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Home My WebLink About6192-zFORM TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office $outhold, N. Y. Certificnte Of Occupancy No..Z~.~I*~ ..... Date .......... 0CtObe3~. 17t .... , 19.?~.. THIS CERTIFIES that the building located at . .i~or. tons. r~,~e ........... Street Map No.. Y.X ........ Block No..Y~ ...... Lot No. ~ .... 3~o~ ................ co~orms substantially to the Application for B~ldMg Pemit heretofore ffl~ ~ ~ office dated .......... 0e~, .~. ·., 19. ~2 p~suant to which Building Pemit No.. dated .......... OCg, .~$ .... , 19.-~2, was 'issued, ~d confoms to ~ of ~e requ~ ments of the appUcable pro~sions of the law. The occup~cy for wMch t~ certificate is issued is . ~$va~ .ae~sao~.b~dg,. (.a~age) ............................... The certificate ~ issued to .. ~tch~. ~..R~C~ ............................. (owner, lessee or ten~t) of ~e ~ores~d buil~ng. S~olk County Department of Health Approval ...... ~ ............................ UNDERWRITERS CERTIFICATE No. HOUSE NUMBER . .~ ....... Street .. ~r~.~n. ~ .......................... ............................................... ........................ Building Inspee~oP FO~M NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PI~EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 6193 Z Permission is hereby granted_to: ~, ~/~ ,~ ~ ~ .~~J~:......~~ to ..... ~....~.....~~ ....... ~-~t ....................................................... at premises [~ated at ..... ~...~~: ..................................................... Building Insp~tor. Fee $l.~..~ .......... Building Inspector / Exomined ,~ ~ ~'/ ~'~ 7-~ ........................................ , 19 ........ Approved ........ :.~ ....... i.~ ................... , 19~...~.. Pemit No. ~/....~....~...~ ............ Disapproved o/c ~ ................ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building inspector, wit.~ 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, anrl~ giving a detailed description of layout of property must be drawn on 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 to the applicant. Such permit shall be kept on the premises available for inspection throughout 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. k 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, Suffo[h County, New York, and other applicable Laws, Ordinances 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 code, housing code, and regulations, and to admit authorized inspectors on ~,remise~and in buildiruae~for necessary.inspections. (Signature of applicant, Or name, if a corporati(~) ~'~' 7, ~".~ .~ (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder~ Name of owner of premises ...~',~.~...~. Z...(~...,,,~..,/~,~'?_, ~' 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.: .................... Lot No .............................................. Street and Number ............................................ ~ ............................................................................ ...~'..: ................... Mumcipality 2. State existing use and occupancy of premises and intended use aqd occupancy of proposed construction: 3. Nature of work (check which applicable): New Building ....................... Addition ..................... Alteration ............... Repair ......................... Removal ......................... Demolition ........................ Other Work ....,.~7~.~.~ .................. (Description) 4. Estimated Cost ..... /..~. ..................................... Fee ..... .~ .......................................................................................... (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 .~.~....~ ....................... ........................................................... Number of Stories ..................................................................... Dimensions of same structure with alterations or additions: Front .....~...~....~.' ............. Rear ....,.~/. ~...~ ........................... Depth ............................................. Height ? ~' Number of ' ......................................... Stones ........................................ 8. Dimensions of entire new construction: Front ......~.,~ .............. Rear ...... ..~.. ................. Depth Height ................................................. Number of Stories ......................................................................................... 9. Size of lot: Front ......?.....~.??~..../. .............. Rear .......~.?..~ ............................ Depth .....L...°-~.../.../. ................................ Height .................................................... Number of Stories ...................................................................................... 10. Date of Purchasa ..'~....~.~ /~.?.'..~.. Nameof FormerOw, ner...-~...A~...~?..~?.../~,,....~., .../~.....~....,~....~....~'...~..C...,~... 11. Zone or use district in which premises are situated .~.k.= ...................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ..... ..~....C~. ................................................ 13. Will lot be regraded .................................. Will excess fill be removed from premises: [ ] Yes [ ] No 14. Name of Owner of prem~sas .......... ~ ....... /~.~,~;'~.~.........'~ ...................................... ~ .................................. (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 wheth- er interior or corner lot. STATE OF NEW_Y_ORI~ ~ ) COUNTY OF .....~.~...~..~[~ ....................... ) SS .......... .~'~.~..~.~,~:~L.~.~....~,.~.~.i~)..Id~.].~...~... .................... being duly sworn, deposes and says that he is the applicant above named. (Name of individual signing contract) He is the .......................... .(~)...~,~..~%...q,l~. ................................................................................................................................................................ (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. TERRI LEE ELAK ....... '"" ....... ......... . ...... ..........; .'- NotaryPublic~S,',~~~ ......... C;'~n~F'''% -'~--.--~--~..:~ ............................... · ($tgr~mr~ o.~ appttcantl_..)