HomeMy WebLinkAbout7103-zFORM NO. 4
TOWN OF $OUTHOLD
BUII,IHNG DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificete Of Occupency
No. Z.?.5~. ...... Date ............ April .... .1.~[.., 19.
THIS CERTIFIES that the building located at ./~/.$. ~.o..u~..d..V.!$~..AYe ...... Street
Map No... ~ ....... Block No..XX. ...... Lot No, XX../kmthald.. I/,Yo ...........
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ............. Jan. 28., 19.7~ pursuant to which Building Permit No..
dated ........... ~/a~ .i~ ......, 19.7.1~, was issued, and conforms to all of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is Aecesso~j. bu~tld~n~... (&l;10roved, .]~y. 2d. ll~p~al~) ..................
The certificate is issued to ... Rober.t .Azm~scl~ ....... .~wr~,l~ .......................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval
UNDERWRITERS CERTIFICATE No..N.R~ .......................................
HOUSE NUMBER .... 60.1.0 ..... Street . Soundv:l~w. A.v$... 8outhold ............
Bmlding Inspector
FOB,M NO. i~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N~ Y.
BUILDING PERMIT
CT'HIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
No. 7103 Z
Permission is hereby granted to:
to ....~..a,.v... ~..~ m.~r~..~.7,~z ..~x~ ~.....a....~.~.o..r.a~...~ ~ ..............................
................... ~.~.~..~...~..~L~....... .......................................................................................
at premises located at ....~.~...~.......~.~..?..~...e~......A..~..q ............................................................................
.................................................. .~.~:L~.....I~.,.Y~ ............................................................................
pursuant to application dated .................... IJ'J~J.....~.J~ ................... , 19.~..., and approved by the
Building Inspector.
Fee $..~JO~.(~ ...........
Examined
Approved
Disapproved a/c
&O (Building Inspector)
~ INSTRUCTIONS ng~
a.~This application must be completely filled in by typewriter o~ in ink and submitted in triplicate to the BuiJdi
Inspector, with 3 set. a~ 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 st.reets or .~.
areas, and giving a detailed description of layout ofptoperty must be drawn on the diagram which is part of this .ppi,cation. t~'~
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 eccupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy ~.
shall h~ve been granted by the Building Inspector.
APPLICATION IS HEREBY MADE to t~e Building Department 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 for removal or demolition, as herein described.
The applicant agrees to comply with all applicable laws, ordinances, building~cnde, housing t~ode, ar;~l~iens, and to
admit authorized inspectors on premises and in buildings for necessary iJ:ml~-t~o~, s. /I /' /
._. ._. ._.__ ....
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Name of owner o remlseS ...
If applicant is a carp/orate, signature of duly authorized officer.
Builder's License No.
Plumber's License No .................................................
Electrician's License No..~.....~
Other Trade's License No ............................................... ~
Location of land on which proposed work will be done. Mop N'o.~r~'~ LOt No .........................
Street and Number ...................................................................................................................................................
Municipality
State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Exisiting use and occupancy ..... ~ ................................................................................
· 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration
Repair .................. Removal Demolition ...... ".Z.: ....... Other Work ......................................................
.................. ~ ~ Fee' /...~... ~ (DeSCription)
4. Estimated Cost ...... J~'e~'""~"'"'~"r~'~ ~'- ....... ([~"l~'e"~i~"~'~"~'i¥i'~g this appli~a~;;~i ..................
5. If dwelling, number of dwelling units ............ "..'T. ............. Number of dwelling units on each floor .............. .' .............
If garage, number of cars ...... ~,,~,Z...~..;. ...............................................................................................................
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 some structure with alterations or additions: Front .................................... Rear ............................
Depth ................................ Height ............................ Number of~tories ........ ;..~.. ~, ............ ~
8. Dimensions ~),e~tire new construction',. Front ....~-'~.,.....~...~..-... Rear ...... ~.~....r... ............ Depth ..~...(~... ..........
Height ....... Number of ~Stories ......... ......................... .; .............................. "~'e~.-~;7~'''~1~'t~'
Size of lot: Front ...... .~.~..~"~..l[~,,,,,,,,,,,,,,,,~.....T....?.../. ..................................... Rear ....... ./.....~......~.....~ .............. '"-'-'-'-'-'-'-'-~ x )~-~i" ~h ~-,~'.~..r.~...~....~T{!~...
9.
Date of Purchase .......... .................... Name~j3~)rr~er Owner .....,..:....w~..4m,4/~.~ ..............
10.
11. Zone or use district in which premises are situated ................ /'...Y. .................................... "'// ........... :;~-...., ...... : .......
12. Does proposed construction violate any zoning law, ordinance or regulation:~...~.;....~...'~'./...-~.....~.~.¢~./-~..~....~''
13. Will lot be regraded ..~.~f,/,./.~'~ Will e cess fill be re, moved from premiss: ( } Yes
14. Name of Owner of premises~,~.'.~.e4('/.c;,/,~.'.{='I'''~R'~'',,,,. Address~'Z2 "¢"'~"~"'"f'~"z"&~f/'"" Phone
Nome of Architect .............................................................. Address ................... ; ............ ~,none 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 comer lot.
STATE OF NE'~YO~'~/.// ~ ~
COUNTY OF A~'~:~.... ~ ~'~
................................... be ng duly sworn, deposes and says that he is the appliconl
(Name of individual signing controctO
above named.
He is the ...................................................................................................................................................... ·
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and s duly authorized to perform or have performed the~said, work and to make and file
this applicat on; that all statements contained in this application are true to t~be'b'~st of~his knowled e~=~nd bel~ and
that the work will be performed in the manner set forth in the application fil~therewitl3/ ~ ~ /
Swam to befa~ me this
........
.......... ........... ...................
/
JUDITH T. BOKEN
Nota~ Public, State of New York
No. 52-0344963 Suffolk Cou~
Commission ~pires March 30,