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Home My WebLink About7415-zFOBM NO. 4 TOWN OF SOUTHOLD BU~.r~ING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. ~2~0 ..... Date ............ Ja~. :..& ....... ,19.?~. THIS CERTIFIES that the building located at .... ~l~th. Ro~ ............. Street Map No.. x~ ........ Block No~I~ ......... Lot No.I... Matt:t~aek...l/,¥.o .......... conforms substantially to the Application for Building Permit heretofore fried in this office dated ........... J~... q~, 19.~ pursuant to which Bu/lding Permit No. '~.¶~'Z- dated ......... Jti~-.-l~ .... , 19~t~., was issued, and co,/fforms to all of the require- ment.s of the applicable provisions of the law. The occupancy for which ~ certificate is issued is ... la~.~a.te .~ae .fa~4r. d~elt/~l~ .wt.t& .&lidit:l.o~ ................... The certificate is issued to .l~eh~el- G~bl,~ll · - :. '0~ll' .......................... (Owner, lessee or tenant ) of the aforesaid building. Suffolk County Department of Health Approval · .Ne~t° ............................. UNDERWRITERS CERTIFICATE No. I~.R,..(ex~t~Jal. ¥~.~®~Lnl ) ................. HOUSE NUMBER ...$&~ ........ Street ... tl~h. tlo~ ............................ / ~ 'Building InSpectOr / FORM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT. TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PERMIT CT'HIS PERMIT MUST BE KEPT ON THE PP, EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 7415 Z Permission is hereby granted to: .~ich~el..g~=i~ ........................................... ...~..u..t...h... M.d. .............. .!.La...t..t..~..t..u...e..k.. ....................... ' at pmmi~$ l~at~l at .......... ~..~l~t~..~ ............................................................................... ................................................................. ~'I~t~uck....~ .......... '. ................................................ pursuant to application doted ...................... -Tz~.,~.~. ....... .~.~ ........... , 19..7.~.., and opproved by the Building Inspector. OUllOlng inspector APIK.I~,ATIOfl FOR BUILDING PERMIT This application must be completely filled in by typewriter or. in ink and submittnd In triplicate to the Building~ Inspector, with 3 ~ of plato, aocurate plat plan to scale. Fee aocordtng te .~duld, b. Plot plan showing location of lot and of buildings on premises, relationShip to adjoining premises or public streets o~ areas, and giving a detailed description of layout ofpraperty must be drawn on the diagram w~ich is pert of this application. c. The work covered by this application may not be commenced before issuance of ~jlltldjhg Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the ~m~rliCarff. Such permit shall be kept on the premises available for impectle~ throughout the work. e. No building shall be occupied or used in whole or in pert for any puq~ose whatever until a Certificate of Occupancy~7 shall have been granted by the Building Inspector. B_..A,~P~P_L_I ~C~__TION~!S HEREB, Y.,MA_DE to .th.e B.,uil.d!ag_ ,D~. ,a. rt~r~ant ~r..t~e ,i.ssu. ance of a Building Per'it pur~ant to the ~,,,,:, .~. ~.amnance. ?_~tn? m? ,o~ ~oum?~, ~uTrom.. %~u..my, r~4~v jor~ and ott~r ~ Ofclinances or .~geUa~>~l~_,~nT~gr~¢T~Ivonw~OaUi[~i,c~t!ons or a.!temhons, or for removal or demol, itlan, as heroin described. admit authorized i- - ' P y . :pp! . _....m~, o,ramances, bull.ding c..ade, housing code, and regulattom, and to n~oe~'ors Orr premises ~ in OUIlalrt~ Tar rl~c~ory Ir'~p~ctlorls. (Signature of applicant, or name, if a corporation) Y (Address of applicant) State whether 9Ipplicant is ow.n~,r, lessee, ~gent, architect, engineer,i general contractor, eleCtr 'c an~, plumber or builder Name of owner of premises L If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ..................................................... Plumber's License No ................................................. Electrician's License No .......................... '"'"' '"'"" '" ' Other Trade's License No ............................................... ~ ~.. 1. Location of land on which proposed work will be done. Map No.: ............ i .., .......... Lot No .............. Street qnd Number ..~.X....~.~.~..~.. ~ ~ ... . ~ .~...C/~' 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: Exlsiting use and occupancy f 3. Nature of work (check which applicable): New Building.. ................. Addition .....~ ..... Alteration ................. Repair .................. Removal .................. Demolition. ................... Other Work ................................................ . .... (Description) 4. Estimated Cost ................/.....~......?.....'.~... ..................... Fee ',.L.:~--~....: ............................................................. (to be paid on filing this application) 5. If dy~lling,.number of dwelling units ............................ Number c~f'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 .......... ~f. ........... Number of Stories ......... ~. .................... ; ................................................................................. Dimensions of same structure with alterations or additions: Front .....................................Rear ............................ Depth ................................ Height ................... ~ ........ N'umber of ~t~ries ................................ 8. DimenSions of entire new construction: Fror~t ........... .~..~.~.,.~. ......... :.... Rear ......... .~..~..~....~. ........ Depth ....... .~.../..: ......... Height ......~. ........... Number of Stories ..................................................... . ............................................................... 9. Size'of lot: Front ......... ~...~..~ ...................................... Rear ......... ~...O....~. .......... ~ ........... Depth ......... ~..~.~.?....~ ........... 10. Date of Purchase ............ .~l..~..~ ................................ Name of Former Owner ...~./~.~..~..~.'...~.~...~...~.~...~..... 1 I. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ........................................................ 13. Will lot be regraded ............................ Will excess fill be removed from premises: ( ) Yes ( ) No 14. Name of Owner of premises .~.[~'~...~..:.~i~.. 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 setd~ack dimensio.ns from property lines. Give street anCbiock number or descnptJon acco ~r~r~r~r~r~r~r~r~r~i~w street names and :~ndicate whether interior or corner lot. STATE OF~ NEW LY~.~*-s~ ~- ~, I ~ ~ ' COUNTY OF .... ._~..~....'~..:......~'~'~ ~,~ . ........................ ..../~...f..~.......~.~...~'~.~.: ......... being (Name of individual signing contracf) above named. duly sworn, deposes and says tl~t he is the applicom He. is the ................................................................................................................................................................................. (Contracto.r, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform' or hove. performed the said work and to make and file this application;.?hat'~a!l statements contained in this application are tru~ to the best of his knowledge and belief; and that the work will~'.be performed, in th· manner set forth ~n the application filed therewith. Swam to before me this ',i,.,.;..../..?...~...~... doy of .i' ........ ....~...~ .................. , 19...~.?J~. ~'~_. ~/_,~ /~/ ~_ ,~ ~_ ~/,~ Not~ry Public,. .............. ~ .......... , ...... .~, ........... Coun~ ........... #...~X¢..e:'..~.lt~,~..,....~-.Z...'..: ./'~.....¢~-~. ............. :.: ........ /~~ lp';i~.~.~ {Signature of opplicant) . ROBERT A; PARKIN I~tary Public, State of New YO~ No. 52-8280300, Suffolk COUD~ Te~m Expires March 30, TOWN OF SOUTHOLD Building Depmtment Town C:le~J Office Soul'hold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF O~CUPANC¥ Insh'uctions A. This applicotion must be filled in typewriter OR ink, and submitted in DUPLICATE to the Building inspector with the following; for new buildings or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, ond unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewerage disposal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installations, a certificate of Code compliance from the Architect or Engineer responsible for the building. 5. Submit Planning Board approval of completed site plan requirements where applicable. B. For existing buildings (prior to April 19,57), Non-conforming uses, or buildings and "pre-existing" land uses: 1. Accurate survey of property showing all property lines, streets, buildings and unusual natural or topographic features, t 2. Sworn statement of owner or previous owner os to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent in- formation required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use $5.00 3. Copy of certificate of occupancy $1.00 New Building ................ Addition ...... .'~..... Old or Pre-existing Building ................ Vacant Land .............. Property-~... ~ ..~..U.....I~...~. ~/(~.'loc'' ~ 0 LO'I'/'~ ~C~ · oco.a. Of ./.i ........................................... /. .......................................................... Owner Or Owners Of Property . ..[/~[ I.~./0~.~..C ... ~ ....~t0~_,~..li.~'.(,~ ................................... Subdivision .................. ~ ............................................. Lot No ............. Bock No ............. House No ............. Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate V~ Fee Submitted $ .......... ~ ..................... Construction on above described building ands,._),.., , / /~ /~ ~'///perm~it meets all applicable codes end regulations. App cant ......,~../d~,z~...~,~,~Z....:./~...~-~?~.%~...., ................. Sworn to before me this I°/-~/,/'Ju-~:;>~._,,[,/ ~.R&)~ ~ .21~...... d~y~of ....~.....I.?..?..~.. .......... (stamp or seal) Notary PUI~c I ......... r-,..,,~,wrER M. COLEMAN ~ 1__ "'j'* '~ .................. "I~I~ItXRY PU~UC, State of New yod~ ! '-~' ' ' ~ ~ · Qualified in suffolk 'County Commission Expires March 30, 197~"