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Home My WebLink About6106-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certi[icate O[ Occupancy No. ~)?~. ..... Date ............ ~1~.. ~ ...... , 19..~ THIS CERTIFIES that the building located at . ~[&~'~,. 8~ .................. Street Map No..~ ........ Block No...~ ..... Lot No. XK~...~®n~..~[.,.~, ............ conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ ~1~.. ~[.¶., 19.72. pursuant to which Building Permit No..64 0~. dated ............ ~p~.. ~[.l., 19. ~2, 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 . P~$V~,~ .ola~ .t'imily d~llilxg ¥~l;k .&dd~,.i;~,0~. ..................... The certificate is issued to .. ROg~l*. & .]~l*,fll .Fo~i;~V ..... 0w~®l~.a ................... (owner, lessee or tenant) o£ the aforesaid building. Suffolk County Department of Health Approval . II.Il, .............................. UNDERWRITERS CERTIFICATE No. ~][, ...... : ................................ HOUSE NUMBER .... 830 ...... Street ...l~v~. Jl~ ............................... 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) 6106 Z Permission is hereby granted to: ...... ~.~.~.~ ...... ~...?.? ....... 5PX.!..*-~ to ....~.. ....................... ~ ...................................................................................................................... at premises located at N .............................................................................. .Q.~.!...~...~...~ ................................................... pursuant to application dated I J ,~/~ PT 19~...~.. and approved by the Building Inspector. Fee $..../.5..~. .... Building Inspector TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUT.O,D, N. / ^ / Examined ............ ~... ........ .~:....., 19 ............ pp icotion No ................................. ........................... APPLICATION FOR BUILDING PERMIT INSTRUCTIONS o. This opplicmion must be completely filled in by typewriter or in ink ond submitted in duplic*te to tho Buildino~ Inspector. b. Plo~ plon showin~ Iocotion o{ Io~ ond of buildinos on premisos, relotionship to od~oinin~ premises or public streots or oreos, ond ~ivin~ o detdlod description o{ Ioyout o{proporty must be dr~wn on the dio~rom which is p*~ of this opplicotion. c. The work covered by this opplicotion m~y not be commenced before issuonce d. Upon opprowl o{ this opplic~tion, the Buildino Inspector will issue o Buildino ~ermit to the ~pplic~nt. Such permit sholl be kept on the premises ~vdloble for inspection throughout the prooress of the work. e. No buildin~ shah be ~cupied or used in whole or in part {or ony purpose whatever until o Ce~ific~te of Occuponcy sholl hove been ~r~nted by the Buildino Inspector. APPLICATION IS HEREBY MADE to the Building Deportment for the issuance of o Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Lows, Ordinances Regulations, for the construction of buildings, additions or o~terotions, or for removal or demolition, os herein described. The applicant agrees to comply with oil applicable lows, ordinances, building code, housing code, and regulations. ..... (Address of'applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ................ O Z-Tf ............................................................................................................................................................. .. Name of owner of premises ........ /~....<:]~......~/~......~~ ............................................................... " If applicant is a corporate, signature of duly authorized officer. (Nome and title of corporate officer) 1. Location of land on which proposed work will be done. Map No.: .......... : ............................. Lot No ......................... Street and Number .......................................................... ...~...~...~.~.. ................... ~ ............................................. Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ........ :.'~.i~..l.]z~.~./~ ...................................................................... b. Intended use ond occuponcy ............... ~ ...................................................................................................... 3. Nature of work (check which applicable): New Building Addition J Alteration 3 Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................ 4. Estimated Cost , ~c) ~ ~ /,5' ~ ~) .................. ~: ....................................... nee .......................................................................................... (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 end extent of each type of use ............................ 7. Dimensions of existing structures, if any: Front ..... ~...~...~./.' ........... Rear .5'? '~- ................................ Depth -?~ '~ ~- Height ........................ Number of Stories ............... ~.. ...... Dimensions of same structure with alterations or additions: Front ~,~r ~ ................................... Rear ............................ Depth ................................ Height ............................ Number of Stories .........../. ................... 8. Dimensions of entire new construction: Front ..... /.~'. .......................... Rear ...... ~ .................. Depth ....................... Height .................... Number of Stories ............................................ ~T ~ ~r ............................................. 9. Size of lot: Front ..... (~../. ................. Rear ..... Z .~.~.. ....................... Depth ../.~.~'. ....................... 10. Date of Purchase ..~.~..../~..././.~.~...~..... Nome of Former Owner~;'~:~.~.~..'-__~ ..~c~. ............ 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 .Z/RG~-.~....~/~t....~.,~..,x?...Address ..,4~'.~fR.~....~'.~,..y.~,,~/x~'~ 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 corner lot. .... ~ STATE OF NE-M/YORK,~-----'~.-t= K' .__.~, ~ t ,0 L__¢¢ COUNTY OF ................................ ~'~'~ ................. .~.~;.;;.;?~:....N..~_ ......... ~--- '~~.'..~.'...~-..;~.....be,ng du,y swot., deposes and says tho, he ,s the opp',can, individual signing application) above named. He is the ..... ~.....~......,~.. ~'--./..~.. . '"'~ ............... i~:'~'~r~'~'r'~'~ent, corporate officer:~;~(~;i ............... 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. Swam to before me this ................ L.l...,~y~ of ............................ ~.. .......-~.. ~.~ .~'~7~ z~ , ~/~~ u ' ~ ~:,,~r'~ .............. ~,-~ ~ ~~.~ ................ TERRI LEE ELAK NOTARY PUBLIC. State ot New York No. 52-6168295 Qualified in Suffolk County Commission Expires March 30, 19 '"/~