The URL can be used to link to this page

Home My WebLink About7482-Z FORM NO. 4 l TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. ' E i Certificate Of Occupancy No.Zb9.51 . . . . . . . Date . . . . . . . . . . .11ax°ch. . �9. J i ., 19.76. THIS CERTIFIES that the building located at -S/S .Sound .11jaw.Ave .�.�t . . Street , f Map No. . .xx. . . .... . . . Block No. . xx. . . . . .Lot No. . .xx . . . Sm-bald.N.-X'��. ,conforms substantially to the Application for Building Permit heretofore filed in this,office ;! 4822 dated . . . . . . . . Aug $ . ., 19. 7 pursuant to which Building Permit No. . . . . . .�607Z dated . . . . . . . . :.. . . . . . . . . . . ., 19. . . ., 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 . ` .(utility.). 'P 1 ..Aoce.ss.ory: .bu3..�.c?l,n'gs. . . . . . . . . . . . . . . . . . . . . . The'certificate is iss xed to . Robent .Bay4e . . . . Owner . . . . . . . . . . . . . .j. . . .. . . . . . . . (owner, lessee or t"enant) of the aforesaid.btiilding. II4 Suffolk County D parment of Health Approval :�7 R+:. . . .f. . . . . . . . . . . . . . . . . . . . . � i UNDERWRITER ' CERA` ICATE W6. . .Tl a ;. . . . . .. . . . . . . . . . . .:. . . . . . . . . . . . . . HOUSE NUMBER . . . . .$2 0 . . . . Street . . .Sound. Xtsv. .AVe.'. . . . .'. . . . . . . . . . . . . . . . �. . . . . . . . . . . . . . . Building Inspector GG � lr f ii �I �;� i FORM NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERIC'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N9 7601 Z Date ..........................................v......... 19.7./ Permission is hereby granted to: T 73A / r I ................................................................................ ................................................................................ ................................................................................ to ........ l.1//:.......... ........ .CC. .. ' . . .. ...Y.........r3 U f i 0 1 of . .......(�N T C.......�/l.l..C. I L-, ................................................................................................................................................................ at premises located at `� DU Al v....... (, I I� /`l� /9 i /—............................................ ................................................................ ................................................................................ ................................................................................ ................................................................................................................................................................. pursuant to application dated ....................................�.........� .� 197�.., .,/., and approved by the Building Inspector. Fee $...... .............. ................................................................................ Building Inspector FORM NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTH'OLD, N,,. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N0 7482 Z Date .............................. ..i .......'' 19a�; .. p Permission is hereby granted to: r ................................................ ...............:: ............................... .........................a9u��'t!ad move; •,_al an accessory storage building to ............................................................................................................................................................ ................................................................................................................................................................ at premises located at .....:,1.;:...:: ::r ;.a.GT .n--jn�.. .......................................................................... .........................................................Anja hnl. ... ....':.:j.;................................................................... ................................................................................................................................................................. pursuant to application dated .........................A:!,- .......... ...... ., and approved by the Building Inspector. Fee : 0 C: ............. _ Lam... Building Inspector FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Clerics Office 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: 1. 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. 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 ..( .GGt. Ln.. ��.7 ......... wlc�e� �+� �ttc�ssoi^� l�v�rlcli�i New Building ................ Addition ....... Old or Pre-existinng Building ............. Vacant Land .............. Location Of Property ll�!��fY.V� .I�i.!.. .�. ?.LL.L .�. �l. :J�..h� .f) '. S..Q(/!. .... ..... ' Owner Or Owners Of Property ......Kokrt...T.J;asjf e.�. .......... .............................. .......... Subdivision ... .1. . .4.................................................Lot No. ............ Block,No. ............ House No.............. Permit No. 76.07...4n... Date Of Permit kllf....l.q Applicant ....................................... ....................... Health Dept. Approval .. .gypp ..................................Labor Dept. Approval .................................. ... Underwriters Approval .=..................................Planning Board Approval ........................................ Request For Temporary Certificate ......................................... Final Certificate .......................................... Fee Submitted $ .................................... Construction on above described building .and-.permit et a ap a "codes and reg ions. Applicant .................... ..... .... ......... ......... r .. ........... .............. Sworn to before me this .............. dayof ............................................ (stamp or seal) Notary Public .................................... County TOWN OF SOUTHOLD ,le_A BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. r Examined 19.71... Application No. �LO G. ..........r Approved .A-,C*K' .� 19�/. Permit No. .�1p ....... - — Disapproveda/c ...............:.... ...................................................................... . ................... ..................................... ..... ....*.��.. . ....................... c ...... ..9... .p .. EBuildin Ins ector) APPLICATION FOR .BUILDING PERMIT Date ....QG1_ 8.................... 19.7�{:. 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 or areas, and giving a detailed description of layout of property must be drawn on the diagram which is part-of this application.c 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 1S 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 necessa nspections. ........ . ..... . ...... .................. Aignaturef applicant, or name if a corp ration) ..........��...��tl �...�.�.. (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ......... Y.�...y v.P......�8.W. ��............................ c� ....................................................................................... Name 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 Trade's License No. ............................................... 1. Location of land on which proposed work will be done. Map No.: ......................................... Lot No. . ..... Street and Number ....Pv. 2.......i.Q.V.N.. ......U.1.1 ... .............. .......: .......... Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ........AC ......F.1Al?.M....aut Lx.>4�..............,.............: b. Intended use and occupancy ....... � �`� ... .L�..��..? :. . V ��......Q..um.... . ....... - d 3. Nature of work (check which applicable): New Building. ................... Addition .................. Alteration .................. PL . . Repair .................. Removal ------ Dan�ok�on.._—.--.— Other Work' (Oeacriptnn) . � 4. Estimated Cont �� ee --..�.-'_---.-----_--_---_--_--------. . °~— . ~.~~-- ....................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ............................Number ofdwelling units on each fkoor --,-------. Ifgarage, number -of cars ----------.--------'---- --'------------------------- h. If business, cnnnnnorcio| or mixed occupancy, specify nature and extent of each type of use ............................ 7. Dimensions ofexisting structures, if .: 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 --../--....................... Reor --.--.------- Depth -------- Haight .................... Number- of Stories ._—,-_.—_-------,------------------------. 9. Size of lot: Front ------------------- Rear .......................................... Depth ................................ l{[ Date of Purchase ........................................................Name of Former Owner .------_..---_--' .................... . ll. Zone or use district in which premises are situated ------.--------------.—.---.---------. 12. 'Does -proposed ' construction violate any zoning law, ordinance or regulation: ........................................................ 13. Will lot be regraded ............................. Will excess fill be removed from premises: ( ) �'aa ( ' ��'��7 �_-. 14. NonienfOwnorofpreh�ises ..------..��c��x--._' Au��rass .-. .......... Phone No ..~....._'�'.. Nome bf Architect ----r--........................................ Address ..... .Phone No ...................... Name of Contractor .............................................................. Address ................................ Phone No. ...................... PLOT DIAGRAM . . ` clearlyLocate all buildings, whether existing or proposed, and indicate all set�-back dimensions from property lines. Give street and block number or description according to dead, and show street nonnao and indicate. whether interior orcorner lot.. ' ` ' ��y �� _ . ' 011 AVE �- o^ , STATE OF NEW YORK' (SS COUNTY OF -----..—.....,i ............................'....... J� �b�ei�un� g duly sworn, deposes and says t hot he is the applicant Mane of individual signing �ontroct above 'riomed.He is the -...-----------.. ----.----..----___..^.______________ (Controctor, agent, ' rote officer, etc } of said owner ordwnars and is duly authorized to perform or h file this application; that all statements contained in this ' upp�|i c i and |thor the work will be performed in the manner set forth in the Sworn tob this t filed the re, Va ----.-01- day of --.----- . . . �-��.�-.�—.—'.L-' ................ -- ----.Notory Public, .—.-- 0(Signature of FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined 19. / ,A�Z.• �� 7� Application No. ........... Approved ..............: ..� 1 j.... Permit No. ..................................... ., Disapproveda/c ........................... .......................:....................................... ............................................................................... .........,................................ f ......: Gf. ...... ...................................................: (Building Inspector) APPLICATION FOR BUILDING PERMIT Date ....2—E:Ke............. 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 or areas, and giving a detailed description of layout of property 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, buildin code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary i ections. ............ ...... .......................................... .... 0..... ............... (Si nature of applicant, or name, i cor o tion) Y 7 ........... 6... ...�1....... r..... ?: C:.... �00 (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. r........................I............................ Name of owner of premises ....K-dV.KN?..r.....��...�,�.A�.�-��{`......................................... .. ............................................ 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-Trade's License No. .............................................. 1. Location of land on which proposed work will be done. Map No.: ........................................ Lot No. :....................... Street and Number .....�O.....� Jt�?T�....�1. UV..... .V .-....}....C��V � �L.1 .. ...... I ......... .. ...... .... ...... Municipa ity 2. State existing use and occupancy of �pre`mises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ....1ST.cC__Fr.54. ..........��"" .,..;,�.�- U l L-AGJl12-� ... znAb. Intended use and occupancy ......r`�k ....G.4U... :..j1 1..t�....� Tom...... .(�. { .. 3. Nature of work (check which applicable): New Building Addition ------ Alteration ---...-' ' � Reooir -.----- Rannovo| ------ n�okbon---.---. Other \A��rk .. ^ �o ' (Description) ' �m � f zi Estimated 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 ofexisting structures, if any: Front ............................ Rear ................................ Depth ..... Height ........................ Number of Stories ---.-.-----.-----_--_----_-_---_---.-_-----__ Dimensions of-some structure with alterations or additions: Front .................................... Rear ............................ Depth ----------- Height ---------'Number of Stories ................................ 8. Dimensions of entire new construction: Front .................................... Rear ............................ Depth -------- Haight .................... Number of Stories --.------.----.-.-.-----------------'------ 9. Size of lot: Front ........................................................ Rear -------------- Depth ................................ . 10. 'Dote of -Purchase ........................................................Name of Former Owner ........................................................ l l. Zone or use district in which premises are situated ---------------.-.--_--------------' 12. Does proposed construction violate any zoning law, ordinance or regulation: ......................................................... 13. Will lot be regraded. ............................ Will excess fill be removed from ' premises: ( } Yes No 21 14. NomeofOwnerofprannisas ------.. ------. Address ................................ Phonm,No ,-~-'...~-..-.. ` Name nfArchitoct ...................:........................................... Axjd,mao ................................ .Phonm No. ...................... ^ Marne of Contractor -------------------. Address ................................ Phone No _---.-._-' PLOT D|/\G�/\K� ' ^ clearlyLocate y 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 mzrnas and indicate whether interior orcorner lot. ^ . LQ M PLAN Ll ` V I&Lkr WE 8~- - -----~--~ °~�- [ STATE OFYOR�. SS COUNTY OF ................................... 1L----'... .--.-' -----'being duly sworn, deposes and says that he is the opp|iconi (Nonne of individual signing contract) above named. Heis the --------'-----.----.--------_--^----------------'-----.------------ kContnoctor, agent, corporate officer, etc.) of said owner or owners, and is duly authorized to perform or � ^^ ' file this application; that all statements contained in this opp|ic and thortha work will be performed in the manner set forth in the *led erewith. pti.fTore Sworn to bm othio 0 -�-'-----' ~, of .____. _______.. _Qjy -bNotorypub|i --. �-c --_,-�-'...-.----' .. ---. �� m of applicant) M117,111,7m Lum!Pq NOTARY PUBLIC, S+"/o of Now York FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Clerks Office 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: 1. 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. 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 ... �i .. -�i.J .7. .. New Building Addition Old or Pre-existing Building dN�Ue� iVi aetCSson1 ................ ................ Vacant Land Location Of Property ... .i��11�..U1C 4 ..} V�I'.�...�. . .L (7144. .(�� .........�:1��. ��...��........... Owner Or Owners Of Property Subdivision ...J-9...................................................Lot No. ............ Block No. ............ House No............. Permit No. _74 OZZ Date Of Permit ...14.Applicant ...... R.Q. ................. Health Dept. Approval ...............................Labor Dept. Approval ................................................ Underwriters Approval ..............................................Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ .................................... Construction on above described building and pe. 't et all applicable codes and/ egulations. Applicant .......... ....... ....... �.c . .. .. . .......................... Sworn to before me this ................ day of ............................................ (stamp or seal) Notary Public .................................... County FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined ...... ( 1.1 � C ...................... 19...... APPlication No. ................................ Approved ......................................... 19.,?..1:. Permit . . ...... ............... Disapproveda/c .... ....... .............. ......... ............ ............. ......... ........... .................................................................... ..... ,...... ................... .......,.... ...............(Building Inspec ..',................................. APPLICATION FOR BUILDING PERMIT Date ...A.V. Z[T�...7....... ...... ., 19: ...... INSTRUCTIONS a. This application must be completely filled in by typewriter oe 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. 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 r gulations, and to admit authorized inspectors on premises and in buildings for necesso nspections. Ji�--n`a-ture-of-ap�-1 .. .. . .. .icant, or na if a orporation) ;Q6.... K...T !. ..4 a5!. ..... �1 :..�r 1. :........... (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ..............C?W. .F(�................................. ................... 7.��Z" T 4 Y F j ... ................................................................................ Name of-owner of premises ...�c 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 Trade's License No. .............................................. 1. Location of land on which proposed work will be done. Map No.: ........................................ Lot No. ........................ Streetand Number .................................................................................................................................................... Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ........... f.�Wr......FAf?-m.....PQ.i.L.- w.. .................................... b. Intended use and occupancy ............ ...... ... ? ... 0 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration .......I....,. 1 . Repair .................. Removal .................. Demolition.................... Other Work ... mc-n (Description) 4. Estimated Cost ..��U .C3z?........................................Fee .......................................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ............................Number of dwelling units on each floor ............................ Ifgarage, 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 .................................... Rear ............................ Depth ........................ Height .................... Number of Stories ...................................................................................................................... 9. Size of lot: Front ........................................................ Rear .......................................... Depth ................................ 10. Date of Purchase ........................................................Name of Former Owner ........................................................ 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ........................................................ 13. Will lot be regraded ............................ Will excess fill be removed from premises: ( ) Yes ( ) No 14. Name of Owner of premises .................................................... Address ................................ Phone No. ...................... Nameof Architect .............................................................. Address ................................ .Phone No. ...................... Nomeof 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. fZOUTF 2F7 r INA (Q _0 1 N (� l�S N !Il �=L001Z El-AW k 3 Aryt i BVI- S - - F �Y t ..l ATE O NEW I COUNTY OF/.. . . .. .. .. ... ...J " ................ `. ........being Y dul sworn, deposes and says that he is the applicant (Name of individual signing contra above named. Heis 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 and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and thar the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this .� 71 ,�. ..�4�day of ".z,��. .. 19�..... NotaryPublic. ............ .. ...... ..:k; -l.. County .................. .... ..... ................................... (Signature of applicant) NC)TARY PUBLIC. State of New York No. 52-4'522026 - Suff-Ik County / Comrnission Expires March 30, 19..y`TyY� FORM No. Y TOWN OF SOUTHOLD . BUILDING DEPARTMENTAV" "' ^��_ say ud.,�r TOWN CLERIC'S OFFICE 3/a :� SOUTHOLD, N.-Y. a y � rr CC �yf r� Examined ....�.....t...l........ 19 ..1... Application No. .�....... Approved .......... ............/1... ., 1192.1.1. Permit No. /.. ol ., "......... Disapproved a/c .... ........ ............. ............ .......... ................... .................................................. .....�_. ........................ r ............... ...... ........ qiin�_ ..... .... ... ..................................... (BInspec J r) APPLICATION FOR BUILDING PERMIT Date ....l.'rU Cwn, .....1 ........... 19 .`1.... 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 plari 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. 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 ori 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 neves inspections. ... .................. ...... ... ....... ........... .............. (Signature of applicant, or na e, if a orporation) Tar 57 ............................`r r' c`�......... (Address of applicant) State whether applicant is owner, -lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. dl.)PJ� . ............................................................................................................................................................................................... Nameof owner of premises ...... ...0. 'EZT...........�... ...�� 1- .(........................................................................... If"applicant is a corporate, signature of duly authorized officer. ........................................................................................ (Name and title of corporate officer) Builder's License No. .................................................... Is Plumber's License No. ................................................ Electrician's License No. ............................................ Other Trade's License No. .............................................. 1. Location of land on which proposed work will be done. Map No.: ........................................ Lot No. ........................ Streetand Number ....................................................................:..................................................... ......................... Municipality 2. State existing use and occupancy of premises and-intended use and occupancy of proposed construction: a. Exisiting use and occupancy .......ITS: 7. ®�2.L�..... K.....[S.0.U-tf.NjC. ...................................... b. -Intended use and occupancy ........tr. .....:f. ..... . ......................................... . .r. .1......... 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration .............. . . Repair .................. Removal .................. Demolition.................... Other Work / 0-0 (Description) 4. Estimated Cost ... ..57.x?:0V...................................Fee .,/........................................................................................ (to be paid on filing this application) 5. If dwelling, number of dwelling units ............................Number of dwelling units on each floor ............................ Ifgarage, number of cars ............................................................................................................................................ b. 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 .................................... Rear ............................ Depth ........................ Height .................... Number of Stories ..................................................................................................................... 9. Size of lot: Front ........................................................ Rear .......................................... Depth ................................ 10. Date of Purchase ........................................................Name of Former Owner ........................................................ 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ........................................................ 13. Will lot be regraded ............................ Will excess fill be removed from premises: ( ) Yes ( ) No 14. Name of Owner of premises .................................................... Address ................................ Phone No. ...................... Nameof Architect .............................................................. Address ................................ Phone No. ...................... Narne 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. Roo TE '7 ' M M oc P _ Sf � 0 \ STATE OF NEW Y RK, . Z S S o Xs `mac >r COUNTY OF '.. .. �. i�r ...j '< •..............,�.... .✓� /... './............... being duly sworn, deposes and Boys that he is the applicant (Name of individual signing contract'I above named. Heis the ................................r ..................... ............................................................................................... (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 and file this application; that all statements contained in this application are true to the best of his knowledge and belief; and thar the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this day of ....... Notary Public, ��.. .. County .. ........ .............. ....... ............. (Signature of applican RvllDftBEf. BrU'�6� 1 NOTARY PUE3LIC, State of New York No. is$ion xpi es Suffolk 19W19 Commission Exp 6"- i. r 7 B U11 L D 1 __ N r' fA I T N? 7607 Z u ISSUED TO _- /3A)C2 L_ Y _DATE - ,ADDRESS t . This notice must be 'displayed during construction L and returned to _ uilding Dept. to, get a certificate of occu aney �upon completion of work. UI�LhIeNG INSPECTOR'S OFFICE, TOWN OF ..SOUTHOLD Y SOVTHOLD, N,, Y. 10 7 U