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TOWN OF 50UTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No. ?i°~~Q~ Date J....6....... , 19 ~7.
THIS CERTIFIES that the building located at ..Ata'i,Hlv1ttW .Drive Street
Map No. Block No. , . .....Lot No.... 54titlsold , N.Y.. , , . .
conforms substantially to the Application for Building Permit heretofore filed in this office
dated 3ept.16 19~~.. pursuant to which Building Permit No. $5~~~ . .
dated ...........Qet ..8....., 196 was issued, and conforms to all of the require-
' ments of the applicable provisions of the law. The occupancy for which this certificate is
issued is . #'t'~V~t~ .4#t~..~'~~,~Y. Sl?ae7.~.~.Tig .
The certificate is issued to .John . & Made, ,B81e2t61C... , , , , , Uwil$r~I .
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval May... ~9~7.. 1i~ala , , .
UNDERWRITERS CERTIFICATE No. N,~36.tJfl~.....Mety..~. 197/^
HOUSE NUMBER ...8~0 Street ~atex'v1~w. A.riva........Spu~hAld.....
Building Inspector
i ~ . ~ .
~~i
t
~n FO&M HO. 2
TOWN OF SOUTHOLi3
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTH'OLD, N. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N° C7 ~ ~ 6 Z Date ...........................0@~............$........, 19..'.~(j.
Permission is hereby granted to:
Romax~..&adder•~•....A/~••~~}~••~e3an~3;a & W.
........Q.....Axtd~g.. Sr....... Miller.. P.ltatse..........
to ~tal.7.ti...naW...ana..S'.anvily...dwed.1.~ati
at premises located at~,(.$..k1A~®3'•V~.@W~1$e..y~...pq.~..~
.....................................................3nuxk~al$.....N..Y.
pursuant to application dated ...................5®;ci'G••••t•6•••.•••••••••••••, 19..."~t6, and approved by the
Building Inspector.
Fee $,39.w$L1...........
.C.'~.........g . ~
Buil in 'In ector
FORM NO. 6
TOWN OF SbUTHOLD
Building Deportment
Town Clerks Office
Southold, N. Y. 11977
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-9 form or equap.
3. Approval of electrical installation from Boo rd 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 ar 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 ~~~7~ ~ '7
New Burldrng Addition Old or Pre-existing Building Vocont Land
Location Of Property .~~~..W,~'•!~!r:.lC/..ls'..!Y......p!~..`.Y...~lil..U.~.l~....~.7........~~:~..~./.>.D.F-!~
Owner Or Owners Of Property .~~..6./-+:.N......~.....,/.>a..f~.Pi..l..0.3........c~3.~ ~::.1~..!~..~;,.. c
Subdivision Gqrpp
..............................................................Lot No.........,.~.. Block No............. House No..8f1.IJ.
Permit No. V../..~.G..Z... Date Of Permit 1....°jG,
jZ, ,Applicant .GC:.~.1.`f.~?..~ ~ ......~.I:.C?..rb?.:F
Health Dept. Approval ............................................Labor Dept. Approval
Underwriters Approval ..............................................Planning Board Approval
Request For Temporary Certificate Final Certificate ~
Fee Submitted $
Construction on above described building and ermit meets ,IIQa~p~plicab~le~cod~es and regulations.
APPlicant . ,....~CrlSyr.?..~~~"./~7.....:(1..~a~FT
- Sworn to before me this jJ ~0~~~
~IilleP Place, Ai?. 1'. f.i7irdw
.~:sfh /~py~/y
day of / ..............l..l../..1 (stamp or seal) ?
f3j~7
Notary Public ....s..~(.~.~/f~..G~``......f(p~J'anu'nt~y,~ Z~~o
MARY E. DAWStlN G' ~ - c + ~ O
NOTARY PUBLIC, State of New or~
No. 52-4643721, Suffolk Coupe
4 _ Term Expires March 30, 19J~
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ll 9 TOWN OF SOUTHOLD
i x ~ lUILDINO DEFARTAAENT ~ rr
TowN cLERlc~s OFFICE - sit ~ "
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Examined 19~% ~ ~ • J1ro aax ~ ccLl.J~"/lppiication No.
r_ `
/ j~p/.o ~ ~s/a.+C s CoLI tf
App 19 ~ Permit No..t~~ Q (O c) co.~ c.~Jl`' ~
roved
3~ 77 m ~
Disapproved a/e ........off / //'n. .r~w+~.. al ,Q.e,..a~, ?
5•'~,i-5~~7~ dm,~* f
~TS.CfI 7 jL ~e~~,~ 9 1~jY~ ~"~l/I iy.Q.inS ~Q@ .G-+~ ICi.Q- 4~..
l'~n.a. c(v. 7'h,T.~, ~nt~" ........................../.u:°.:r:
1,4..~............ /~.caA'- Of~~~--"c' V
(Bw ding Inspector) 7zi ccd e-r.
APPLICATION FOR lUILDIN6 PERMIT Q
O
Dote 19~~....~
INSTRUCTIONS
a. This application must be completely filled in by typewriter or' in ink and submitted in triplicate to the Building
Inspector, with 3 sets of plans, accurate plot plan to scale. Pee according to schedule. ~
b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or m
areas, and giving a detailed description of layout ofproperty must be drawn on the 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 port for any purpose whatever until a Certificate of Occupancy ~
shall have been granted by the Building Inspector. ~
APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to tha
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 heroin described.
The applicant agrees to comply with all applicable laws, ordirwrrces, building code, housing code, and rogulatiara, and to 1
admit authorized inspectors on premises and in buildings far nece,/sary inspections. ~0
(Signature of appli nt, or home, if a corporation)
.
9 ~r .fit:.. `lT.?.,~~.~,r...1'-~~r..~1.z.:..y
(Address of applicoM)
State w,h~ether appp_l'ican`t is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
.........~f~s~sa~C~GI~/............~./
Name of owner of premises ..:>.!..a ~`.N......Y.....l~T~.ILA..C~...........s~~.L:.~K.G.!.C•
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. ..w~.~.:3..ifs
Other Trade's License No p
1. Location of land on which proposed work will be done. Mo No Lot No.
Street and Number s..!'~..:1.!.QE.-:....~'Y..•lSl.T~:?...?..1.~k?.....~11.s ...................~9.~f.F!.1.F..W..•...............................
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed ~t ~
a. Exisiting use and occupancy ......................................................................................~y.Fi~..l..!:'•
w
.
b. Intended use and occupancy
.......l....GI.tM.~~jt G.~t~.?.:~.F.:.4.1..!.Y..G
-1r
y~
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3. Nature of work (check which applicable): New Building Addition Alteration
Repair Removal Demolition.........:.......... Other Work
S $ D (Description)
4. Estimated Cost ....r~.~..o..°....°
..................................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 tors ....../.'!.f?.N.. ¢
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 same structure with alterations or additions: Front Rear
Depth Height ............................Number of Stories
8: Dimensions of entire new construction: Front ..........~.3....G~:."......... Rear....~f..~.~.~ ° Depth ...cab„'O "
Height Number of Stories N.A!............................................................................................
9. Size of lot: Front ........l.. a.Q Rear ...........1...Q.A................... Depth ....../..o-f..-o..............
10: Date of Purchase-~t.~~..,.....~..9..1...~. .................Name of Former Owner ..~'.p..~:...~Q..°..~:.7...!1.7..f.1:!Y..............
11. Zone or use district in which premises ore situated
12. Does proposed construction violate any zoning law, ordinance or regulation: .........t1:.f.~
13. Will lot be regraded .....%E.S............ Will excess fill be removed from premises: ( )Yes OC9 No
,jai
14. Name of Owner of premises ~.Ff1X.../~.~G.f.Y.%Y.G./..~...... AddressN~~f ~d:.hl./..~:r•Phona Na .~.~,.~n:.~.y~r
Name of Architect Address Phone No.......................
Name of Contractor ..~.6.!y..~:.!r7....,Qk<t.la.,1:........... Address /.ty.%.l
~,tfl./..~. ~!JPhone No..lt.,C1:,~.........
PLOT DIAGRAM i`~'z>-
Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from
property lines. Give s11~~g~tt and block number or description according to deed, and show street names and indicate
whether interior or corn~Tl~.T~ Q y~~W
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COU E OF NEW YORK, t 1dD'pa
NTY OF ....&ixffral]c...........15.5
...'~4..ftl!~.....~G:.lr~.ils..Cl?.~. d...QC...f.~ ..................:..being dul sworn, deposes and says that he is the applicant
(Name of individual signing contract9
above named.
He is the ......................(.,r:.U.d.:f~P..~4..~..T...lS..4°.............................:.................................................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the sold work and to make and file
this application; that all statements wntained in. this" application are true to the best of his knowledge and belief; and
thar the work wilt be performed in the manner set forth in the'applicat' n filed ther~G
Sworn to before me this J~D~/~
....S~kx......... day of ...........QCXG.I2~X 19....7.6 NuF ~~~~~~~"'S/.
Notary Public . .............................Sazffolk..... County ..f~... ~?l~(~..........
\ar7\~ ` - , (Signature of applicant)
fLIZABEfN ANN NEVIt.LE l
- NpTARY Pi18UG, Stale at New Yar4
No. 52-8125850, Suffntk Cou t
Term E><Dtres March 30, t9,~
owNtR: ~ . ~
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r1TL[ IHE ASSiGNES OE THE IfNDIN('. INSFF
C[~ITir. 7 TON. GUARANTEES ARE NOT TNANEiiRNlt
R ~ T ADDITIONAL INSTITUTIONS O0. SUBBlpNBR
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'o p5oi.._ g.. FOR APrROYAL OF CON67lRtlCi'ION ONLY
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_ OCT 0 g 1976
9•
xtnd DAT[: - pIMEO~?L sYlT®11~ MKi1!• 41'116
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- EDUCATION LAW. -
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