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~NO. 4 TOWN OF $OUTHOLD BU'fl',~ING DEPAR~T Town Clerk's Office Southold, N. Y. Certificate Of Occupancy THIS C]~RTIFIES that the bugrl1,~g located at .. D'~. Po~tc~. Road ......... Street Map No.. ~ ...... Block No.. ~ ..... Lot No, . .:XXX... IL~utmko~ue .... !~,¥.~ .... conforms substantially to the Application for Building Permit heretofore filed in th!.~ office dated ............itl~ .... l}~, 19..7.~ pursuant to which Building Permit No.. dated .........A..~...~..~ ...... , 19..7.~, was issued, and conforms to all of the require- ments of the applicable provisions o! the law. The occupancy for which this certificate is issued is )lult!~.le resid.e.~.~..e (mo..tql) vith <eratio~ & addition The certificate is issued to . P.o.13([. ~t~T'p~.lllels..~I1~ ..... 0euer .................... (owner, lessee or tenant ) of the aforesaid building. Suffolk County Department of Health Approval .~.,.B. ? ............................... UNDERWRITERS CERTIFICATE No. 111~93 .... .~1~,I[. · ~.8... ~.~ ............... HOUSE NUMBEB .... 3800 .....Street...l)uek .Pon~.Ro~d ....... Cuteho~ne .... Building Irmpector TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, Hr. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Permission is hereby granted to: ... ~.~..P..¢m~..~ ......... .r~,~ h~te ................ to ..9~.~.~..~.~.~[~..~..~.~.~..-....af~.~..`~.e.~.~4.~.[.~.~...~=.~.st~.~.~i~[~£~..~e~...~tse ....... at premises located at ....~/.~.....D..~.~..~..~.TL~...~.f~.~,..~..~,.e.[.e.~O.t,II~ ................................................ ...................................................... .0..~..¢.~.~.~ ....... ~[.¢. ~.~.~. .................................................................... pursuant to application dated ......................... ~,~ .......... ~.~. ......... 19..~..~.., and approved by the Building Inspector. ....... ~uilding Inspect~ TOWN OF SOUTHOLD ~ Building Deportment Town Clerks Office $outhold, 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 af 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 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 Date ....~.'--~iE.~ ~i.~ ...... J/.../..?..~...~..... New BHilding ................ Addition ...~... Old or Pre-existing Building ................ Vacant Land .............. Owner Or Owners Of Property ..N.~./].¢..~.?....~.....~.' ............... / ........... ~. ............ .C~..G. ...... ~. ............... ,~..~ ....... Subdivision ........................................................... ¢...Lot No ............. Block No ............. House No ............. Permit No. ~..~..~...~.. Date Of Perm t ..~,.~.//./..~.4.¢..?App icant ..~...~...~.....,S,./~.._~.~.~.....Pt...C-:...: .......... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval ............................................... Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Find Certificate .......................................... Fee Submitted $ .................................... Construction on above described building a.d permit~ meets all applicable codes and Applicant .....,~(.9....w~.....~J~.....,~...~% .'.~. ~...R. ,~.,~...t/¢'~.¢.,......~....~...(.. Sworn to before me this C~ (.~)~'~ ~ , / ................ x tmp or seal) Nota~ Public ..........,~b.:..: .............. Coun~ ~' FOZr~ NO. 1 TOWN OF $OUTHOLD '~ BUILDING DEPARTMENT ~TOWN CLERK'S OFFI~" Exom ned .... ~.~ ........ L....~.., 19,~.W.. ' .................... ................................. APPLIC LDING PERMIT ...................... INSTRUCTIONS a. This application must be completely filled in by typewriter o~ 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 oF 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 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 o 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 the Building Zone Ordinance of the Town of Southold, Suffolk County, New 'Cork, 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. ............................................... (Signature of applicant, or nome, if a corporation) ..... ........ ................................ -- (Address of applicant) ~ State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.'-'~ ........................................... . ........................................................................................................................................... Name of owner of premises ...~..O. iS~..kl~J;~.Lp.~.L~fl&...~2tC ................................................................................................. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No ..................................................... Plumber's License No. 1~1. Fork Oil Hea~ Electrician's License No ............................................. Other Trode's License No ............................................... Location of land on which proposed work will be done. Map No.: ~ Lot No. ~ ~/S .D..qc..k.P.o..n..d. ~.o.~ .......... ~.~.~.qhPg~ ............................................................. ~. ....... Street and Number ................................. Municipalityt State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ..l~..o..~.~.~l,......(,..}?.~,.~.:kt;~k~..J;'¢~.~.~.¢~O.~.) ........................................................... b. Intended use and occupancy ....... .~.'8..~.(~e....?.~..~.~"~);...8.~.~.~.~..~..~....~...~...~.....~..W~9...z~.!.~...~$.~.}L.z~9.a .................... Nature of work (check which applicable): New Building~· ................. Addition .....~ ........Alteration .~X .......... Repair .................. Removal .................. Demolition .................... Other Work ................................................... (Description) 4. Estimated Cost :~0,000 + ~ 1.1,1.00 (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 ...o..w...~.?...r..-...~...s..e. ..... 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 ..... 2g .......................... Rear ...... 2.0. ................. Depth ~.Z].6. ................. Size of lot: Front ........................................................ Rear .......................................... Depth Date of Purchase ........................................................ Name of Former Owner ........................................................ Zone ar use district in which premises are situated ..~...-...1 .......................................................................................... Does proposed construction violate any zoning Iow, ordinance or regulation: .D.Q .................................................. Will lot be regraded . ....... r~a ............... Will excess fill be removed from premises: ( ) Yes ( ) No Name of Owner of premises ..P..9..~..c.~...e...~..t..9..z:P..r.i.s.e...s...~..~..9... Address ................................ Phone No ....................... Name of Architect ....l',.....E.~S.%1g.QQfl ................................ Address ................................ Phone No ....................... ~-v Name of Contractor ............................................................ Address ................................ Phone No ....................... ~u PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions fram property lines· Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. 13. See original plot plan under Rossi (original Builder) See plan attached STATE OF NEW ¥~OR,IG ~ ~ ~ ~ c COUNTY OF ..... .~ .~. ~'~,9.a:.Z.~ .......... f '~"~ ~icholas Aliano ................................................................................................ being duly sworn, deposes and says that he is the applicen! (Name of individual signing contrac0 above named. He is the Corp Officer (Contractor, agent, corporate officer, etc.) of safd 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 tha~ the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this ~,. .1.)+..... day of ..; .......... J~l~g~,~. ................ , 19..?.~'.. ]/~ /0 . /) J · ~uffolk ~ '~ta ry Pubhc ................................ .~......~, ......... County .............. .~.J. ................~ ...................... ~'~ ~ ~ (S gnature of applicant) ~ ~ JUDITH T. BOKEN Jxi~ Pt~[~lk, State of New York NOTIFY BUILDING DEPARTMENT AT 7~5-~660 9AM TO ~PM FOA ~ tNSPECT ONS: 't 0 V SUFFOLK COUNTY D~F&RT~ENT OF HEALTH The pi' os~d arr'ang~lents for sewags L kssec !Ls '1 i ti , r/ I .---4- , <--- .I 3"iL 8" 'I 0 © // APPROVED ~,S NOTED ,/ J 0 '0 r- i -1 ~J 0 Z4L .%" 1!4-" Ck:t CC} ,/WT~4 B,~(, ~. ~.,~ oF /2.