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Home My WebLink About8053-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office $outhold, N. Y. Cerli~icnte O~ Occupnncy THIS CERTIFIES that the building located at ...C$.d.a.~ .9~. ............... Street Map No...~.x. ........ Block No. xx . .Lot No. xx conforms substantially to the Application ~or Building Permit heretofore filed in this office dated ........ ~Y ..... ~..., 19.~. pursuant to which Building Permit Ho..~. dated .............. J.~y...~, 19.7~, was issued, and conforms to all o~ the req~e- ments o~ the applicable provisions o~ the law. The occup~cy ~or which this certificate is issued is . Pr~VO~..ao~.a~orX. ( gr~.~9~.~ .D~!;4$~g ........................ The certificate is issued to .~gP~D..qqDg~ ..... ~gY ............................ (owner, lessee or ten,t) of the ~oresaid building. Suffolk County Department of Health Approval .. ]~...;~ ~ ............................. UNDERWRITERS CERTIFICATE No .... ~.'.~ .................................... HOUSE NUMBER ...~.~ ...... Street Gaoler Pu~ve '~Building inspector FO~ NO. ~ TO~N OF $O~T~OL~ BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING P, ERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) Ne 8053 Z Permission is hereby granted to: ~.~ .e.p.,.~.e., ,a..., ,5. :....~ .o. ~.9.~ .t. ....................................... .............. .~.~,:~.....~. ......... ,~*.~J;..~.;LC,~t .......... at premises located at ...1...~..~..~. ....... .~.?..~..~...?..?. ...................................................................................... ....................................................................... ~;.~.~.~:.~......~.~r~.~.a.... ~.~ ~L~ ........................................... pursuant to application dated ................... ~...q~. .......... ~. ............... , 19~.~...., and approved by the Building Inspector. Fee $.!..0..:...~... ........... TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOU'THOLD, N. Y. ..... ........... Application No. 0~-0 ~' '~ Disapprage~. a/c ....................................................... APPLICATION FOR BUILDING PERMIT ....... ................. , .... INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, with 3 set~ 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 or areas, and giving a detailed description of layout ofpraperty 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 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 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 code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. .... ........ ...... State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Nome of owner of premises .................................................................................................................................................... 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 ............................................. Other Trode's License No ............................................... 1. Location of land on which proposed wJ3t'k, will be done. Map No.: ....... L~...c~.~.. .......... ~ ........ ~-o~t"'No ..... ../Z ............... Street and Number ........ ..~...~../.~.,-./-~.*~.,. ...... Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ................................................................................................................................. b. Intended use and occupancy ....... ~.~.~O~....~.~.~.~. ................................................................................. 3. Nature of work (check which applicable): New Building.. ................. Addition .................. Alteration ................. Repair .................. Removal .................. Demolition...~ ................ Other Work ..................................................... (Description) / Estimated Cost ~,_~'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 cars ............................................................................................................................................. 6. If business, commercial or mixed occupancy, specify nature and extent of,each type of use ............................ 7. Dimensions of existing-~S'tmeta~e~i(any: Front ..... ~/~...'....~... ...... Rear ......... ]/~...]...o~..]~ ....... 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 .......... ................ Rear ....... ~2.....~.. .......... Depth ...... ........ Height ...~../....~...:~.. Number of Stories ....../.. ............................................................................................................. 9. Size of lot: Front ........... ~.~.~.....~. ............................. Rear ........ ~.../.¢..~...../. ............ Depth ..../..~.¢.~.. ............. 10. Date of Purchase ....L..-: .~..~...7..~. ............................... Name of Former Owne~..,~//.~......~:2~l/~.~'~ff/.... 11. Zone or use district in which premises are situated ....~.a~..~...~--/J~.~...~.../~.~,~...L~..~,...~...~.(~"~. 12. Does proposed construction violate any zoning law, ordinance or regulation: ...... . ./~'.~.. ........................................... 1'3. Will lot' be regraded. ........................... Will excess fill be removed from premises: ( ) Yes ( ) No 14. Name of c~wner of premises ...~...~......~.:..~.~.~.. ..... Address ..,/~..~'~ Phone No. ~.,.;g~ Name of Architect .............................................................. Address ................................ Phone No ....................... Name of Contractor .......... ~....~).~.~,-~ .............................. Address ................................ Phone No ....................... PLOT DIAGRAM L0cote Cl~early and distinctly all buildings, whether existing or proposed, and indicate all set-bcmk dimensions from property lines. Give street and block number or description according to deed, and show street names and indicate whether interior or corner lot. <30/, STATE OF NEW Y-DI~K, [ c c ~ ..../.~/~....~...~ ......................................... being duly sworn, deposes and soys that he is the applicon! J v (N~me~o~N.individual signing contract~ ''~ abovenamec] ~ ~.. . . . ... He is the~f.........~'.~/J:~2~/-~... ........................... : .............................. ¢~ .............................................................................. / ~,.,~, (Contractor, agent, c~rate officer, etc.) 9f sc~d .owner~r 9whir.s: and is~dUiy~ouJhorized to perform Or have performed the said work and to make and file this application; that all statements c~tained in this appti'~ion are true to the best of his knowledge and belief; and thor the work will be performed in the manner set forth in the application filed therewith. Sworn,to be[ore me this ~ ......... day of Q Notary Pubhc, . ............................ ~,~..~ County ~/~T..,~',~..~¢.~...,.~......; ...................................... r. (,45 i~ re o pjicant) ARV PUBLIC, S~,te ~/ New York No. 52.8125850, Suffolk Term, Expires