map No.: ......... ~..~.. .......................... Let No..../..~...7.. ..........
Street and Number ................................................ ~.. ........................................................... ~.. ..........................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed constructien:
a. EXisiting use and occupancy t~.,.TIZ)~/I/C..././.~....,
b. Intended use and occupancy TOOL ~ ~ ~'~ /, STO/~AG~ ~tD/iC,~...~ .~/'c . ...
/
3. Nature of work (check which applicable): New Building ..... .V... ........ Addition .................. Alteration ..................
Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................
......,................,....................................Fee ......................-.~..~.'...'.''........~......'.~..~........~.......~..... ..........
4. Estimated Cost
(to be paid on tiling 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 ext~nt 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 ....... ./..~....~..~.:.'~ ............... Rear ....... /...~.~.~ .......... Depth ....... ./..~..~...~.'/' .......
Height ...... ~...~'~..'. .... Number of Stories ..... -~. ..............................................................................................................
9. Size of lot: Front ......./...O..~....../~..~... Rear ........... ./..~..~.....~,~.. ...... Depth
10. Date of Purchase ..... .~.~..~......./.~..~.~. ........................... Name,o~f~w m .Farmer Owner ......~...~...~...~...~..~...~...~.~.. ......................
11. Zone or use district in which premises are situated ............ ..~........~ ....................................................................
12. Does proposed construction violate any zoning law, ordinance oLreg_ula~t, iop? ....,./~O.., ................................................
13. Name of Owner of premises ...~...~.~...C...~.....~.:..~.(....~.......Address .~....~.~...~..~.~..~..~.~...~..e~Phone No..~..~..~..T...~...~.~.~
Name of Architect ...................................................... Address ............................................ Phone No .....................
Name of Contractor .................................................... Address ............................................ Phone No .....................
PLOT DIAGRAM
Locate clearly and distinctly oil buildings, whether existing or proposed, and indicate all set-hack 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.
STATE OF NEWx~OJ~/~:'
COUNTY OF ............... .f:"--'
............. ~...' ................. ~"~ ~,..~....~' ............................... being' duly sworn, deposes and says that he is the applicam
(Name of individual signing application}
above namecL~e 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 all 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.
Swom~t~/T~,c_/~to before me this
..... ?. .. . doy, .. of . , , ,,
Notary
J ELIZABETH ANN NEVILLE--V~ - ,( ~.~z~
NOTARY PUBLIC, State of New York
lto. 52-8125850, Suffolk Coum.v
Term Expires March 30, 19,~