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Home My WebLink About2940-zFOItM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's O~[ice $outhold, N. Y. Certificate Of Occupancy No. 7,6391 ...... Date ... Ap~,il. ~.~ .. THIS CERTIFIES that the building located at .Blue .Ea~.~.in. DI~ive ....... Street Southold Sho~e s Map No. ~?~. J85~. Block No. X ......... Lot No, . .~ .............................. conforms substantially to the Application for Building Permit heretofore filed in this office dated . Eovemb~r. 21~ ...... , 196.5. pursuant to which Building Permit No. 29.~.0~.. dated . November. 2b% ....... , 19 6~., 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 ..... P.z, ivate .One..Pamt. ty. l)w~l, lir~g ................................... The certificate is issued to ..... Ha~.olcl. geese ..................................... (owner, of the aforesaid building. Suffolk County Department of Health Approval .... h~-a~.ch. 2.~., · 19.~.~ ............... UNDERWRITERS CERTIFICATE No ....... Lt/,t% .................................. HOUSE NUMBER .3~0. ......... Street .... Blu~. M~rli~ .DriM~ ~ ...G.~eel~.q~'.t.~..N.Y. Building inspector FOI~~ NO~ ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT '(THIS PERMIT MUST BE I~EPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 2940 Z Permission is hereby granted to: pursuant~t~ apph:cat~on dated ..............i ...... :...NO.~.Cl~l~e~'.....2~......., 19~..., and approved by the Building InspeCtor Fee $.~..o. ,..9..o...:..'. ..... SUFFOLK COUNTY DEPARTMENT OF HEALTH EASTERN DISTRICT County Center, Riverhead, New York PA 7-4700 H.D.Eef. No.~O 9F~ APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYSTEMS Inspection for approval is requested, pertinent installation data herewith. 1-Name of Owner ~ ~ Address 2-Name of Builde~ Address 7-Sewage System installed by Address 8-(a)Deed location of property Phone Phone 3-Subdiv. ~O~q 8~U~ 4-Section No. 5-Lot Number ~ 6-Bldg.Permit No. Phone (b)Hamlet or Village 9-Septic tank-Gal L ft.W ft.Liquid Depth ft. 10-Cesspools-(a)No.pools ~ (b)Blocks below inlet-i)__2) . 3)~ (c)Block size-L in.W in.H in.(d)Precast pool~ (e)l 2 (f)H ~ ft. ~'~ in; Diem ~-~. 0'~ in.(R)Finished grade to cover ft. (h)Backfill'M'aterial ll-Water Supply: Public System ~O ; Private Well '~ If Private, the following questions are to be answered: 12-Private Water Supply System installed by Phone Address 13(a)-Total Depth of Well .(b)Depth to Static Water Level 14-Diameter of well pipe ~ in. 15-Name of Laboratory k~tt%a~M~-I¥~O~i~t~516-Method of Disinfection 17-Date ready for inspection !'~ "The undersigned CERTIFIES: Above systems have been constructed and are in compl~nce.~iwlth the Suffolk County Health Depart~;~ent~~, Bulletins and ~'endment,s~hereto. W , ~ 19-D~se~ ~tch of location of Water & Sewerage Facilities with accurate dimensions. STREET Inspected by ~./~/~t ~ ~-~ ~ Date ~-- ~F'-~f Based upon the info~ation stated above, satisfactory functioning of the above systems can be expected with proper maintenance and care. S-Se Instructions for Submission of Installed Private Sewage Disposal and Water System Appltcattor i Applications are to be submitted in duplicate. Required information should be t_~_~or legibly printed in .ink. Inspectors are not permitted to make inspections of installations until applications have been submitted to and accepted by this de- partment. The item number on the application form and item number listed below are the same: 1. iOwner's name and address - if owner and builder are same, so indicate. 2. iBuilder's name and address - approvals will be mailed to this address. 3, ]Give name of filed realty subdivision map, 4. Section number of realty subdivision map. 5. 'Lot number of plot on which disposal unit is constructed. 6. Building permit number assigned by the Building Department. 7. Name of person or firm who actually constructed the sewage disposal facilities. 8. i(a) For example: s/s Jones St., 100' e/o Smith St. (b) Hamlet, (unincorporated larea in township), for example: East Moriches, Village (incorporated area), 'for example: Northport. (c) Tovrnship, for example: Brookhaven, etc. 9. iGive inside length and width in feet. Liquid depth is measured in feet from !bottom of outlet pipe to botCem of tank, 10, .(a) State number of pools, (b) State number of blocks below inlet pipe for each pool. (c) State length, width, and height of cesspool blocks in inches. (d) Indicate by check if precast sections are used. (e) Give number of leach- ing sections per pool. (f) Give height and diameter of each leaching section. (g) Give depth in feet from finished grade to cesspool cover. (h) Describe Ibackfill material used. i1. !Indicate by check if water supply is public or private. 12. iName of person or firm who actually installed the water supply facilities. 13. i(a) Give depth in feet from top of well pipe or casing to well point. (b) 'Depth in feet from top of well pipe or casing to water level in well. 14. 'Inside diameter of well casing. 15. Name of laboratory performing the examinations. 16. iDescribe method of disinfection, for example: quart of laundry bleach in ten igallons of water poured into well and allowed to stand six hours. 17. State date on which installation will be ready for inspection. 18. !Application must be signed by builder or owner. Signatures of subcontractor, superintendent, etc., will not be accepted. 19. [Indicate location of Water & Sewerage Facilities with accurate dimensions on [sketch. / "' ~ FOI~M NO: 1 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Exomined 19... Approved ........................................ , 19 ........ Permit No .... Application No ......... Disapproved a/c .................................................... ,.,..,,,.,,:,. ,....~ ........ .,~. ............. ....................................................................... -,;.i? ....................... . . ..................... ........ ............ (Building Inspector) ( APPLICATION FOR BUILDING PERMIT INSTRUCTIONS a. This application 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 of property must be drawn on the diagram which is pa.rt 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 sh.all 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 oil applicable lows, ordinances, building code and regulations. (Signature of applicant, or name, if a corporation) (Address of apphcant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ~ ~--~ .............................................................................. Name of owner of premises .....ff'....~.~?.....~.)~...~.~.~ ..................................... If applicant is a corporate, signature of duly authorized officer. (Nome and title of corporate officer) 1. Location of land on which proposed work will be done..Mop No.: ...~.~...N...~..!.TT..~. ..................... Lot No.: .../'Jr. ................... Street and Number ~'~'~' ~ Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ..~..i~.~?..N:[ ................................................................. ' ................................................ b. Intended use and occupancy ..i,~..,~,,~.~..6:..N..~.~. ......................................................................................................... 3. NaTure of work (check which applicable): New Building I/ Addition Alteration ' Repair .................. Removal .................. Demolition ............. ..... Other Work (Describe) 4. Estimated Cost ~ I~'~o~ (to be paid on filing this application) 5. If ~lwelling, number of dwelling units ....... .I. ................... Number of dwelling units on each floor If ~arage number of cars 6. If j)usiness, commercial or mixed occupancy, specify nature and extent of each type of use 7. Dirhens ohs of ex st ng structures, if any: Front ............................ Rear ................................ Depth Height Number of Stories Dimensions of same structure with alterations or additions: Front ....................................Rear De~th ................................ Height ............................ Number of Stories ................................ 8. Dim.,ensions of entire new construction: Front ...... .~.~ ......................... Rear ..... .~-. .................... Depth Height ....~...~t..[ .......... Numb. er of Stories 9. Siz~ of lot: Front ......... !~..?. ............. Rear ..... ./.~..i ....................... Depth 10. Dat'e of Purchase /~1~'/ ~'~/~ Name of Former Owner c ~i~ltk~r, ~. ~(,_ 1 1. Zode or use district in which premises are situated '~F~&~t~4 12. Does proposed construction violate any zoning law, ordinance or regulation~ No ................ /L~/~ f~Ro0 '~' 13. Name of Owner of premises ....~...:~.~..~...~. .................. Address .~.~....~.~..~).~!??..!~..~.~ ...... Phone NaMe of Architect ...................................................... Address ............................................ Phone No. Na e of Contractor .................................................... Address ............................................ Phone No. i PLOT DIAGRAM I~ocat~ clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions property lines. Give street and block number or description according to deed, and show street names and indic whether nter or or corner lot. NEW ~ORK, ~' ¢ ( /ofit'~~ STATE OF COUNTY OF ..~.'././~ ....... .............................................................. being duly sworn, do~os~nd soys thor he is the opplicc ~Name of individual signing application) above na~ed. He is the (Contractor, agent, corporate officer, etc.) of sa~d owher or owners, and is duly authorized to perform or have performed the sa~d work and to make and this applicbtion; that all statements contained in this application are true to the best of his knowledge and belief; that the work will be performed in the manner set forth in the application filed therewith. Sworn to b~fore me this ~ Notary Pu I c County (Signature of applicant) I '