HomeMy WebLinkAbout5280-ZFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
$outhold, N. Y.
Certi[icale O[ Occupancy
No..Z. Ifg.~. ..... Date ............ .D.eg. ...... ~ ..... , 19.72.
THIS CERTIFIES that the building located at .. ¥.a~s~;on. Road ........... Street
Map No.. ~ a~.~ ,..P~. Block No ........... Lot No.. 3.~.7 ...... ~. ~;~.~q g~... ~ ~
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ......... gay .... ~ ...., 19..?~ pursuant to which Building Permit No.
dated ......... .l:~y .... ~ ..... , 19.?.~., was issued, and conforms to all of the require-
merits of the applicable provisions o£ the law. The occupancy for which this certificate is
issued is .. P;~.~¥a. ~;.e..ac. .c.e.s.~grY. .b..u.J.~.d. ~..rig. ( ~.t. qx: .a~e.). ...........................
The certificate is issued to . .[~¢hard. P.~e$ ......... (~¥ner .........................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval ..... .N.,.R.: ..........................
UNDeRWRITeRS C~RTIFICATE No ..... .I~.I ,~3.* ........................................
HOUSE NUMBER... 2.1~9~ ..... Street ...... .V. ans.~on. Ro~d ............................
Building Inspector
FOR~ NO. :~
TOWN OF $OUTHOLD
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)
Ne 5280 Z
Permission is hereby granted to:
........... RlMm~..~rAo~ .....................................
................ C.,teim~me ............ Ilo~:o ....................
to .... latl;t~. ~a~..&eceaste~...tm:t;1A Zul ..................................................................................
at premises located at ........... L~t,...~ ....... II&l~a&tt...Pe;Jtlt.t..~ ................................................
pursuant to application dated ......................... ~. .............. ~[ .......... , 19..~.%., and approved by the
Building Inspector.
Building Inspector
Approved ........................................ ,
FOEM NO. 1
TOWN OF $OUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
19 ........ Pemit No .....................................
Application No.
Disapproved a/c .~....~. ............................. ~
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
a. This dj~plicotion must be completely filled in by typewriter or in ink and submitted in duplicate to the Building
Inspector.
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 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 progress of 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
TR~geUal~lC~aS~°argtrhe~sc tCc~Sctc~mU, ncl~il~nwiOtfhF~lilld~pglsi,caabdlc~tlaO~ss, Corrc~i tn~r/~cces' b u.~iolsS~Ol~ ifnC~ cr~dr~?~eolusOirngdec~lle',t iaOnn~ raeSghulearteiionnsd, esc r bed
..... ....
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
~ .
Name of owner of premises ...... z~/..~r~.......~...:....~.....~.../...~.~...-~... ...............................................................................
If applicant is a corporate, signature of duly authorized officer. .
(Name and title of corporate officer)
t. Location of land on which prjgposed work will,-b~ done Map No'/...~.4~'.'~'~/ ~- ~/~ Lot No ]'~ ~'~
Street an~/~Nymber ..~_..~?.~/~.~.~ .~.........~./~ .............. ii.iiii.....iiiiiiii~i~~.~:~.i.iiiiiiiiiiiiiiiiiil;iiilMunicipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Exisiting use arid occupancy ....]......F.....~../../...'~/.........~......(~...~/....~....~'... .............................................
b ntended use and occupancy S~- L/J ['f~ A~C~--~'~rc~/ .~..O~L.~oZ.~....(~.'~7'~ ~)~~
3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration ..................
Repair ............... ~. Removal ............... Demol tior ........... Other Work (Describe)
4. Est mated Cost ....................... 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 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 ....~d~.../. ...................... Rear /
.... ~ ................. Depth ..../4~. ..............
Height .................... Number of Stories .
9. Size of lot: Front ...~..~6-/ Rear ~o 7 Depth ~/ ..................................................
10. Date of Purchase ........ /..~.~..~. .................................. Nmame of Former Owner ..~....:..Z..~....~...~.~.
11. Zone or use district Jn which premises are situated .................................................. ~ ;"/~ ...............................................
Does proposed construction vig~e any zon ng aw ord nonce or reau at on> ...A/.....~.
13. Name of Owner of premises ~.,/~?.~.~..D..g .~......~...Address~A/ ~ .~..' "~'"~..~......~....---- .......... Phone No."Z.~..~.Z'....~..../..~..
Name of Architect ...................................................... Address ............................................ Phone No .....................
Name of Contractor ................................... Address ............................................ Phone No .....................
PLOT DIAGRAM
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, ~) jcl'-
STATE OF NEW..~"O_~K,, I ~ ~ S S
cOUNT . .........
............... ~;.,~W,4~.~.~4,~'.....~....../~Z./~ ............ being duly sworn, deposes and says that he is the applicant
(IName of individual signing application)
above named. He is the ............................... ~ ..................................................................................
(Contractor, agent, corporate officer, etc.)
of said owner or owners, and is duly authorized to perform or have performed the said work and to make ond file
this application; that all statements contained in this application are true to the best of his knowledge and belief; and
thor the work will be performed in the manner set forth in the applj~atto~ filed therewith.
Swam to before me this _
~ day of 19 ·
................ ....... , .......