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TOWN OF SOUTHOLD
BUTLrJING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
THIS CERTIFIES that the building located at..~. ~r.d..A.~...&...l);L.e.k~l.l..~.. ~reet
Map No. pe.e.,. 8)~ .2. Block No ........... Lot No..6.~...&~.....P.e.e..o~..S.e....ll;.Y.; .......
conforms substantially to the Application for Building Permit heretofore filed in this office
Jtme 18 62 178~.~
dated .........Ja~..1.e ..... ,19.7.1~. pursuant to which Building Permit No..?0~.gZ.
Ju~e 23 ~.
dated .............. ~.a~ .... ~ 19. , was issued, and conforms to a~ of the require-
ments of the appilcable provisions of the law. The occupancy for wh/ch ~.hi.~ certificate ~s
The certificate is ~ssued to ...W.i):l.i..a~...R.e.B.l.a..e..k~..~.. &..w.i.f.e. ..... . .~..e.r..s ...........
(owner, lessee or tenant)
of the a~oresald budding.
Suffolk County Depar~nent of Health Approval ...N.o.R.? .............................
UNDER%VRITERS CERTIFICATE No....N...R.: ............................ .' ........
HOUSE NUMBER ...... ~. ..... S~eet ....~..~..A..v.e .... .~.e.c.o.~$.e .................
FO~M NO. ~
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N~ Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PP. EMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N.o 7059
Permission is hereby granted to:
...a JJ,;[J, aa..L ..~;~,;Lc.~.~ .... ~ ~ ~..e.~ ~_~ ..............
.......... .1.~.....3~ad~.,L ,~. ........................................
..... ~ o..,If a,~:~,~;o~',~,...~ t. ........................................
~o ~b~u.L1.d~`a"~`~;~;~;~;~.i;~;~c.~.~g~.~b....u$....~.~Ln.~ .....................................
at premises located at .~Q..t~.'s~f~.~'.~c~g~.`r`j~.~.~g.~:~)~.c.~.~.~. .......................................
.............. ~h~..-~t..~..D~c~l~s~u..~l; ............. ~ac~.'l.e ......... .E.,.×.,. .......................................
pursuant to application dated .............................. ,J~.~.....1.8 ......... , 19..~.~.., and approved by the
Building Inspector.
Fee SI.Q..(~O .............
Budding Inspector,/
FOI/~ NO. 6
TOWN OF SOUTHOLD
, Building Depn~tmnnt
Town Clerks Office
Southold, N. Y, 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instructions
A. This application 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, and
unusual natural or topographic features.
2. Final approval of Health Dept. of water supply and sewerage disposal--(S-g 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 1957), 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.
2. Sworn statement of owner or previous owner as 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
Dote AUGU~ 21, 1975
New Bqi)ding ................ Addition ...... .X..X. ...... O)d or Pre-existing Bui)ding ................ Vacant Land ..............
95 THIRD AVENUE, PECONIC
Location Of Property .....................................................................................................................................
WILLIAM AND EILEEN BLACKHAM
Owner Or Owners Of Property .......................................................................................................................
Subdivision ..... .P..E..C..0..N..I.C....S..H..0..R..E..S. ............................... Lot No.6.3..&..6..4..... Block No. Z7. T..Z.Z... House No..9..5 .........
Permit No....7..0..5.9.;~. ........ Dote Of Permit ..!/...2..4/..Z.4.....Applicant ..................................................................
Health Dept. Approval ....... .~..~. .............................. Labor Dept. Approval ......... N.J~ ................................
Underwriters Approval ......... .N..,..R ............................... Planning Board Approval ..N..~.I~.: ...............................
Request For Temporary Certificate ........................................ Final Certificate ..........................................
Fee Submitted $ ........$.[~.,.0.Q ..................
Construction on above described building ~t~~~~~ulations'
Sworn to before me this/pphcant ''~'''''~'''~''''~ '" ~~"~,~_
................ da'~.f~:z.:_....?z__~_ - ............................... Cstamp or ~1) ~/~ r~ [
Nota~ Public ................. 2..~:~,~ .....Coun~ ~
SOUTHOLD, N. Y.
Approved ...................................... i '9Z-~..- Permit No. Z..~.....~..Z~ ............
Disapprc~ed a/c ........... ~ ............................ ~. .....................
INSTRUCTIONS
a. ,This application must. be completely filled in by typewriter o~ in ink. and submitted in triplicate to the Building
Inspector, with 3 set~ o~,plaris, accurate plat plan to ~ale. Fee according to echeclule.
b~ Plot 'plo. h Showing. 'loccr~ion O.f. 10t and ~f bulldif~gs on premises, relationship t6 c~l|oining premises or public streets o~
areas, and giv nga deta~ed descnphon of layout ofptepe~y must be drawn on the diagram which is part ~f this application.
c. The work.covered, by this application may not be commenced before issuance of Building Permit.
d. UN lapProval Of this application, the Bulling Ir-.4~ector will issue a Building Permit to the applicant. Such permit
shall be kept on the premises available for inspectmn throughout the worl~
e. Nobuilding 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.
i~ .A.P..PLI _C~TIO~N,!S HEREB. Y MADE to the Building Department for the issuance of a Building Permit pursuant to the
u,alr~.' ~on,e ur.amance at t. he Town of Southold, Suffolk Cou~_?y, New York, and other applicable ~ Orcllnancos or
egu at~ons, tar me construct,on of buildings, nddltioas or alterations, or for removal or. clemoJitlon, as herein descr bed
The applicant agrees to comply with .all applicable laws, ordinances, building code, housing code, 'and regulations, and to
admit authorized inspectors on prem~see and irt bui~ ~ necessary inspections.
(Signature of applicant, or name, ,f ~ boqx~mtion)
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
If applicant is a corporate, signature of duly authorb~lkl officer.
Builder's License No ......................................... .~ ..........
Plumber's License No. .......... 9./.~ ...............................
Electrician's License No ...... ~.~. ..................... ~ ........
Other Tmde's License No ........ .~'.& ...............................
1. Location of land on which proposed work will be done. Mop No
2. State existing use and occupency of premises and intended use and occupancy of.proposed construction:
b. Intended use and occupancy ...... ~a.~t...e,~..~.hD.','.e ...........................................................................................
3. Nature of work (check which applicable): New Building .................. Addition ......~ ......... Alteration ..................
Repair .................. Removal .................. Demolition .................... Other Work ................................................ . .....
(Description)
~ 75.00 Fe ~10.00 ..................................
4. Estimated Cost ............................................................ e ......................................................
(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 ................ ~..f~ ......................................................................................................................
6. If business, commercial or mixed occupancy, speci~ nature and extent of each ~pe of use ............................
7. Dimensions of existing structures, if any: Front ...~..[.~.[.~ ............. Rear ...2.k8~ .................... Depth ..~!1 ..........
12~ 1
Height ........................ Numar of Stories ....................................................... ~ .........................................................
Dimensions of same structure with alterations or additions: Front ....... ~. .................... Rear ...~s ................
Depth ........ ~ .................. Height .....~. .................... Number of Stories ....... ~ ......................
8. Dimensions of entire new construction: Front........~tS" ............ ........ ........ Rear ....Z.L~.'.'. .............. D~th .,~.[ ................
Height ..... ~.~ ......... Number of Stories ....... ~ .............................................................................................................
9. Size of lot: Front ~0~ Rear ~07~ Depth 1~5~
10. Date of Purchase ..~.~.~.~a.~.~ ............................Name of Former ~ner ..~.~.~...~.~A~~. ...................
11. Zone or use district in which premises are situated ....~.~.~.~.0...~.~..~.O.Q~ ............................................
12. Does proposed construction violate any zoning law, ordinance or regulation: ............... ~ ....................................
13. Will lot be regraded' ...~.~ .................... Will excess fill be remov~ ~~s~.) Yes ( ) N~20~)
14. Name of ~ner of premises .~,~,~ac~m ...................... A~ress~.,.~.~..~.Q~.... Pho~ No.~$...~.~9.~ ....
Name of Architect ................~.~. ....................................... A~re~ ................................ Ph~ No .......................
Name of Contractor ............. ~/a ....................................... A~ress ................................ Ph~e No .......................
PLOT DIAG~M
k~ate clearly and distinctly all buildings, whether existing or proposed, a~ indicate all set~ck dimensions fram
prope~y lines. Give street and bilk number or description according to de~, and show street names and indicate
whether interior or corner lot.
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.
Sworn to b~f~e me. this ,- ,
.... y\of .......... ,
' Nota~ Public, .~i~/~.....~ ..... Coun~ ......... ~':;'"'~<~;'~'":'"~'TP'"':~'"'"~ ..........
COU~::~a.,~2..~.:2;...¢.52.i.v¢;.~.2.~..5~:~.~,:~.~..~.;.~.;;.~;.;~ ................. being duly sworn, deposes ~nd sa~: that/he is the applicant
above named. /
He is the ....................... ~.~. ............ ......... ....................................................