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FORM NO. TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. . . c ` t y � q � � Date . . . . . . . . . . . . . . . . . . .. .. . . . . . . . ., 1977 THIS CERTIFIES that the building located at . �"'. . .W}r0�.. .t!... . . .`. . . . Street Map No.& .&A Block No. . . . .x. . .Lot No, .1.1 . . . ^^? ^' A-'. . . conforms substantially to the Application for Building Permit heretofore filed in this office dated . . . . . . . .lw. . . . . . . .. 19.T1 pursuant to which Building Permit No. J/.0.3 Z. _dated . . . . . . . . . l� 19.77, 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?"' . . . . . . . .` . . . . . . -�^' Q� y . . . . . . . . . . . . . . . . . VVV /. _ n _ t The certificate is issued to .4�J . . . . . . . . .R4C,4luv ,�. . . . . . . . . . . . . . (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval UNDERWRITERS CERTIFICATE No. . /� 36 3/r J � . . . . . I. . . . . . HOUSE NUMBER . . . ./ . ,S?0. . . . . Street . � � .�. .E-)4 . . . .��— . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(. . . . . . . . . . . . . . . . . . . . . . . Building Inspector C T� ;. logo M& s - Aoa `i A +fs1i3� Fi M L fAA.L fG CmoumbN OF Daft go „ ..•.•.... Y .r*.....•. ............ y� /VyA\ riMnF •/�� /- .�( a ♦AA ••avY�jq r •aaiVa • rrr•a••rifr i a4 rr• r••• r•r•�r• .•.(♦•. } ••••••a•• ♦ •• • ••• .............Yi • • • • • Y arY a•iY a•i•♦ pursuant .to 4Md.......... ......................... .''4s ♦ .. .•., 19. � and .ap aV y 111W trnp�ctar. .. ri............. }}�.... .irl•puiwu i 1'a 5 ` PIF g S t =a2 .xl "Yi t' _4. SiN4A• � �3kLna�kY,e a y-m-='4 w FORM NO. 6 ' TOWN OF SOUTHOLD Building Department Town Clerks Office (J ° Southold, 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: I, 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 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. r 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent 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 Dote ........., .�.. ...................... New Building .....Cf Addition ................ Old or Pre-existing Building ................ Vacant Land .............. Lt Qu/�.......n., Cr,��� t� 0 Location Of Property ................. 1 .......................................�.......... ....................... Owner Or Owners Of Property Z ......lt/�.........fl'AC A,i-i }� PY ................ ..............................,.,...............................//..��...... Subdivision !� W&m.... � ..............Lot No. ..�....1... Block No. ............ House No..1.1. .................. Permit No. �.... Date Of Permit ..�a4 I.A pplicont .................................................. Health Dept, Approval ........ Labor Dept. Approval ........(.. ...k:. .......................... q r3� Jul Underwriters Approval :.......................................Plannin Board A ...... :........g Approval ................ Request For Temporary Certificate ........................................ Final Certificate t__�.� Fee Submitted $ ..... 00.................. Construction on above described building ap"ermit meets 11 applica c"and regulations. Applicant ..... ..dol(................. ....... ............ ... .R.....Vp..J ............. Sworn to before me ts p//') .......... .. day of ..:.....:...`....:. 4 I.. . .............. (stomp or s/ I 1� V_ ..c Notary Public ........ - a ,f�1.... .� County THE N ",A, I YORK BOARD OF FIRE UNDERWRITERS hr BUREAU OF ELECTRICITY 55 JOHN STREET, NEW YORK. NEW YORK 10038 Appli,a,tion No. 931415 0 IAATHAT ......... ,klm......... :. .. rimy the,eleetricel mmt wd"rrlbed,b and in4j�i��y,thevpp on the's , P—Ts,c-, equip 2, E, atwo oo Dr. Ti -mber 7. ski 7q _7 �.I , 77.7 A 1?h �3ffaw 2A 4w 5- OTHER APPARAT4115 motors 1-1/3hp. 2 1-smoke detector Peder Rolnestad 5 "East Field,L ane ....... .... M, f M�4*'19 110151MP ,Ni. 't'fi FORM NO. 1 VO 71 „Qe�7�a.e.� ®k_ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE f o e< SOUTHOLD, N. Y. 7 t/4,` - Z �7Examined .........�'..�4.......... ......... 19........ c�5DA'J/ Appljcgtion No. Approved ......................................... 19...✓.... Permit y Disapproved a/ ...................... .......... ...... .. . �AL ..................................................................... �.....:.. ys.:. 7 L T ......... ............. V-7- .... ..s ............ ...... ............... (Building Inspector 1 -Jg-7,� d-t �C, fair °1 �1tz�Q nn v� �nnagz y-- WO �4, AA Av n mow`?/; wAM . APPLICATI ERMIT VC o . MM c) O Ito aer.l y , ,d'�PGyi av to ....fflo1 'Cy.......`.. ............-, 19.2).... ^1 Cj 77 � 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 or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part of this application. C j 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 Occupancyiyi 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. rtI 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. o }J®mss 0� m�i2RU!(1......Lib....................... j ...................... ....Pp........;....... P (Signature of applicant, or name if a corporation) (Address of applicant) 119 "7 fState whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builderlA I .......................I...,...............................................,........................................................................................... Name of owner of premises ....... /.�.� �.�. ........... 1�C ..j'/.!. .5�. .................................................................. j It applicant is a rate ' notur?,of duly authorized officer. 5�............... .. ..........................................t :............... C ( and title of corporate officer) Builder's i se No. .................^�.................................... 14,p 7 # 7--5-0 Plumber's License No. ............................................... '0 3 - /N- i Electrician's License No. ......�................................... Other Trade's License No. .............................................. 1. Location of land on which proposed work will be done. Map No.: LA3,.'....?��� . �!Rtot No. ...�...1............... Street and Number ..f:.AS.!. O O n�1.WZ..............�� 4............................................. Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisitin use and occupancy rr�� 9 P Y ..........V......... ........................... b. Intended use and occupancy ................�} "' IJ ...... ............ ..... ... .................................. . ..... .............................. .................................................................. Ilk) N N \r, v 3. Nature of work. (check which applicable): New Building� ....... Addition .................. Alteration .............. . . Repair .................. Removal .................. Demolition.................... Other Work ................................................ ... (Description) 4. Estimated Cost ............. ?.�'...tro J-1 .................Fee ........ Y... .............................. .................................. (to be paid on filing this application) 5. If dwelling, number of dwelling units .....0 Kgt..........Number of dwelling units on each floor .... ....................... If garage, number of cars .......D.�5........................................................................................................................ . 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 ............................N umber of Stories ................................ �s 0K,G a;v,[ 8. Dimensions of entire new construction: Front .....��.......................... Rear .9�.................... Depth ... ................. Height .�.. °. .y... Number of Stories .....P.V9..............1..`�..�............................................5...............I....... . r 9. Size of lot: Front ..... ...U...t�.)...................................... Rea r .......................................... De th ................................ 10. Date of Purchase /0lg1i. Cl ��=� . Jv .......... .............................Name of Former Owner ............. 1 11. Zone or use district in which premises are situated .... ..........................A.[...''................................................ 12.' Does proposed construction violate any zoning law, ordinance or regulation: .../A .b............................................ 13. Will lot be regraded ............................ Will excess fill be removed from premises: ( Wles ( ) No '93l1 I cLr.,M .< M. (� a a, cz Ro )7- Y� 14. Name of Owner of premises ....................................... ....... Address ..v dill >.r..%17L�. ...JP7 one No. ............... Name of Architect ........... ............. Address ................................ Phone No. ...................... Nome of Contractor ./!om r.S......of �7M6 o,ct�..hOAddress .......... Phone No. . PLOT DIAGRAM �'` MO/b V. � 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 corner lot. 1 a� b/ I I ��r t 3�' m •'� !� D (- � a STATE OF NEWRI i 5 S COU TY OF .. .. o.i .......f ' /� JJ '... .. . .... Q.... a!�lfX.�� .....being duly sworn, deposes and says that he is the applicant (Name 'Fin signing contract) above named. Heis the .......................... z.,. '—. .kD 6Q.........9�. . . L .. .. ....................................................... (Contractor, agent, cb4Parate officer, etc.) of said 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 tP,aT the work will be performed in the manner set forth in the application filed th ewith. Sworn rt�o before me this / /� ��5� ....CK.a-rld..... day of ......� /I................... 19.7 7 _- �m ` yy, ; vl Notary Public. .........................#Yor fZ.f ... County — ..., ....................... dre of a plicant) A ETH NN NE II LE NOTARY PJJS IC, State of New No. 528125850, Suffolk Co"j1, Term Expires March 30, 1114 1"LC '. \ ,� .AVL•-�- C-C+_ v\S\ \4)(JO .7GC. ,YQl�(f�LY ��Y' L..OT C3 ' T , • 's' N 3"�" 43� 3o"t~ ISo.. #—.x�,S '� � LO I, to.15 F ;a,.(! V`� 'S„a '.�.• ; BI AJ w l = r. Oil X P'' { 1� t •� a i j I ( 5 Po v.aO C .. L5 ro t . E�.�vA�ctoYa VA'cvrl A',SotK�cp. � � .'�+ r + , 3. `3�D49� '�vCLFAtE CoLav\-c\otas tNo`c' SG1oB,aN•.?� , Ar. CES4,Pr_�I_ >~ 1.47A,.t ,e2, itJFo2MATtot.� LS AS Z�N ,�2 I �'1 Ol-lGS OF�� F•IOCLQ4 uJ. l-'�57, ��'� �: 1,(AT�D`> C2ETe.� QV. FAS•'c NAKP'coY.a E �1-,e. \\c> , WS r11 SUFFOLKMIMPT.OF WEALTH 66 S t" �� FOR APPROVALOF Ct*STRUMM ONLY r> ('� OA � H�' APPROVE¢ Nv �c1Z N4 )'FCn `S 1A O�jO �S mass,* k{i7v�jE 'STAKES' S F�.O¢vACL.Y \�i'1 TI 5 TO THIS SURVEY ISA VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING OF NEW !•O ' THE LAND SURVEYOR'S INKED SEAL OR EMBOSSED SEAL SHALL NOT BE CONSIDERED V TO BE A VALID TRUE COPY. GUARANTEES INDICATED HEREON SHALL RUN ]y'^ ONLY TO THE PERSON FOR WHOM THE SURVEY 15 PREPARED,AND ON HIS BEHALF TO THE 1\Iltl I TITLE COMPANY,GOVERNMENTAL AGENCY ANDHca h > LENDING INSNIFUTION LISTED HEREON,AND �jC �Oj ,W xy - ." t F�i,.l,`T;• ✓ TO THE ASSIGNEES OF THE LENDING INSTI• �/ (� TII O.GUARANTEES RE NOT ORTRANSFERABLE OSUBSEQUENT f ANS�J � ��' '���•( `,z\+-'_�'L`T,z ; t�'t`t�.l: .. t:"`; "�. OWNERS. +:+`74�`t:'f: O/{sete shown hereon slmuld ow be used as a basis for consErootion a) F i tencea or other permanent structurea, d +I zr_ i v 7 •. .C. N` to-n 5 F`r Fc;:>nr 41 W N a EJ, 3�� 43 3o"E 15o' •!� s �7 -4A 7 N Geos- {� J 01' Ir 2Y r� m f rtAUK ro W/ HI y n F n EL.:zo.5 Fi=,B3 v -� • {v `, •-f ce � h 01 m au CY 4 � TO 14 1 • y � 7 m tJ � t ti �5, �* T VK Irl 4 '7 I - 'l 3 4u t- p mW , 4 , ('F GAR. { �• �,,''� fs• ��7 7J N Z$.L• ri iD G y `j W COKE SEc \Q,.r Fc.ogo t5 iy a• t . �`�va,-C\ow� DA'cvK A,sSut•lE'O, �, � 2. Plcc AtzF.A= 20250"-'�' OCZ O•A�o•4 Ac. { �� i 3. S�0• Sv2GAcE CotJv\-c5oTJ5 noo•c SHo�ata. i 40 �• CSSPne7L_ t•.�A-eE¢ \T.n\'roCLMA`CLON \�s AS J m C SE�•.�A6E. < oSAL- SvgtE.\-t5 F-o�z Tu.\5 'CZ6S t•pENcE \,.�\\-L b : Cow�FO<Z,T-1 •To SHE SZ4NVARDS bF -'CHE •ms's-� m SvFRo`Yc ca. 'S7F=cn. of '.IEA�-';H SEev\cEs` y� m� rf` \�OME.S OF -Zb r10CLQbLA7, \—Y T7. S t-LAND`S C.Q,^mTc.K r2t7. °m U FOLKCO.,DEPT.OF HEALTW%ENV{CE APPROVALOF CONSTRUV4 'PN ONLY-1 DATE...., HS REF.NO. APPROVED s Woo ---_,_�_� - Rr=v<•s\-o>v: ''S' ©EcEeUlBECZ \g`1^( \ . 4'",6..'l'f�t>S•t:'l A"CFSA.1, r'Fal`s`5•:�'.kVr_j C-C>Y'-i<'. 1.,.PC ATVON•. 19 .1uN6. A�r1 r1 2. 'SAS+ t-lA2BoR SAV\u6S 6AUK F�IjO�G 'STAKES'• S F£Pa¢�A,�.Y .G - Trb-,.!�'7 iG bJ • \'a C�-•t•c>gC2 \K*i`'S Cc rte-. UNAUTHORIZED ALTERATION OR ADDITION TO THIS SURVEY 15 A VIOLATION OF SECTION 7209 OF THE NEW YORK STATE EDUCATION LAW. COPIES OF THIS SURVEY MAP NOT BEARING (\F Nt=W yo Cr LC Q• ,}J{j J.�lC�rGj•(a e�. N'�Fa.,y j,,C? a,-Z"\Cj THE LAND SURVEYOR'S INKED SEAL OR '��Q.ERT REQ��' -�'Cjt.,> �j bL,,, l �jL�`r f•�t-sC C;,y,Y 1}:•�, EMBOSSED SEAL SHALL NOT BE CONSIDERED ' - a.l " s' TO BE A VALID TRUE COPY. ��b"yp,:r`� Z IA' '�JGF�t„t`,� : , A 7y(:•>` GUARANTEES INDICATED HEREON SHALL RUNyp",, - ONLY TO THE PERSON FOR WHOM THE SURVEY tD`F, 'I aa22 15 PREPARED,AND ON HIS BEHALF TO THE 1�Y��'!I�� •O) C,S ,O .. ',[alp\�.,1Ca TITLE COMPANY,GOVERNMENTAL AGENCY AND LENDING INSTITUTION LISTED HEREON, AND {� ,� t' 4•'�� ` �4�E+C�Y• ��L'=? � ASSIGNEESTO THE FTHE LENDING INSTI. SE °• TUTION.GUARANTEES NOT TRANSFERABLETRANSFERABLEE�oFyFIVN kyJQ• (.,A1,;rp ,'tC. ,` ha, 5. DDI \..\c• h) 4•�yC�Saj 7WO ADDITIONAL INSTITUTIONS OR SUBSEQUENT Sf� LAND A l .a, 2,_,u,13 .s,�`".'-si... ,,., at..•�.ee . -_ . '��:}_ ws- .ro1�.tz �a..�',+sa�< ".. ai ,. rt ...,,3 r.-1.. . .,_ � '{, lfillSi .yrs +� ! �,y�� Y' ill �� � + �� � HIG ,(bCJ/L• r \ ' — - LT --- fir+ Ir� 1 8• Ei" .L2 'Iw I - i °O r 3°G' A N. !, r'ThIP 2' • ¢'2'D.H. - q- DR. I ¢ —_,� _.-- ¢ (OPriON4U .i=o.a D.L.• - L. rl (D � � SL9rE TOP _+ 2•,0'..3=21 bH , BED 2M , cca m BED l2M= ASH 0 oemj '4 un _ A h ✓ — , -1 m., ✓ t ry� i. m 3'-O' _ ENRTN — -� I ♦ I �� � DhY I C For 9EO /ell ➢,w S/Nk 2lJN0E, -„5 �' � - :p 1 ,eaEreas F/2 PGAeE ecGow 11,4 N 2V �',I,, 4Up 0 O /Q�� SNACK ���' G" G Il focr) `v Ih .. 4 0 2 41 MUD �.� C �.�. I L yl - A I Ld PPNT4Y _ I I n� azoz - HFl( L _I v�o KITc14L--N a� C . MZ it FAMILY 2M. J SP117 . >tl v �, .. �)-��'(J'I H b+ •.I � D c. Ie � 'eirA•n h ' , .e. a AZy6 j � I I � CAAF l' marGA6AGEL nJ„ 1—L- 4'•CONC SGAH 1 II') OB. ,x a '✓ } Y 4N.• CLO, CLO. .�,' t9 �Q I�0 2+6' v 0 : -V ArzE,o CII 1 � fl >.,�,, � I •, a —_� _ �. � '2b` 3 0 � ¢' ��-p-".- "�j �.p- f'�1 - _ �6!p• � �• �,�_� v I i I r u� I � ¢ 5 o G .� 1'hU 1 . � _. V.__ _ --_ _ •7�Py ___ t_ _+__ OJ U 1 / ��Ir1 i I - 9HDA1E•Q \ p � I � n - __ I __ __ � I I I I ` • f V PROVIDE MLN. y I 2R'• SC✓76E .1 IN a10 rc A777C CO TS p I, f7a) �e /V/N6 RM . n�, DIN,/VG /2M. 2•' " 4• ' PL US/J 1 '�/2E 2ETH2D � YP . �D 4/ACL45CE/G. i� K Dou!•7Ce /e GYfS,s.,ni �I•, ' l�J I '� I • --- (�� , i galas d' Fy g.B':S !L 'U/FLGB0�2D U2 U/48a r yWOi .L �" •. 1 Ip ER LOOA[ emeorx. _ - 2e2� BEL? 2w1. s'S I� TOP 5r_n7•E s>aPDT � 9 -�t �i. r - — o VEI HC DoaN d 1— rt \/(tee z' II�>(5,4� ;DF✓ c ,. 1 .-.. �• APROVFDAS-NOTEDDATE FE D w - � AT -a' 'I 7651660 1 ho 4PM 1:-'R +kWt1l R. ED V Pt- tin _ T-O - _ 1. BEFOv E [-V ,I - G _ .- - _ .. - _ . . _ - - _ - TION Ufa i i! 3. Fd. Pik Cf- 114'v 'I czu I 5. A DU REMN G . -. - - il:❑c Ilvl� frii$T P-i�BF' :I.Y. STATE, CO®E If O 51'NG CODE & ZO Z Y I tEpED ARCk,/ aS W — A WO �p�S M YOq DATE: ONE FAMILY RESIDENCE _.,�. i � OaN.. east dry R6VIEilONS; - . _ PLAN NO ..:=�2L ��' . ._ I. J ✓ _ HERMAN H . YORK ARCHITECT" NYORKRAWING NO. . ..... NEW � - D / DPS Aid I -- -- --- -- /O O °" v2osr Cu/z,3 ¢a co" 9So VE - 7-e /'-&' LH, `1I V F✓. - � o0//oN9L� - LUa NFcE FL o6— LdOK l P.C. IrIll FU2N_"hli h o L ,5 v4GovP7 "�., r - G/2n E2�. POCKET L `, � „ P _ 111 I {- �': POCKEY 3'OgTH TO Doo.fl 6•_ ! - �'. /!� I- —rl'I� 7 � or 6utn, — � ���, OPEN POCKGT `I II � - "tk CEM. F/N/3H /Nrlap4L LWIN �L9LGY Coe's y1” Covrkare SG.08 - i ON 24i 24"r/2 CnNG .,..y I . afFSET LiiVq _eh — _ -- -- — --=---- --- --� -1"t Ir to16,GM/o�J/Q� -- -- -- - z _. src✓ vavc . W 2 1 _ 442 C:5 � LL cc Q Ito- r - _ 0 NOTES: !. PRO V/DE AdpRLE F4002 TO/STS gELOt� qLG PA2T/T/ON5 Py?ALLel ra .ro/ST5. r ' FC�07/NG 5/Z ES= /6" 6" UNDEK G"' Fh'D. 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