HomeMy WebLinkAbout5300-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
THIS CERTIFIES that the building located at .. ]~1~. ~ ................ Street
Map No.~..O~t....~.t4~bck No ........... Lot No.. ~]~[ ....... 3~'a~h~l .............
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ........ l{l~.. ~..lb.., 19.71. pursuant to which Building Permit No .... ~
dated ......... MIt~ ..... tl~..., 19.~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 ..... .&g¢~;;.ao. zy..(~;-O;~.age..b.;Ldg)., l~$~tdtn$ ..........................
The certificate is issued to ...~a~h~. I~w~l~k~ ..... ~1' ...................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ........ ~ .,.R? ........................
Building Inspector /
~E
PERMIT
to
pursuan¢ to application doted .............................. ~ ..........~ ........ , 19.~.., and approved by the
Building Inspector,
£ee $ '~'~'~,00 ............
FORM NO, 1
vow~ o~ SO~¥~O~D
SUILDING DEPARTMEN~'
TOWN GLERK'S OFFIGE
$OUTHOLD, No Y.
Approved ........................................ , 19..//..... Permit No.
APPLIGATION FOR BUILDING PERMIT
Application No...?..~ ...........
Dote ; May 1}+ 19..,7.1 .....
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted irt duplicate to the Building
Inspector.
b. Plot plan showing Iocahon of lot and of buildings on premises, relationship to od o n ng pram sas or public streets or
areas, and giving o detailed description of layout of property must be drawn an the diagram which is part of this application.
c. The work covered by this application may not be commenced befo!e issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issu~ 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 port for any p!Jrpose whatever until a Certificate of Occupancy
shah have been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pur,~uant to the
Building Zone Ordinance of the Town of Southold, Suffolk County, New ~ork, and ether applicable Laws, Ordinances or
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, os herein described,
The applicant agrees to comply with oil applicable laws, ordinances, buil~Jing code, housing code, and regulations,
Anthony Le.andowski
(Signatgre cf applicant, or name, if a corporation)
....... ........... ............................................
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, gener~al contractor, electrician, plumber or builder,
.................................................. ....................................................... ........................................
Narne of owner of premises .&~.t.hol~.,.Le.¥.az~do.wski .....................................................................................................
If applicant is a corporate, signature of duly authorized officer.
(Name and title 'of corporate officer)
1, Location of land on which proposed work will be done Map No.: NT~q. ekoma :Waters Lot No.: .,~.~. ..................
Street and Number ............ .l~.~.....~ow...~d .......... $~)~.+,,h(.~.¢t..I ............................................................................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ........ .~...e.~.~?~;O,,[ ..........................................................................................................
b. Intended use and occupant, . .......... .s..,a..m..e....}.c.].':~..~X3..,~R,.g.!~.~g~..~..~l,j[ .....................................................
3. Nature of wo~k (check which applicable): New Building _...~,~C.,.~. ....... Addition .................. Alterahon .............
Repair .................. Removal .................. Demolitian .................. Other Work (Describe) ....................................
4. Estimated Cost ............ ].~.~......~ .................................. Fee ...~.,.f).0. ............................................................................
(to be paid on filing this application)
5. If dwelling, number of dwelling units ..~9.~ ................ Number of dwelling units on each floor ............................
If garage, nurnber of cars ............................................................................................................................................
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ....~.e...q.e...s.~..o.~...
7. Dimensions of existing structures, Jf 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 .......... .1..0 ...................... Rear ........ .1..0. ............... Depth .......... .8. ............
Height .................... Number of Stories ...........,o..~...e. ...................................................................................................
9. Size of lot: Front ............................ Rear .................................... Depth ................................
10. Date of Purchase ........................................................ Name of Former Owner ........................................................
! 1. Zone or use district in which premises are situated .......... ~.~.A!.~...(i.'l.$.t, ........................................................................
12. Does proposed construction violate any zoning law, ordinance or regulation? ......... ~ ..............................................
13. Name of Owner of premises ..~.~t~J~.O.~r...~.¢.~T~f~.~f~c~ess ........... ~.0.!~,~ .............. Phone No .....................
Name of Architect ...................................................... Address ............................................ Phone No .....................
Name of Contractor ....... .s.~.e. .................................... Address ............................................ Phone No ....................
PLOT DIAGRAM
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions fram
property lines. Give street and Nock number or description according to deed, and show street names and indicate
~vhether interior or corner lot.
STATE OF NEW~OP, K
COUNTY OF .... R..~.~:,6,.1...~. ........... ~'~'~'
................................................................................................. being duly sworn, deposes and says that he is the applicant
(Name of individual signing application)
above named. He is the ................. ..~.,~.~f~...O.;~...~).~',10,f}~'. .....................................................................................................
(Contractor, agent, corporate officer, etc.)
of sc, id owner or owners, and is duly authorized to perform or have performed the said work and to ~ke end fife
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 foffh in the application filed therewith.
Sworn to before~me this.~..~ 19..~..
.................. of ...... ...... ....... ,
~O~gRY ?~fl[l~, S~ate'o~ ~ York
~o, ~2.8125850, Suffolk Count~.
Term [xpires ~arch 30,
T~WN OF soUTNOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFIGE i
SOUTHOLD, N. Y.
....... ...... . ...........
Approved . ~ '/ , 197. .... Permit No...Z~J~/..'..~.~
- -Di~pproved a/c ........ ....~;~ ................................ . . : ............................ ...~...
..; ......................... ....... ............ , .....
INSTRUCTIONS
a. 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 premises or public streets or
areas, and giving a detailed description of layout of property must be drawnion the diagram which is part of thie application.
c. The work covered by this application may not be commenced b,fo~e issuonce~of Building Permit.
d. Upon approval of this application, the Building InspeCtor will issue a Building Permit to the applicant. Such permit
ehall 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 p~lrpose whatever until a Certificate of Occupancy
shall have been granted by the Building Inspector.
APPLI~TION IS HEREBY MADE to the Building Department for the issuance of a ~ullding Permit pursuant to the
Building Zone Ordinance o~ the Town of Southold, Suffolk County New ~ork, and othe. applicable Laws, Ordi~nces or
Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, os herein described.
The applicant agrees to comply with all applicable laws, ordinances, ~uii~ing code, housing code, and regulations.
Anthony * , '
(SignatUre cf applicant, o~ name, tfa corpa~tion)
Bo~,~ R~ ~outhold
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
................................................... !;:;, .LL.q,'.Lq .................................................................................................................................
Name of owner of premises ,~.~,~L~.~.24A~....L,~.,,~Z.~J.&~,~i .....................................................................................................
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
Municipality
2. State existing use and occupancy of premises and intended use a6d occupancy of proposed construction:
a. Existing use and occupancy
b. Intended use and occupan:',
3. Nature of wo~k (check which applicable): New Building ~.~.~ ....... Addition .................. Alteration .............
Repair .................. Removal .................. Demolition .................. Other Work (Describe) ...................................
4. Estimated Cost ............ ].2.~.....~ .................................. Fee ...~'.~0.0. .............................................................................
(to be paid on filing this application)
5. If dwelling, number of dwelling units ..~,GIX~ ................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 .....~f~.~.f.,,.~..o...~...
7. Dimensions of existing s?ructures, [f any: F~ont. ........................... 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 .......... .1..0. ..................... Rear ........ .~.O. ............... Depth .......... .~. ............
Height .................... Number of Stories ............o..~...O. ...................................................................................................
9. Size of lot: Front ............................ Rear .................................... Depth ................................
10. Date of Purchase ........................................................ Name of Former Owner ........................................................
1 I. Zone or use district in which premises are situated .......... t~.~.~J...E;~..J.~.~ ........................................................................
12. Does proposed construction violate any zoning law, ordinance or regulation? ......... .Z.z..o. ..............................................
13. Name of Owner of premises ..O,~'t~O.~r...~b.~¥f.e,~Q~.fJ~ff~J~ess ........... ~.O.g,lg~D~ .............. Phone No .....................
Name of Architect ...................................................... Address ............................................ Phone No .....................
Name of Contractor ....... (~.~.r.;!.e. .................................... 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
~hether interior or corner lot.
STATE OF NEW ,y,O~,l~,,. ~ ~ e
COUNTY OF ....
................................................................................................. being duly sworn, deposes and says thor he is the applicant
(Name of individual signing application)
above named. He is the ..................6.F.f~.~...O.~'....(~/l.~ig~ ............................................ '~ ........................................................
(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 therewith.
Sworn to before me this .,
,....~
................... L-r.y.~da y of ....... ...... .......... ,
' ........... ' .......... ...... ............ ,,.., ....... .................
Notary
Court ~, "-, (Signature of applicant)
// ~! ~B ET H^ ~r'/?~l LL, t~~
~ NOTARY PUBLIC, Sta~ of New York
Ne. 52-8125850, Suffolk County
]'erm Expires Marct~ 30, 19~
FOEM NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Examined ........................................ , 19 ........
Approved ........................................ , 19 ........ Pemit No .....................................
Disapproved a/c ......................................................................................... ~..
Application No .................................
(Building Inspector)
APPLICATION FOR BUILDING PERMIT
Date ........................ :~...../.. .............. , 19..~..../. ....
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 on premises, relationship to adjoining premises or public streets or
areas, and giving a detailed description of layout ofproperty must be drawn on the diagram which is part of this application.
c. The work covered by this application may not be commenced beford issuance of Building Permit.
d. Upon approval of this application, the Building Inspector will issue q 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 Deportment 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 f~r removal or demolition, as herein described.
The applicant agrees to comply with oil applicable laws, ordinances, building code, hou,~ing~:ode, and regulations.
(S~notu~f o~p~i~ont, ~r no~e, Jfo corporation)
(Address of ap~icant)
State wh~er applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
owner of premises ...../~/''/?/~,7./~]zZ~//_./~.z.../~.~/~.~.~?.Z~.'~.:.~."/../. .....................................................................
Name
of
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
1. Location of and on wh ch propose_work be done Map No,'
e~) ~/w r~ ./~ , ,. ~ * ,-- ?. ........... o./J..'
at NI,_~.~ ..................
Street a,d Number ....... .......
/
Municipality
2. State existing use and occupancy of premises and intended us~ and occupancy of proposed construction:
a. Ex.siting use and occupancy ................
b. Intended use and occupancy ................................................................................................................................
3. Nature of work (check which applicable): New Building .... Z~ ......... Addition .................. Alteration ..................
Repair ............. ;,[~ Removal .................. Demolitior .................. Other Work (Describe) ........................................
(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 construction: Front .................................... Rear ........ ~,~.. ............. Depth ........................
Height .................... Nurnber of Stories ......................................................................................................................
9. Size of lot: Front ............................ Rear .................................... Depth ................................ · ,
10. Date of Purchase ........................................................ Name of Former Owner ....~.,'~.~..~......~Z,//Z/..~../~_.
11. Zone or use district in which premises are situated .....................................................................................................
12. Does proposed construction violate any zoning law, ordinance or regulation? ............................................................
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 end 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 corner lot.
STATE OF NE?~'~..~_ '~c c
COUNTY OF ~,;....~,~,~',~,, ,,~c~/~~
............................ ~ ................... .~.....~ ................... ~lf~"l:lly sworn, deposes and soys that he is the applicant
(Nam~ of ~dividual signing applic~i~n)
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 all statements contained in this application are true to the best of his knowledge and belief; and
thor the work will be performed in the manner set forth in the application' filed therewith.
Sworn to before me this~ day of ............................................ ~~-r"--/~ ~~
................ 19~ /' /
Notary Public, . ........................................................... ~ounfy ~' (Signature of applicant)