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Home My WebLink About3982-zTOWN OF SOu-.t'rlOLD BUILDING D~PARTM£NT TOWN CL~RK'S OFFICE $OUTHOLD, N. Y. CI~RTIF'II~AT£ OF' O0~-UPANCY No. Z. 3.42~... Date .... F.~z'us, r.~. Lg. ........... ,1969. THIS C~ that the building ]o~t~ at .~O~ .~e ............. S~et Map No. 3~4 ....... Block No ............. Lot No. 7,....~o~..~ .~k ........ ~nfoms substanti~ly ~ the Application for Building Pemit hereto~ ffl~ in this office dated ....... A~8~ .5, ...... , ~19..~ p~u'ant to whi~ Bulldog Pemit No.. ~ .~ dated ....... ~8~..5~ ...... , 19.~, was issued, and co~orms to all of ~e require- m~ of the applicable provisi.ons of the ~w. The ~cupancy $or which th~ ce~fficate is issu~ is .... p~lv~te. ~ne..f~$~ .~ ....................................... The ce~fficate is i~ued ~o .... ~KI~. ~81~ ..................................... (owner, lessee or tenant) of the ~or~aid building. S~folk County Depa~ment of Health Ap~val . .~. ~*. ~,. ~..V~ Building Ins~ctor FORM NO. 2 TOWN OF SOUTHOLD 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) N? 3982 Z Permission is hereby granted to: .... to 'll~"~"J~"t~"~J~z~ .................................................................................. at premises located at ..... ~1t~..~. ...... ~3EI~.~J~..O~ ............................................................. ........ :.....::.%?:.....Job~..I,~ .......... ~ ...... .H.~. .......................................................... pursuant to application dated ............................... AJ!~ .......... ~. ........ , 19...~, and approved by the Building Inspector. Fee $..~J~'~J .......... Building Inspector J S-9 SCHD RECEIVE9 OCT 13 II..;l I0:07 :~T OF ~'IEALTH SUFFOLK COUNTY DEPARTMENT OF HEALTH Bldg. Permit No. -~ ~<~ ? TO WHOM IT MAY CONCERN: at The sewage~ disposal ~acilities for a structure (Give deed location) located have been inspected by this department and found to be satisfactory. District Engineer District Engineer SUFFOLK COUNTY DEPARTMI~T OF HEALTH WESTERN DISTRICT H.D.Ref. No. One Old Indian Head Road Commack, New York 543-1116 APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYSTEMS Inspection for approval_is ~equested, pertinent installation data herewith. 1-Name of __ __3-Subdiv. Address ~ · Phone__.__ _______~-Section No. 2-Name of Buell:let ~4~ Ce~ C%fEe~. ~ rhone 5-Lot N~ber ~ Address ~ -- ~-Bldg. Pe~i~ 7-S~age Sy~ ins=ailed by ~~ Phon~ Address~ 8-(a)Deed loca=ion of prop~y ~ ~ ~ V~' ~~. (b)H~le~ or Village ' (c)To~ 9-Septic tank-Gal L__ft,W ft,Liquid Depth ft, 10-Cesspools-(a)No.pools~- .(b)Blocksbelow inlet-1) l$# (c)Block eize-L t& in,W F in,H r in,(d)Precast pool (e)l__2 (f)H ft. in; Diem ft. in.(g)iintshed grade to cover ' ft. (h)Backfill Material il-Water Supply: Public System ; Private Well ~ If Private, the following questions are to b~ answered: _ 12-Private Water Supply System installed by~Phone~-~¥$¥ Address 13(a)-Total Depth of Well (b)Depth to Static Water Level 14-Diameter of well pipe ~" _kn. 15-Name of Laboratory '~ ~~ 16-Method of Disinfection 17-Date ready for inspection % ~ ~ The undersigned CERTIFIES: Above systems have been constructed and are in compliance with the Suffolk County Health Department's ~urrent Standards, ~ul~;tins and Amendments thereto, d~~ /~l~ 18-Date ~'~~S/6~ Signe ~,~ ~er - Builder 19,Insert sketch of location of Water & Sewerage Facilities with accurate dimensions. O O STREET FOR HEAL, TIi-,-~EPAI~,,~HEN~j~SE ONLY Inspected by ,~J .~C~c~i D~'te Based upon the info~ati~ state~ above, sa~isfaciory functionin~ of ~he above syst~s can be ~pected with proper maint~~e~ S-Se Instructions for Submission of Installed Private Sewa2e Disposal and Water System Application Applications are to be sub~itted in duplicate. Required information should be typed or legibly vrinted in ink. Inspectors are not permitted to make inspections of installati, o, n8 until applications have been 8ubmit~ed ~_o and accep,t,,ed by this de- O~e lt~ n~ber on th~ application fom~li~r ~'.~e the 1. Ouner's name and address -~Lf~-~ud~b~t~-~x~same. so indicate. 2. Builder's name and address -~~~ to this address. 3. Give~la~,-~/'~r/~lt~'~bd/w~&o~-~v~~''~ 4. S~~ber of r~lty subdivision map. 5. LoC n~ber of plot on which disposal unit is constructed. 6. Buildin~ pe~iC n~b~ ass~ by the Buildin~ Departme~. 7. N~e of person or rim who acc~ll~ consC~ced the~a~e disposal facilities. 8. (a) For ~ple: s/s Jon~ St., 100' e/o Smith St. (b) H~let, (unincorporated ar~ in to~ship), for ~ple: ~st Horic~si Villase (~corporated ar~), for ~ple: Not. port. (c) To. ship, for ex~ple: Broo~aven, etc. 9. Give inside le~$h'and width in feet. Liquid depth is m~sured in feet v e v~ of outl~ t~ ~.ol tank. 10. (a) State n~ber of pools. ~SS~e number of blocks bel~ inlet pipe for each pool. (c) State leith, width, and heisht of cesspool bloc~ in inches. (d) Indicate by check if precast sections are,used. ~e) ~ive n~ber of leach- in~ns per pool. (f) Give heisht and ~er-~ ~ch l~chins section. (S) Give depth in feet fr~ finished g~e ~ess~ol cover. (h) Describe backfill material used. Indicate by check if water supply is public or private. 12. ~e of person or fim~ho actually installed the water supply facilities. 13. (~ ~ve~dept~ in feqt ~p~f~l pipe o~c~linl to well point. (b) 14. Inside di~eter of well casins. 15. N~e of laboratory perfo~ins the ~inations. 16. Describe method of disinfection, for ex~ple: quart of laundry bleach in ten Eallons of water poured int~ well a~ allowed to stand six hours. 17. State date on which ins~l~]vill be ready for inspection. 18. Application m~t be sisneCby b~lder or ~er. Sii~tures of subcontractor, superintendent, etc., eill n~t~epted. 19. Indicate location of ~ater & S~e~e Facilities with accurate d~ensions on sketch. - ~ ~ , ~~-~ HI~¥3H 30 1[: ,1 .... ~ u3AI333 [ 'DOWN OF SOUTHOLD BUILDI NG DEPARTMENT TOWN GLERK'S O~IGE SOUTHOLD, N. Y. ...... ........ A~mved ~ 19...[.~.. Permit No...~..~..~.~.~ APPLICATION FOR BUILDING PERMIT Date ............. ~.........'~.. ....................... , 19...~..~ .... 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 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 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, h~using cod,e, and regulations. (Signature~of applicant, o.r..nam~, if a .ce~'r~'i'~'r~ ....... (Address of applicant) State whether applicant is owner, lessee, agent, architect, en~neer, gen~eral ~entractor, electrician, plumber or builder. .......................................................................... .............................................................. Name of owner of premises ......... ~.?...~....47~ If app. J~ar~t is a corporate, sig~ture of duly authorized officer. · .......... (Name and title of corporate officer) 1. Location of land on which~ropased wo~ will be done. Map No.: ....... ;~.~.Y. ............. ,Lot ~o.: ...~ ................. Street and Number ...... .......................................~~ ............. ~~.~ .............................. ~ ~ ~ Munici~li~ 2.State existing use and ~cupancy of premises and intended use and ~cupancy of propos~ constmctlon: a. Existing use and ~cupancy ................ ~~ .............................................................................. b. Intended and ................. ............... ........................ ............................................... 3. Nature of work (check which applicable): New Building. ................. Addition .................. Alteration .................. Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................ ..... x7 4. Estimated Cost ............................ : .......................... Fee .......................................................................................... (to be paid on filing this application) §. 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 ........... .~....~... ................ Rear ........ ~'.~....i ......... Depth ....'~.....~.. ............. Height ......~...~. ......... Number of Stories ~ 9. Size of lot: Front ......... IJ..~. ........... Rear .................................... Depth ........ .~.~....-"~m~. ....... iX ~q, 10. Date of Purchase .........../~..~ ..... ~.~. .................. Nome of Former Owner ................................................. 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction v rdinance or regulation ...... ~,~ .............. ~...../ ................. 13. Name of Owner of premises" ................ ;...~..Address ..."/:].~..~......:~.(.i.~.~.~.;~Phone N~ ..'...[..~- ........ Name of Architect ............. ~..~.._ ....... ./~c~ ................ Add ress i.~.~..~~ii Phone No ..................... Name of Contractor,".~..'~..'~.~....~......'~f...-?/..."~.. ........... 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. STATE OF NEW ;I~DRKo ~ l I c ~ COUNTY Of ...~ ....... ~'~'"' .. j) ........................................... ~..~...~.i..~.....~,..../~...,..~..~being duly s~'orn, deposes and says that he is the applicant (Name of individual signing application) ,~/-- , //u) above named. He is the ........................................ ~..~...~ ....... "'.~...¢..~.~ .................................................... V (~'dntractor, 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 ~- __,z~/') ~ / ............... .. ............. No,o ~^RION A REGENT ~ (./ ' ' ......................................... (Signature of applicant) ~OTARY pU~]LIC, State ol i~ew YorV .o 52 3233120 Su,io~) C~n~; ~,rm'Ea~res M~ch , Lot G MAP OF LAND ~T ~=) EC..ON 1 ~. I t , 4',