Loading...
HomeMy WebLinkAbout3327-zFORM NO. 4- TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. OEI~TIFIP. ATE E)F I-IP.I-:.UPANP. Y THIS CERTIFIES that the building located at ¥/~ .CaWl .!~ ............... Street Map No.. ~ ..... Block No.~t~[ ......... Lot No. ~...~,~t,~bOgU~t. ~.,'/ ......... conforms substantially to the Application for Building Permit heretofore filed in this office dated ........... ~e~. · :~8 - , 19. ~5~ pursuant to which Building Permit No.. ~']. Z dated ........... ~o~'- · '~8 ...., 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 .... ~l~'~,e- ~le..i~ami~.,'~ .c~l.l-i.~g .................................... The certificate is issued to . F.~r~. e~h .l~,. ,toll~g ......... t~.~ll~:~, ..................... (owner, lessee or tenant), of the aforesaid building. Suffolk County Department of Health Approval A~lg.. 3~ .~-I-~7.- h;z.i~o..¥i];ta .... Building Inspect;or Fo~iVI NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, Iq. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N.° 3327 Z DaCe .................. N~em1~ex'.....28 ......... , 19_66. Permission is hereby granted to: ....... · ,To-'/m...~B[el~ ~ ~e.. A/~'..~enr~e t~.. F- ,-. J:one ~ ............... So~h~l~ .............................................. to I~$~IA-. mew .- ~ne..$e~.$.Z.y.. ~lwe.~.]:-.$~g ................................................................................. et premises located at .... ~o~-.-~uo.l%e ............................................................................................ ...................................... g~ ~;~LO.~.e,...~ .,.L ...................................................................................... pursuan¢ to application dated .......................... ~0~.,~ ............ ~J~ ....... , 19/~6..., and approved by the Budding Inspector. Fee $.l.O..,,O.q ........... S-9 SCHD Date Bldg. Permit No. TO WHOM IT MAY CONCERN: The sewage disposal facilities for a structure located (Give~d~ed location) have been inspected by this department and found to be satisfactory. District Engineer SUFFOLK COUNTY DEPARTMENT OF HEALTH EASTERN DISTRICT County Center, Riverhead, New York PA 7-4700 H.D.Ref. No. APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYSTEHS InsPection for approval is requested, pertinent installation data herevith. 1-Name of Ovner ~¢c~sw~ (?~W~ ~cf) Address ~ ~ z% c~-~ c~ ~-~ ~- Phone 2-Name of Builder ~ ,~ ~ ~ ~ [ .... ~ a Phone Address ~ ~ ~ ~ ~o~w~o 7-Sewage System installed Address '2. Y ) ~d~ 8-(a)Deed location of proper~y (b)H~let or Village 3-Subdiv. &-Section No. 5-Lot Number 6-Bldg.Permit No. 9-Septic tank-Gal L__ft.W ft.Liquid Depth ft. lO-Cesspools-(a)No.pools ~_ .(b)Blocks belo~ inlet-l) /r~ 2)/~ 3)__ (c)Block eize-L /./ in.W ~; in.~ in.(d)Precast pool (e)~2 (f)H ft. in; Di~__ft.__tn.(g)Finished grade ~o cover / ft. (h)~ackfi11~terial Il-Water Supply: Public Syat~ ~o ; Private Well ,~ If Private, the foll~ing questions are to be answered: 12-Private ~ater Supply Syst~ installed by ~cc~.~/c ~/~ Address (~ ~ ~ ~ ~o~b ~ · 13(a)-To~al Depth of ~ell ~ ~ ~ (b)Dep~h ~o S~a~ic ~a~er Level 14-Dive,er of well ptp~ ~ in. 15-Name of ~boratory 16-Method of Disinfection 17-Date ready for inspection f~ ~- ~] · The undersigned CERTIFIES: Above systems have been constructed and are in compliance with the Suffolk County Health Department's current Standards, Bulletins and Amendments thereto. ~/'~-/~ 18-Date /~ / -~ ? ~igned ~~- ~ O~ner - B 19-Insert sketch of location of Water & Se~erase Facilities with accurate dimensions. C~ f j~ ~. STREET /// RTHENT USE ONLY Inspected by Date ~-~ ~/~ Baee~ upon the information stated above, satisfactory functioning of the above systems can be expected with proper m,~~c~.. ~ S-Se Instructions for Submission of Installed Private Sewage Disposal and ~ater System Application Applications are to be submitted in duplicate. Required information should be typed or legibly printed in ink. Inspectors are not permitted to make inspections of installatio~s until applications have been submitted to and accepted by this de- partment. The ite~ number on the application form and item number listed below are the same: 1. Owner's name and address - if owner and builder are same, so indicate. 2. Builder'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. Hame of person or firm who actually constructed the sewage disposal facilities. 8. (a) For example: s/s Jones St., lO0' e/o Smith St. (b) Hamlet, (unincorporated area in to~nship), for example: Bast Moriches. Village (incorporated area), for example: Northport. (c) Township, for example: Brookhaven, etc. 9. Give inside length and width in feet. Liquid depth is measured in feet from bottum of outlet pipe to bottom 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 pretest 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 backfill material used. 11. Indicate by check if water supply is public or private. 12. Name of person or firm who actually installed the water supply facilities. 13. (a) Give depth in feet from top of well pipe or casin$ 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. Describe method of disinfection, for example: quart of laundry bleach in ten gallons of water poured into well and allowed to stand six hours. 17. State date on which installation viii be ready for inspection. 18. Application must be signed by builder or o~mer. Signatures of subcontractor, superintendent, etc., will not be accepted. 19. Indicate location of ~ater & Sewerage Facilities with accurate dimensions on sketch. FORM NO. 1 TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, ti. Y. Approved .................................. ~....., 19 ........ Permit No ............................. Disapproved o/c~:... (Building Inspector) Application No ............................. 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 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. ,~PPLICATION 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 and regulations. ........ ~*'%' ° (Address o applicant) ~ State whether~pp,i~,c~n~ is owne;le~ngineer, ge~.r.~., contractor, electrician, plumber or builder. If applicant is o corporate, signature of duly authorized officer. (Nome ond title of corporote officer) 1. Location of land on which proposed work will be done. Map No.: ........................................ Lot No.: ........................ Street and Number ...~.~ ................... ~~¥~'1i'~/ ...................................... 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: // a. Existing use and occupancy ....... x.~ ................................................................................................. b. Intended use and occupancy ....... ~ .......................................................................... ~ ..................... 3. Nature of work (check which applicable): New Building ..... ..-~... ...... Addition .................. Alteration .................. Repair .................. Removal .................. Demolition ............. ,... Other Work (Describe) ........................................ 4. Estimated Cost ...... .~..../~...~¢:~..~...4~;r1~. ............. 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 ................... .~......(~i~:... .............................................................................. 6. If business~ commercial or mixed occupancy, specify nature and extent of each type of use ............................ 7. Dimensions of existing structures, if any: Front ....~J~..... ............. Rear .......~:~.. ............. Depth ...~J~... ..... Height ........................ Number of Stories ................................................................................................................. Dimensions of same structure with alterations or additi(~ns: 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 ..../..2..~.. ................ 10. Date of Purchase ........................................................ Name of Former Owner ........................................................ 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction/~vi°late~'~ zon~law, ordinance or,~ulation?,,~ -.~ ~ ~ ............................................................ 13. Name of Owner of premises,,/~w..~-,~r:'~L~~dress ...~.~jg~e No Name of Architect ------- Address ...... Name of Contrac~~....Addres~(~hone No~..o.,J...~.~../_~ 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 Jot. STATE OF NE'~/-~YOR~,/ a~ tcc . COUNTY OF ~.,.~....,---...~-o.o. above named. He'ts'"the ...............~:: ................................... .T....~~~ ......................................... (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 that the work will be performed in the manner set forth in the application filed therewith. Sworn to before me this ............ of .............. Notary Publi ',~)...~Z~ ~'-' '~-~r ~// ~ ....L.:7,7~/...~?.7.,, ,/z~'"v":"4~"C'"~Z'""~'""~'"'"~" ............................. ............................... ~*¢=..'.. ............. L, ounty ~/ (~igna~e of applicant) T~rm Ex~ir~ M~fC~ 30, 19_~~ -?