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HomeMy WebLinkAbout3846-zFORM 1~0. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. OEI~TIF'IOATE OF' CIOI~UPANOY THIS CERTIFIES that the building located at .FOI~. ItOi~Olg. ~O1~[ .......... Street Map No. ~ ......... Block No .... ~ ...... Lot No.~. ...... . .l~..~.~.~.t.ll.~..k.~...}1.,.~.., ......... conforms substantially to ~the Applicati, on for Building Permit heretof~ore flied in this office dated ............ ~.p.~.:~....].~.., 19.~1~. pursu'ant to which Building Permit No.. dated ........... ApX'~:['l...]8.., 19.6~, was issued, and conforms to all of the require- ments ,of the applicable provisions of the law. The .o,ccupancy for which this certificate is issued is . P.:~i.V.t~t~ .Ol~O. i'l~Itl:L~y, dwelling .......................................... The certificate 'is issued ~o .~[Q$1.~. ~;. ]~l~Ol~. KtlOyt~ .......... .~,17.1~I~ ............. (owner, lessee or tenant) of the aforesaid building. .Suffolk County Department of Health Approval ~11~...].~...]~...by..R,. ~illa ..... TOWN OF $0UTHOLD ~UILDING DEPARTMENT TOWN CLERK'S OFFICE 'SOUTHOLD,~ N;~Y. ' Permission is hereby to - BUILDING PERMiT (THIS PERMIT MUST BE KEPT ON THE PR[M!SES UNTIL COMPLETION ~ OF THE ~WORK, AUTHORIZED).,' ":~.~:ii~. fill ~:~ : :~:,~: ~ .......... ~ .... ~"~ ~ .~ ~.~z.~a~z~.....,.::,..::.....:.. ........ ~:.,..+:~ ....... ,:..,.~...,..~..~....~..~ ........ FULL at premises located at J~.~..~g~,l,~[,.(:~'..~f~.~: ...... (.~e~.~e~..~,D,,~,).....~tlJt~..~O~ ~ ~~..~.~ ............ ~~....:~.,X,.,..~ ...... ~ ....... ~.; ................. :. ................... ,, ................... pursuant to appilcat,o~ dated ,. .............................. ~?....:j~...., 19~.,, and approv~ by tho Building Inspector: Fee $.][~ ........... SUFFOI~ COUNTY DEPARTMENT OF H~ALTH F~STERN' D~.~TRICT~'~oY, H.DoReference No ~P~CATION FOR ~PROVAL TO CO~TRUCT PRIVA~ S~AGE DISP~ SYST~ Date~ Approval ~ construct s~d syst~ is r~uested,pert~ent data her~th: 1-Appnc~t ~ ~ ~ ~ Phone ~Sub ~v -- ~ ~ ~ 7 Section 2-Det~led b~perty ~a~%~ ~~ ~ -- ~t No. 3-P~b~c ~er s~.~ n~e,, , ~-- , , ' , ' ' .Dist~ce to newest ~-~t size: Len~h~ft. Width~ft. (Also enter on center plot pl~ bebw:) lO-Proposed s~t~.Septic ta~Precast~Cesspools~Sh~ow.~e~ /other~ ~-Septic ~ ~side d~ensions: Vol~e~M. Length~t.Widt~ Jt. ~quid depth jr. ~-Precast sectio~ :~N~ber.//%~/Square ft,Cess~o~: Block size ~ .D~s.~s. PLOT PlAN No~th Capacity~)-Gals Test Hole Data Fee__t 0 2 10 18 The Undersigned CERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Health Departments' current Standards~Bulletins, and amendments thereto,covering Private Sewage Disposal Systems". (~ I ' ~ or Builder FC~ HEALT ARTMENT USE ONLY. Based on the information presented herewith,it is the opinion of the Health Department,that an adequate and satisfactory Sewage Disposal System can be installed on this Plot. Dat. ~r Signed vis.) APPLTCATION FOR APPROVAL TO CONSTRUCT PRIVATE S~AGE DISPOSAL SYST~2~S ~STRUCTIONS: Applications must be submitted in duplicate. 1-Means Owner or Builder. Address to which mail should be directed.~ 2-Means detailed description of property location, together with street name and distance to nearest intersection of main thorofare, also Hamlet/Village'~ ToWnship 3-Eater name of Public Water Supply District, together with ~he distance to their main. 4-Enter Length and Width of Lot under appropriate heading, also enter these dimensions on the center plot plan sho~ on the face of this application. ~-D~ellings: Check.mark "V" items applicable to the proposed new dwelling. ?~he Sub-division, Section and Lot numbers may be obtained from the Applicants' property ~.~map, or from the office of the Town Tax Assessor. 9-Private well: Enter "No" if Public water supply is available. Enter "Yes" otherwise. PROPOSED SYST~24S: Answers to Items number 10, 11, & 12 please consult the Suffolk County Bealth Department's Standards, Bulletins and Amendments for Sewage & Waste Disposal Facilities. i.e., Part II-Residential Sub-surface Disposal Systems covering Cesspools Part III " " " " " " Septic Tanks Part IV " " " " " " Unusual soil conditions Part V " " " " " ". Shallow Leaching Pools PLOT PLAN: The following information is required concerning the Applicant's Lot: Lot size-Length and Width in feet to be indicated at the Lot lines of the heavy lined square in the center of Plot Plan Shown on face of t~is application. Surface waters-Streams, Lakes, & Bays, et$., located within a distsnce of 50 feet'of'Applica~t's Lot lines, must be shown on the plot plan also. Wells and Cesspools now on adjacent lots must be shown on the Plot Plan together with the distance t'o the Applicants proposed Sewage Disposal Systems and Well. Where no Buildings exist on adjacent lots, stat~ "Vacant" on the plot plan. Streets adjoining applicant's lot to the right,~ left' or rear, enter street name. Well.location- To locate the well & se~age disposal systems on Ap~lica~tl's lot, the following Standards must be observed: , Well-lO0 feet minimum distance from the nearest cesspools Well-25 feet minimum distance from rear, and rear sides of property lines Well-lO feet minimum distance from front, and front sides of property lines Well-50 feet minimum below grade for well point. Well-40 feet minimum into ground water for well point. Well-$ feet 6 ins. minimum below grade to well head and lateral water pipe. Cesspools location- Upon determination of the Sewage & Waste disposal "type of systems" required, the following Standards must be observed for the location ~f same: Cesspool-lO feet minimum distance from lot lines to center of cesspool Cesspools exterior must be 100 feet minimum distance from nearest well Septic tank exterior must be 75 feet from nearest well Cesspool "Center" must be 1~ feet minimum distance from nearest water line. Cesspool "Center" must be 15 feet from house foundation. Cesspool exterior must be 50 feet minimum distance fr~m s~rface Waters, Streams, Cesspools must be 20 feet minimum distance ~om la~ze ~b~e~S ~ Cesspool center to Cesspool center must be a~;~'~16' ~eet Bottom of Cesspool to ground water must be held too~'~-m~hum of 1 foot.  SOUTHOLD, bi. Y. Examined '~ ~ 19.....~...~ Application No....~.....~.....~....~,. ......... Approved .................................. :.~...., 19.~..~..Permit No..:.~.....0~...../~...~......~... Disapproved a/c .~..... ..................... APPLICATION FOR BUILDING PERMIT Date .~...~...Z...~.... .................., 19.C.~.. 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 drown On the diagram which is part of this applica- tion. 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 applicae~t. Such permit shall be kept on the premises available for inspection throughout the progress of th~ work. e. No building shall be occupied or used in whole or in pa rt 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 alterations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances arj.d regulations. A (Signature of applicant, or name, if a corporation) (Addrd~s of applicant)/ State whether applicant is owner, lessee, agent~ architect, engineer, general contractor, electrician, plumber or builder. Name of owner of premise~......c..C.......~.~.-"~..~.....L ."'~...~ ........................................... ~, // If applicant is o corporate, signature of duly authorized officer. ~' (Name and title of corporate officer) I. Location of land on wh ch proposed work w be done. Map No ..... . .................... LOt No.: ....:....~,." "... 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'"i ...... ................. ':' ............... b. Intended use and occupancy ....~~ ...... ..././~;.....:. ............. ~................... ........... ~ ........ / 3. Nature of work (check which applicable): New Building .:;..~ .......... Addition .................. Alteration .................. Repair .................. Removal .................. Der~olition .................. Other Work (Describe) .................. 4. Estimated Cost ...... e~...~.;/...~J...O'ZTt~ ................. ....... i. Fee. .......... ~.....6...~...~,~f. ...................................................... (to be paid on filing this application) 5. If dwelling, number of dwe na units ~ ' ~ ........ - - ............ ; ............ , ..... ~NumDer OT awelllng 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 ............................... 't Nu%ber of Stories ......... v.-.../., ............. 8. Dimensions of entire new construction: Front ...;.~....~.,,-..~2,-- ..... Rear ..... (,,~....~..;...~-.. ...... Depth ..,~.:~..'.(~ ............... Height ...... ,~. .................... Number of Stories .......... ~ ...... 9. Size of lot: Front ...... ~.../..~,.../. ........ Rear ........ ././....,~..~. .......... Depth ...~....~...,-,~...~. ...... 10. Date of Purchase ...)~3.~,..,..../..~..(~..J. ....................... No,me of Former Owner .~.~ ..~/.~ 11. Zone or use d~stnct in which premises are s tuated ..... ....~ ................ ~:~ 12. Does proposed construction violate any zoning law, ordinance or regulation;) ......... ~;Tt,,MT......-~.. ..................... 13. Name of Owner of premises~...~.~'~ddress ../~ 3~ ,.~.~ Phone No ...... i .......... Name of Architect .. . .......... .e.. Ad,r__- ' ...... ~J ................ ? ..................... "~;~'""~"~'~"'71 ......... ~"[ ..... ~ u ~s .....;~ ........................................ Phone No ................... Nome af Contractor PLOT DIAGRAu~A Locme clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lines. Give street and block numbers or description according to deed, and show street names and indicate whether interior or corner lot. L ! cou Z; i~ i~ication) ..... s s a that he is the applicant above named. He is the ............................... ~...~.., ........................................................................... (Contractor, agent, corporate officer, etc.) ..................... of said owner or owners, and is duly authorized to perform or hove performed the said work and to make and file this application; that oil statements contained in this application are true rathe best of his knowledge a,nd belief; and that the work will be performed in the manner set forth in the application filed therewith. Sworn t~ef0re me this /~_ _ , /1 /"-'~,~-, ~ ,~ ...................