HomeMy WebLinkAbout3504-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
BERTIFIBATE BF nBBLIPANE:Y
No. Z2823 ...... Date ............... ~g ..... 30., 19.67.
THIS CERTIFIES that the building located at .~/~ .~o~r~..~I.a.x'.~.o.l!~. ~a ..... Street
Map No.. ~ .... Block No...:g~ ........ Lot No. ~ .... ~.~.'~.~;.hg.~.~.~. ~,.~..~ .......
conforms substantially to the Application for Building Permit heretofore filed in this office
dated .......... F~F .... 2.~.. , 19.6~ pursuant to which Building Permit No. 3~0~ .Z.
dated ............ J~.~e. · · ~. ·., 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~. iw~.e..o.n.e.. £..~.!.J-Y. fl.V.*j,.3,..:B!.g .....................................
The certificate is issued to . ~To,hlt. &..I4a~g. leG'l;.. I41111~11. ........ 0l~o~ ..............
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval . ~lu~Ly...26t..~96g..by. 1%. trilla.
Building Inspector
FOF,~I NO. 2
TOWN OF SOUTSOL~
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? 3504 Z
Permission is hereby granted to:
........ · ¢~....~.~a..~ ................................
to . ~.Lq...~.~w...~.~ ,...+.~,~:...~ ~.t~,~,J,~ ..................................................................................
pursua:~ to application dated .................. ...J~.....~.....~... ........ , 19...~.~.., and approved by the
Building Inspector.
Building Inspector J
SUFFOLK COUNTY DEPARTMENT OF HEALTH
EASTERN DISTRICT
County Center, Riverhead, New York
PA 7-4700
APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYSTEMS
Inspection for approval is requested, pertinent installation data herewith.
Address ~iqq ~A/~/~.~/ A% ./Z'~Phone ----~ 4-Section No.._.~
2-Name of Builder ~:~,~_,,~/~_ ~57~,~/~ Phone ~ ~.?~f~'~.~$/~ 5-Lot Number ..~/~
Address ~;~,~j~/,~' /~ z~/~>~3.5.-~ ~ 6-Bldg.Pe~it No.~
7-Sewage System installed by ~r _%/~)/ ~~ ~ Phone ~--
8-(a)Deed location of property ~$~/~ z)~? Z/~/~ ~ ~'~/~ ~ /q ,v~n~
(b)H~let or Village ~3~ ~ f~/~ ~ . (c)Town ~
9-Septic tank-Gal__L ft.W ft.Liquid Dept~ ft.
10-Cesspools-(a)No.pools ~ (b)Blocks below inlet-1)~2)
(c)Block size-L ~in.W ,/~ in.H ~in.(d)Precast pool__(e)l 2 3
(f)~__ft.__~n; Diam ft. in.(g)Finished grade to cover ft.
(h)Backfill Material
ll-Water Supply: Public Syst~ ;/~A A~/~$/~'~/~;~-~Prfvate Well
If Private, the following questions ar~'to be ~ed:
12-Private Water Supply Syst~ installed bM Phone
Address
13(a)'-Total Depth of Well (b)Depth to Static Water Level
14-Diameter of well pipe in.
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 current Standards, Bulletins
and Amendments thereto.
19-Insert sketch oflocation o~ Water & Sewerage Fac~lities with accurate d~ens~ons.
FOR H~LTH DEPONENT USE ONLY
Inspected by Date
Based upon the info~arion stated above, satisfactory functioning of the
above systems can be expected with proper maintenance and care.
S-Se
Instruction,~, for Submission of Installed Private Sewage Disposal and Water 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 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. 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. Name of person or firm who actually constructed 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: Hast 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
bottom 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 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
backfill material used.
I1. 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 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.
1.5. Name of laboratory performing the examinations.
1.6. Describe method of disinfection, for example: quart of laundry bleach in ten
gallons of water poured into well and allowed to stand six hours.
1.7. State date on which installation will be ready for inspection.
1.8. Application must be signed by builder or owner. Signatures of subcontractor,
superintendent, etc., will not be accepted.
1.9. Indicate location of Water & Sewerage Facilities with accurate dimensions on
sketch.
S-9
SCHD
TO ~HO~
SUFFOLK COUNTY DEPARTHENT OF HEALTH
Da~e
Bldg. Permit No.
&aL 2 6
IT MAY CONCERN:
The sewage disposal facilities for a structure
'- (Give deed location) /
located
have been inspected by this department and found to be satisfactory.
~ Dis t°rict Engineer
Z
FORI~ NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N. Y.
Approved/~'/ ~ , 19....~..~.. Permit No...~..~.....~....~../.......~
App'icot,on No..?.g.'2....ff .........
D~sapproved ~,
APPLICATION FOR BUILDING PERMIT
Date ........................ J~[~..~.~ .................. , 19...6.~ ......
INSTRUCTIONS
a. This applicatio6 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 thisapplication, the Building Inspector will issue o 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 shell be occupied or used in whole or in part for any purpose whatever until a Certificate of Occupancy
shell hove 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, end 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.
Original Suffolk Builders Carp,
(Signature of applicant, or nome, if a corporation)
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engi'neer, general contractor, electrician, plumber or builder.
............................................................................ ......................................................................................................
Name of owner of premises ..~.o.~.,_L~...~.~.c]...~?.g~..r.e.~...~.?....~...g.a...h.-~ ......................................................................................
If applicgnt is a corporaJ'e, sig.~a~,re--of duly authorized officer. '
(Name and title of corporate officer)
1. Location of land on which proposed work will be done~ Map No.: ..D.~.~..o.~.b.?.~..~.o.~.e.~..~... Lot No.: ........................
Street and Number .... ~/.~.~.~.~9~.~.9..~.9~.~:~.b~.~.~.~..~?.~.~:~.d.~?.~.~.~...~.e.;~:~.e.].~.~.~:~:!~:~.: ................
Municipality
2. State existing use and occupancy of premises o~d inter~ded use a~-d occupancy of proposed construction:
a. J~xJsting use and occupancy .................~.o.g.~. ..........................................................................................................
b. Intended use and occupancy One farmily residence.
3. Nature of work (check which applicable): New Building ..... ..X. .......... Addition .................. Alteration ..................
Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................
4. Estimated Cost $18~000.00 Fee $~L0o00
(to be paid on filing this application)
5. If dwelling, number of dwelling units .~..?.9~...*...~..~.°..°..m..~Number of dwelling units on each floor ......3: .....................
If garage, number of cars 2 Car attached
6. If business, comrnercial or mixed occupancy, specify nature and extent of each type of use ............................
7. Dimensions of existing structures, if any: Front ....... .N..o..n.?. ............. Rear ' Depth ....................
Height ........................ Number of Stories .................................................................................................................
Dimensions of same structure with alterations or additions: Front None Rear
Depth ................................ Height ............................ Number of Stories ................................
8. Dimensions of entire new construction: Front 60~ 60t
.................................... Rear ............................ Depth 30-37
Height 1St Number of Stories i story
9. Size of lot: Front ..... .3:~ ................. Rear ..... .1..?? ......................... Depth ....,1.~ ......................
10. Date of Purchase ....... ~.i. .1.. ..3:..9..6. ?. ............................. Name of Former Owner ........................................................
1 l Zone or use district in which premises are situated 'A" t~esident.
12. Does proposed construchon wolate any zomng law, ordinance or regular on. ..N.o .........................................
Nome of Owner of rem ses John ~unch A r 139 Wellington Rd. G~rden City. ""
13. p ' · ....................................... dd ess ............................................ Phone No......N.c.. ............
Name of Architect .~?./~.e..n...c..e..,I?...a...n~. ......................... Address Ix!e~ ~'ork O'ity~ No¥o Phone No. No
Name of Contractor Q.ri.E~i...n..a..~..,S.~..f..f.9,,,lk....B.~..d~..~,..g..o.~ddressl.0.,~2...B..~.9.w...n.~..~t...~.~.~qg.~.~hone No. AriS-2120
PLOT DIAGRAM
Locate clearly end 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 YORK, l c¢
COtJNTY OF ............................. :.~ ....
................ :...;...:.~..1..1.~.~.....L..o..n..~.b..o..a.}.....:.: ....................... '~.i.'..bein~' duly sworn, d/~poses and says that he is the applicant
(Name of individual signing application)
abow.~ named. He is the Contractor - Corporate Officer
(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 i~n this application ar._e 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 befo~'e me this ~ ,~ ~ ~
............ of
................. ...................................
Notary Public, ....~.~~../.....~..~ (Signature/~f applicant)