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Home My WebLink About8743-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Cerlificate Of Occupancy No. $7,~.0.~ ...... Date ............ ~. ..... ~,~. .... , ~9.77. THIS CERTIFIES that the building located at .P~ ,~oa~ .~..t.8 .Or~,~ce~ ~eet Map No. ~ ........ Block No. ~ ...... Lot No.~...~a~taak.. ~.,Y, ........ conforms substantially to the Application ~or Building Permit hereto[ore filed in this office dated .......... ~mn~,..%~.., 19 ~6. pursuant to which Building Permit No.. dated ............. ~u~y..20.., 19.76., was issued, and conforms to ~1 of the requ~e- ments o~ the applicable provisions of the law. The occup~cy for which this certificate is issued is . .Pr~.~ate..(.acce.a~ory.).. ~,r~g~ ...... ,, ~rpy~a. ~ .~. ~9~ .... The certificate is issued to . ~hoe.,.aor~aa ....... ~r ............................ (owner, lessee or ten~t) of the aforesaid building. Suffolk County Department of HeMth Approval . .ii ,R,. ............................. UNDERWRITERS CERTIFICATE No...N,R., ...................................... HOUSE NUMBER ..... ] 87.~ .... Street .... ~t. a aa. ....... Building Inspector FO]~M NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permission is hereby granted to: ~4m. Jacobs A/C Thos Goz, man ................... ..c.~ ?.~.o. ~..u..e. ....................................... ~o ~:~...~.!.?.~:f...~ Lz.~..t.~...~.~? .................. (. ~?..c.°.z?..~..~...~...~..~.z...~. ~ ....................... at premises located at ..~..v.~....B....o.~.d....~:...J.~ ....... ~..e.~.~...e.?...~...D..~..J....v..e....~../~....~.o.?s~.d....~,¥.~ ................ ....................................................... ~.~.~i~uck ................................................................................... pursuant to application dated ........................~.~?.......1..~. ............ , 19.~.,~...., and approved by the Building Inspector. Fee $.!.k'.:.,r?O. ........... Building Inspector FORUM ~0. ! ~ TOW" OF $OUTHOLD ~/~7"7(' 7~*'"'~'4'~*'49 ') ~- ~/ ~ TOW. C~.K'S OmC. ~ ~ ~UTHOLD, N.Y. ( ' d ............................ pp 'ca ion No ................................ ................ ...................... APPLICATION FOR BUILDING PE~IT 9~ ....... ............... 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. Fee according tO schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets o~ areas, and giving o detailed description of layout ofproperty must be drown 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 part 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 i~suance 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 code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inSPections. ............... ~ ................................ ~ ....... .= ................. ~. .......... (Address of applicant) State whether ~plicant~Js owner, lessee, agent, architect, engineer, general contracfoC electrician, plumber or buJlder.~ .................. /.~.~..z.~ ~...:.....~ ........................................................................................................................................ Nome of owner of premises t~: d 4 .~.~i. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ........ ~..?.y,. ................................. Plumber's License No ................................................. Electrician's License No ............................................. Other Trade's License No ............................................... ~ 1. Location of land on which proposed work will be done ~/~,lap No ' Lot o ' St re et and N u m be r ................ i: .~.~.../~.. ~ .~ ~;iZ.... ~.~...* i~.~';~] ~ ~J~ "/~/~/_ ~ C. ~. ' Municipali~ a.. ................. ....................................... ............................................ b. Intended use and occupancy ......... :~ ........ ~ ............................................................. 3. Nature of work (check wh'lL~ applicable): New Building~· ............... .'~'kddition .................. Alteratioa ............... Repair .................. Removal .................. Demolitio~ .................... Other Work ................................................ ~ (Description) (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 ...~.....C.~. ....... leight ............... Number of Stories Dimensions of same structure with alterations or adr]itions: Front .................................... Rear ............................ Depth ................................Height ............................Number of Stories ................................ 8. Dimensions of entire new construction: Front ....... ~...~.=-- ..................... Rear ...~...~/..J"' ................. Depth ..~.~...r.~, ......... 9. Size of lot: Front .......... ,~3..4, ................................... Rear ......../.~..~.. ...................... Depth ................................ 10. ' Date of Purchase ........................................................ Name of Former Owner ........................................................ 11. Zone or use district Jn which premises are situated ................................................................................................. ~ 12. Does proposed construction violate any zoning [aw, ordinance °r regulation: ...~..~......: ................................ 13. Will lot be regraded ............... ~ ........... Will excess fill be removed fromDremises: ( ) Yes Name of Architect .............................................................. Address ...... ~ ......................... Phone No ....................... Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-bock dimensions frore property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. STATE OF NEW,.~OP,~g~n~ I c c COUN- ,Vr ,..,o -- OF ............ ............ ¥.~/.J.~.l..JJ~J~.,....~J..~ .................. '~-~ (¢~;:~--,~.~.. ............ being duly sworn, deposes and says that he is the applicanl (Nome of individual signing contrac¢) above named. He is the ~.~..~I/~-~e.~ (Contractor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or hav~ 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 before me this /q ~ ~m ........ J..~...~. day of ........ ...(~..~.~ .............. , 19..~..~.. ~------~y~ /'z'~) /""~) ,~ Notary Public,. ............................ ~-~'~¢~.~.~,~. Cou ty ............................................. ,~.~...,;.--~,. ................. ~ ,~ ~ ,. ~ (Signat,t~f~'of ~KJ~cont) A N ¢IEVILLE NOTARY PUBLIC. State of New Yprk No 52-8125850, SuffolkCountmly_ T~rm £x~res M~rch 30, 19