The URL can be used to link to this page

Home My WebLink About3140-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. CERTIFICATE OF OCCUPANCY No.Z .2cJ3~ ..... Date ............ Nov, .... 16 ..... , 19.67. THIS CERTIFIES that the building located at .$,/S. ~/es]snd. Read ........ Street Map No..x:c ..... Block No ..... XX ...... Lot Noz:~X~ .... BoutheldI -1~,,.~-, ....... conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ Jlme.. 2~, 19.66 pursuant to which Building Permit No. dated ............ June- · Pg' ', 19.66, 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 . PI'irate..one..f. amli.}'. ~w~lling ....................................... The certificate is issued to . .~clw. ard. Me~ulltn ....... 0~el- ....................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .Nov,. 11'~ .196~.- .by .ti,. Villa.... FOI~iV~ NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISE5 UNTIL FULl.: COMPLETION OF THE WORK AUTHORIZED) N? 3140 Z Permission is hereby granted to: ? ........ :. E&~.d..lCc2t~:t~a-% ..i ........................ :.... .......... · 19~-0 .~..-Br .-- 6 ~j.~n.. C ~e see~¢, ........... .......... Elushing~,....E~Z~ ....... 11~6.~ ............. to h-~ kt..n~r...o~..i:.~til.Z~...Gwel,t.in~ ...................................................................................... ct premises Joccted at ..~/~..-.We6~,P~...~. ....................................................................... ~ ......... .................................... ~o,uf;hald~....E~Z~ ......................................................................................... pursuant to application doted ........................... ~..~,~ ....... ~.~ ............. 19~6..., and approved by the Building Inspector Fee $....].~,,O.~,O..O. ......... Building Inspector TOWN OF $OUTHOLD , Building Department Town Clerks Office $outhnld, hi, I'. 1197] APPUCATION 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), blah-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 1/30/79 New Building ................ Addition ................ Old or Pre-existing Building .....X.. ......... Vacant Lend .............. Location Of Pro/;r?; wesland Road, So.u. th..o, ld, N.Y. (See attached survey) Suffolk Co. Tax Map Designa_tio~n: Dist.. 1000, S_ec. 59, Blk. 2, Lot 19 Owner Or Owners Of Property ...... ~.~.~.qg..J.~.a..s.~.:~..~.g..~.~.e.~.a...~..d.~.~..~.~.~.Y~.D..:~.~...~.9.r...e. .............................. Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No ..................... Date Of Permit .................... Applicant .................................................................. Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval Request For Temporary Certificate ........................................ Fin~ Certificate Fee Submitted 5 00 Applicant . .~~~~.. ~ Sworn tR before me this '~nd Mar~).'Moore ~OTARY PUBLIC, State ot New York 4)q ~ , r ~ ,,'::' ~ORM NO. $ TOWN OF $OUTHOLD , Building Department Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions 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. For existing buildings (prior to April 1957), Non-conforming uses, or buildings end "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 o certificate. Fees: I. 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 ~/30 79 , Date ........... ~.. .................................. New Building ................ Addition ................ Old or Pre-existing Building ....~ ......... Vacant Land .............. Pro err/,~ ~.~.~ ]~.q. ad, $outh..o. ld, t,~..y...{See ,a.t;tached.surveM)' Location Of p y ......... . ............................................................................................... Su~£o~k^C~. Tax~p Dgs£gn~tion~ Dist. ~O00__Se~. 59~ ~B~, 2, Lot 19 uwner ur uwners ur~roper~y ...... mD. ug.~a~..Mo.,.Momr~..an=./%ax~.,.~.o..,HQ~ .............................. Subdivision ................................................................ Lot No ............. Block No; ............ House No ............. Permit No ..................... Date Of Permit .............. '......Applicant .......................................................... ~ ....... Health Dept. Approval ............................................ Labor Dept. Approval .......... : ..................................... Underwriters 'Approval .............................................. Planning Board Approval ........................................ Request 'For Temporary Certificate ........................................ Final Certificate ............ ..~. ........................... Fee Submitted $ ..... 5.,.(~) ...................... Construction on above described building and permit meets all applicable codes and regulations. Sworn to before me this ................ day of ............................................ Notary Public ..... i~!,~ ~.;~ ~..~ .............. County Applicant ......................................................................................................... Rudo3.ph H~ Bruer, ~ttorney fo~ Douglas (stamp or seed (~ ~&~ SUFFOLK COUNTY DEPARTMENT OF HEALTH EASTERN DISTRICT County Center, Riverhead, New York PA 7-4700 H.D.Ref. No.~0-~ 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 ~,~m. /~{cz~z~ Address /,z~m~'~/+~w'~ ,~ , Phone 2-Name of Builder~ ~oL(z~U Phone Address ~X/~ ~. - ~ 7-Sewage Syst~ installed by ~ =~ ~ ~ Address ~ ~ ~ ~ -- ~& 8-(a)Deed location of property ~/~/~~ ~ ~' (b)H~let or Village ~eu~ ~ ~ ~ '.(c)Tow~ 9-Septic tank-Gal~do L ~ ft.W~ft.Liquid Depth~6ft. 10-Cesspools-(a)No.pools / (b)Blocks below inlet-l) 2) 3) (c)Block size-L in.W in.H in.(d)Precast pool ~(~2 (f)H/3'ft. .,in; Dtam ~ ft.__in.(g)Finished grade (h)Backfill Material ~/F~n ~d~ /~ ll-Water Supply: Public Syst~ .; Private Well If Private, the following questions are to be answered: 12-Private Water Supply System installed by ~/2 ~z~ Phone Address ~ ~ ~ ~ ;~ 13(a)-Total Depth of Well .(b)Depth to Static Water Level 14-Diameter of well pip~ in. 15-Name of LaboratorM 16-Method of Disinfection 17-Date ready for inspection 3-Subdiv. 4-Section No. 5-Lot Number 6-Bldg.Permit No. Phone ~'~ '~-~-'~ ~ 0 ~/~ ,f t. The undersigned CERTIFIES: Above systems have been constructed and are in compliance with the Suffolk County Health Department's current Standards, Bulletins and Amendments18-Datetheret°'--~n~/~ ~/kZ~igned ~~Owner - Builder~X'~ 19-Insert sketch of location of Water & Sewerage Facilities with accurate dimensions. FOR H LTM DEF EMT USE ONLY Inspected by ~ ~_~-~---- ~Z~ ~ate Based upon the ~fo~ation stated a~ove, satisfactory~fu~t~oning of the above systems can ~~ be expected with proper ma~ na e ~d ~e.~/ /~,,:/% · .... Da~e ~ ~ } ]~7 Approved /% ....... ~ ~nginee~ Il. 12. 13. 17. 18. ;ions for Submission of Installed Private SeweRs Disposal and Water System Applicatiol Applications are to be submitted in duplicate. Required information should be t~p~_dor legibly printed in ink. Inspectors are not permitted to make inspections of installations until applications have been submitted to and accepted by this par:ment. The item number on the application form a~d it~a number listed below are the 1. [Owner'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. 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 fin~ who actually constrpcSed the sewage disposal facilities. 8. (a) For example: s/s Jones St., 100' e/o Smith St. (b) Hamlet, (unincorporated area in township), for example: ~as~ ~ortches. Village (incorporated area), for example: Northport. (c) Township, for example: Brookhaven, etc. Give inside length and width in feet. Liquid depth is measured in feet from bottom of outlet pipe to bottom of tank. (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 pr,cast 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. Indicate by check if water supply is public or private. Name of person or ~irm w~o actually installed the water supply facilities. (a) Give depth iff 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. Describe method of disinfection, for example: quart of laundry bleach in ten gallons of water poured into well and allowed to stand six hours. State date on which installation will be ready for inspection. Application must be signed by builder or owner. Signatures of subcontractor, superintendent, etc., will ~ot be accepted. Indicate location of Water & Sewerage Facilities with accurate dimensions on sketch. 19. TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFIGE SOUTHOLD, N. Y. Approved ........................................ , 19 ........ Permit No. Disapproved a/c ......... ~~ ~ INSTRUCTIONS o. This application must be completely fiiJed in by typewriter or in ink and submitted in duplicate to t~e 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 o 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 port 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 t~ 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. ....................................... (Signature of app4'icant, or name, if a c6rporation) (Address of ~plicon~) ....... ............................................................................................................................................................... ............................................................................. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) 1. Location of land on which proposed wp,rk will be done. Ma?,No.: ........................................ Lot No.: ........................ Street and Number ..~.:....~V~....~z...D~.~.:~.7.~'/.~g~..~.::~3~'~e~t.~.~4.~.....~o.a.~x~.O.~.'a .................... Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Ex,st,ng' ' use and occupancy ............ ~.~.' ~.~ ........................................................................................................ ~. ~m~ ~ ~ ~ .............................. ~.~.~ ...... ~ ............... ~ .............................................. 10. 11. 12. 13. Nat Jre of work (check which applicable): New Building // Addition Alteration Rep, Hr .................. Removal .................. Demolition ........... ;.....: Other Work (Describe) Estir rated Cost ................ P....: ........... % ......................... Fee /6 ~ (to be paid on filing this application) If d welling, number of dwelling units ....~.'./~.~.~ ........ Number of dwelling units on each floor ..... ,.C?~...(..~T~. ........ If garage, number of car~s ........... J...:.~.~.'~..¢~. ............... tf usiness, commercial or mixed occupancy, specify nature and extent of each type of use - Din- ensions of existing structures, if any: Front ......... :. ................. Rear .......... ~ ...............Depth ......~.:'~: ......... H~i ht ~ Number of Stories Dimmsions of same struature with alterations or additions: Front ............. ~ ................. Rear Dep'h .................. ~ .............Height .......... ...-;=T ............. Number of Stories ................................ Din- ~nsions of entire new construction: Front ............ '~. .................. Rear ......... ~. ............. Depth ....~...~..'. ......... Hei! iht ...... I..&j. ......... Number of Stories ............................. ~.J..~* ....... Siz~ of tot: Front ........ /..~...i. ......... Rear ..... ./~..~.Z~..~., ............... Depth ...~./.~:.,/.q.~.- .~,~:.~..../.O..,~ Dat~ of Purchase ....... ~.'.~/~./4....L~.(e~.. ...................... Nome of Former Owner ....~,,....~.4~.~.~'...~.. ................... zoqle~ or use district in which premises are situated ........ ~.~.....~.~.~..~.~4/...~..Z~'~...~..,-~,.. DoeJ~ proposed construction violate any zoning law, ordinance or regulation? ........ ~ d / Na~e of Owner of premises ................................................ /~"'~'>'~',~'~k~/';~;~/'""z; Na~e of Architect ...................................................... Address ............................................ Phone No. Narhe of Contractor .................................................... Address ............................................ Phone No. Locat property I whether in PLOT DIAGRAM clearly and distinctly all buildings, whether existing or propased, and indicate all set-back dimensions fi 3es. Give street and block number or description according to deed, and show street names and erior or corner lot. STATE O~ NEW YORK,//' COUNTY !OF: ............. :~.....~f o.,~. ............ .~.~..~.../ff~....~..'~...~.....?.,L...~.~...~..?..~.?..fih.~..~. ................................ being duly sworn, deposes and says that he is the !(Name of individual signing application) above narbed. He is the ........................... v~ (Contractor, agent, corporate officer, etc.) of said o her or owners, and is duly authorized to perform or have performed the said work and to make and this application that all statements contained in this application are true to the best of his knowledge and belief; that the wprk will be performed in the manner set forth in the application filed therewith. Swornt~ I:lef~m me this ........ ...... dayof ....... ..l. ............ Notary Pu.~,ic, . ................ .~...~...~..; .~. · .~.~~ ?,:,:, ~ot~tv~' ~;~'~ ,pplicont)