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Home My WebLink About4721-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at . F~m~. I~ .&. ~l~ &~Street Map No..F,a~. Block No. Bee. ZX.. Lot No. ~ .... ~at, ehe~lo .... II,]~, ...... conforms substantially to the Application for Building Permit heretofore filed in this office dated ....-:~ .... &]~l*l.1... ~., 19. '~0 pursuant to which Building Permit No. I~1~. dated.. ......... &I~FIJ. 2'~.. , 19.~, was issued, and conforms to all of the reqmre- ments of the applicable provisions of the law. The occupancy for which this certificate is issued is .P~l~ate. ~m. fantl~..dve~ ....................................... The certificate is issued to ...lla&'Old. ~ObeF. ..... OVlleF ........................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval &~' · '~t' 'q~" .by. R, .V~ .... ...... Building Inspector Approved ........................................ , 19 ........ Permit No............~'/ · ow. oFSOuT.OLD BUILDING DJ~PARTMENT~ ~ ~~' % TOWN CLERK'S OFFICE ~ ~TH~D, N.Y. ~ ~; / . ~. ~ mm,an ....... Disapproved a/c .............. · 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, relationshi to ad'oin n rem sas or ubl'c 'r ' ~ areas, and giving a detailed description of layout of praperty must be drawn on th~diagr~m w~c~ is port of fl~is ap~ice~o~r.~ c. The work covered by this application may not be commenced before issuance of Building Permit. I'q~ 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. ~t Bu~PiPnLICATION IS HEREBY MADE to the Building Department for the issuance of a Bu Id ng Permit pureuant to the~ · d' g 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 remova or demolition, as herein descr bed The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations. (Signoture of applicant, or name, if a corporation) (Address of applicant) State whether applicant is pwner, I,~ssee, agent, architect, engineer, general contractor, electrician, plumber or builder. Name of owner of prem sas..~~ ~. ~. ,~.... ~.'iiiii iiiiiiiiiiii .............. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) 1. Locatonof and on whi_.ch/prapoeed work w bedone MapNo.: ....~,.....'~.. ! 0 LotNo' ~* .~. 2, StYe eXi~ing use and ~cu~ncy of premiss Qnd intended use and ~cu~n~ of p~ can~mcti~: a. ~,i,g ~,,n~ ~,~ .~.A.S ~ ~ ~. ................................ ~. ~,t,~ed ,se ~n~ ~,po,~ ................ P.~..~..E..&..~ ........ ~.~.E.6. ...... 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration .................. Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................ 4. Estimated Coat ...........¢ ............................................... ~ee ........... i~'~"l~"~i~"~'n filing this a'l~'l'i'~i~r~i .................. 5. If dwelling, number of dwelling units ........ .J~...~...~ ...... Number of dwelling units on each floor ............................ If garage, number of ............................................................. ~ ............................. ~.. ..................... 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 ...~..~..~.~.~...t.~ ............ Rear.....~.......... Height '~' '~ I Number of Stories 9. Size of lot: Front ........~....°.....~T.. .......... Rear.~ ........ ..~...I...~.. ................. Depth ............................... 10. Date of Purchase ,~'/'~ ~0 ' ............................ J..~. ....................... Name of Former Owner .~..~....~....~.'.~.~/.(.~. .......... ~..~....~...~....7~.. .... 11. Zone or use district in which premises are situated ................................................. 12. Does proposed construction violate any zoninn aw ord nonce or renu at on? ~ ........................................... Name of Architect ...................................................... Address ............................................ Phone No ..................... Nome of Contractor ~...~..~.....~....~..~...C.........~....d....~..~. ......... Address ...4J~ ........................... .~...~..~-Phone No?.....7..-....7../../.../.. 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 i~terior or corner lot. STATE Of NEW YOR.K4 ' -- IS3 COUNTY OF ...... ~'...u.j,~.~.~.~.....~, · ........................................................................................... =mng duly deposes and says that he is the applicant (Name of individual signing application) above named. He is the ................ .~.....o...~.....-~...~... 14 ..c....~..o...~... . (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 app cat on are,true to the best of his/fFnowledge and belief; and that the work will be performed in the manner set forth in the opplicaf/l',6n f ed therewith. Sworn to .beJ~ore me this J/ /2 ,~ // ...... ~--...~. ..........~ day of ..... , o _ Notary Public,.~° ~~-i C~;~'~,~ ..... ~a-~"t~;"~'t~'~'~;)'')'' '''~'''' .................... ' J~IOTARY PUBLIC, State of New York No, 52-8125850, Suffolk Cou~y,, ~rm jT, xpires March 30, 19~_~ $-9 SCHD SUFFOLK COUNTY DEPARTMENT Date Bldg. HEALTH Permit No. TO WHOM IT MAY CONCERN: at The sewage disposal facilities for a structure located ~/ (Give deed location) J 'be~s been inspected by this department and found to atisfactory. 1970 D~strict Engineer SUFFOLK COUNTY DEPARTMENT OF HEALTH ~ EASTERN DISTRICT, RIVERHEADi, N.Y. APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DIS~O~AL SYSTEMS V- ~ ~proval {o construct sa{~ Systems is requested,pertinent ~ata herewith: Date / .,~ Add e ~7~f . - , ~ - ~ ~ <~ ~W~~ ~~ ~-rr~va~ well? ~-~blic ~%er supply na~ Distance ~o eae ~in 8-Lo% Size: Width ft. Length ft. (al¢o ente~ on cen%e~ plot plan below:) 5_Dwelling: Single Family 10-Proposed system: Septic tank l~-Septlc tank inside dimensions: Volume Gals.Length ft. W%dth' ,ft. Liquid. depth 12.Precast sections: ~_./Number/ /Square Ft. Cesspool~: Block sizeL__incs. D ins. H Total blocks below inlet: PLOT PLAN / / / ins. Capa cit~'~Gals. G.P.M. ~ .... ~ Indi , ~' No. The Undersigned CERTIF~S: "Construction of authorized installations will be in accordance with the Suffolk County Health De~rtments' c~rrent Standards, Bulletins, and amendments thereto, covering Private Sewage DisposaliiSystems". - ' ........ Owner or ~, Builder FOR HEALTH DE~RTMENT ~E ONLY. Based on the informatio]n presented herewith, it is the opinion of the Health Department, that an adequate and ~tisfactory Sewage Disposal System can be installed on this Plot. Signed (.10/65 Revis.) Data ~eet - oP ~ 2 6 8 i0 ~ :[8 .APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS INSTRUCTIONS: Applications m~st be submitted in triplicate i-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 ~-.Enter name of Public Water Supply District, together with the distance to their main. 4-.Enter Length and Width of Lot under appropriate heading, also enter theee dimensions on center plot plan shown on the face of this application.. 5-Dwellings: Check-mark "V" items applicable to the proposed new dwelling. 6-Name of sub-division 7-Section Number S-Lot ~umber 9-Private well: Enter "No" if Public water supply is available. Enter "Yes" otherwise. PROPOSED SYSTEMS: Answers to Items number 10, 11, & 12 please consult the Suffolk County Health 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 IPLAN:r The following information is required concerning the Applicant's Lot: ~LOt ~izeTLength 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 this application. S~rfac~ waters-Streams, Lakes, & Bays, etc., located within a distance of 50 i feet of Applicant's LOt lines, must be shown on the plot plan also. W'~ells and Cesspools now on adjacent lots must be shown on the Plot Plan together with the distance to the Applicants proposed Sewage Disposal Systems and Well.) Where no Buildings exist on adjacent lots, state "Vacant" on the plot plan. Streets adjoining applicant's lot to the right, left or rear, enter street name. WE.__LL LOCATION: To locate the well & sewage disposal systems on Applicant's lot, the following Standards must be observed: Well-100 feet minimum distance from the nearest cesspools Well-25 feet minimum distance from rear, and rear sides of property lines Well-10 feet ~inimum 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-4 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 of 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 12 feet minimum distance from nearest water line Cesspool "Center" must be 15 feet from house foundation Cesspool exterior must be 50 feet minimum distance from surface Waters, Streams, Lakes & Bays, etc. Cesspools must be 20 feet minimum distance from large trees Cesspool center to Cesspool center must be at least 16 feet Cesspool cover top to grade must be held to minimum of I food to maximum of 2 feet Bottom of Cesspool to ground water most be held to minimum of i foot · )ii 1 \ PLAb-~