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Home My WebLink About5584-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy THIS CERTIFIES that the building located at . [}/8' l~alFat~ew .,t,~ ........ Street Map No. 811~1" R~I~ Block No ........... Lot No. ¶~.I~. i,¶ ~l'?'' GTc~ellp~lq; ' ' }I i]f ~'- conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ 0e~; .... 1.9 19.71. pursuant to which Building Permit No. dated ........... 0~/' ' '26' '" 19' ~?1" 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 .. Pl'iVtt%'~ ' 6i~ia' ' £&~':l.'l,~- ' ak'~ Il. ~,-qg ...................................... The certificate is issued to . .l~,~ene./,.i .¢otala~ ...... 0~rtl®l, ........................ (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval ' '/l'l~ "12' 't'972' l~lr' R¥ 't[~1~[~ .... UNDERWRITERS CERTIFICATE No... ~ .2~14; ...................................... HOUSE NUMBER... '['ll.~O ..... Street' ' '~t&~-'~'~.~'~' ~"~1[I ................................. Building Inspector FOI~M 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? 5584 Z Permission is hereby granted to: !~,~,...~....e~.e...~.....~...J...~..~.....~m ............ l.$39....w...ll~l~.~t ............................. to .. J,j~...~m.. ,e~ .. f.e~l,~...J~l,J.l~ ................................................................................. at premises located at ...... ~*dJ.~JlJ,..J..~,J~.....,t~.JJJ.....~ll~JJ~J~JM~lJL~l~JJ ....................................................... ..................................... ~.J."J.....J~....T.I~...~.'~ .............. .I/~,~ ................................................ pursua~t to application dated ................................. ~ ......... J~....., 19..~IL"J., and approved by the Building Inspector. S-9 SCHD SUFFOLK COUNTY DEPARTMENT OF HEALTH Date ~.~.~_ /~ Bldg. Permit No, TO WHOM 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. 'ctUN 1 2 1972 /,5'0.0 q /FUGELIE,.4. ~ /EL THE4 K SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D. Reference WESTERN DISTRICT, COMMACK, N. Y. APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Approval to construct said systems is requested,pertinent data herewith: Date i-Applicant da,,,/~ ,,-t' , J~ I P ~ ~ Phone~_%J.~Sub div~_,: ./; Address mi ~'9 %"/. mmA~~ ~'~' I~,~,~-,~ ,~ ?, ?-Section ~,~ ':,~% 2-Detailed property location &'/~ ;~ ~, ~ ~, ~:~ 8-Lot No. ,,/,~ - Hamlet~[,~,~ ,~,,~,,,~ e ~, ~ Towh (,.,¢~ ~ ~ 9-Private well? 3-Public 'water Supply nam6 ~ # ~ '' Distance to nearest main ~-Lot Size~ Width_~ft. Len~t~l_~.~_ft. (also enter on center plot plan below:) ~-Dwellin~. Single Family ~ Two' ~amlly? / /Cellar? ~,'; Slab? ; ~ Crawl Space? lO-Proposed system: Septic tank ~ /Precast ~ /Cesspools"~-~/Shallow pools / /Other ~_/ ii-Septic tank inside dimensions: Volume Gals.Length f{. Width ft. Liquid depth_.__ft. 12-Preoast sections: / /.Number~_/Square-~. Cesspools: Block sizeL~_~_incs. D ~ insoH_~_ins. Total blocks below inlet. ~1~2~3____ PLOT PLAN 'ad~ Capacity ~ls. G.P.M. ~ Street ;ate -th Data ~eet 0 2 4 6 8 10 12 14 ~6 Ind~ The Undersigned CERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Health Departments' current Standards, Bulletins, and amendments thereto, covering PrivateSew~e Disposal Systems". Da t ~_~%~ Signed~~ ~ or Builder FOR HEALTH DEPARTMENT 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. Date (10/65 Revis.) S-15W Signed ~ ~ ~ 'r~ APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS INSTRUCTIONS: Applications must be submitted in triplicate 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 N~mlet/Village & Township 3-Enter name of Public Water Supply District, together with the distance to their main. ~-Enter Length and Width of Lot under appropriate heading, also enter these 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 8-Lot Number 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 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 this application. Surface waters-Streams, Lakes, & Bays, etc., located within a distance of 50 feet of Applicant'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 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. WELL 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 minimum distance from front, and front sides of property lines Well-50 feet minimum below grade for well point Well-DJ) 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 1 food to maximum of 2 feet Bottom of Cesspool to ground water must be held to minimum of 1 foot Approved ........................................ , 19 ........ Permit No. .. ~ ~-/--~_,~ ~ Disapproved a/c ......... ~ .................................................... APPLICATION FOR BUILDING PIRMrt .,~ Dat. ........................ ~,.Z.Z,,,, 19. ,~.~. ..... ~ INSTRUCTIONS o. This oppllcation must be completely filled In by typewriter or In Ink ond submitted In duplicate to the Building Inspector. b. Plot .pi.an sho.w!nj;I I,oc.ation. of lot .o.nd of buildings on premises, relationship to adjoining premiere or public streets or areas, a_,na giving a acta,ca aescnptlon or layout eT property must be drawn on the diagram which c. ina work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building nspector w I hue a Building Perm t to the applicant. Such perm t shall be kept on the premises available for Inspection t]~raughout the progress of the work. e. No building shall be occupied or used In whole ar In part for any purpose whatever until o Certificate of Occupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the Issuance of a Bud ng Permit punwant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, end other applicable Lawl, Ordinances or Regulations, for the construction of buildings0 additions or alterations, or for removal or demo t on, as herein described. The applicant agrees to comply with all gpl~llcable laws, ordinances, building code, housing code, and regulations. ...... / (SlgnlJi~ure cf applicant, or name, If a comoratlon) ........ /. ,/,~,,,,9. ....... .. ,~,.,',,...,.,~.,~,~,i~.,,.~., ,T., .................... ~/aapll¢ont) State whether aapllcant Is owner, leflee, agent, architect, engineer, general contractor, electrician, I~lumber or builder. of own.r of .......... ,f opp.,c.., ,..co.orate. signature of duly authorized officer. ................................................................................................ '~ /~ (Name and title 'of corporate officer) //~. 1. Location of land on Which praposed work will be done, Map No,: ....... ~.(.,(t~,. ..................... Lot No.: .,,/.~',.~.. .............. Street and Number ..~. ..... ~... ~. ......... /..~.~.......~./.'~. .... . v / ,/~-o /f Mu.:c,~.,~ C7" ": ........ 2. State existing use and occupancy of premises and Intended use and occupancy of prapo~ed comtmctlon: a. Existing use and occupancy ,,.., ....................... u .............................. ~ ................................................................... b. Intended Use and 3. Nature of work (check which applicable): New Building ~....~. ........ Addition .................. Alteration .................. Repair .................. Removal .................. Demolition .................. Other Work (Describe) ........................................ ....... ~...~.~:?.....O.. ................................. Fee .......................................................................................... 4. Estimated Cost (to be paid on fi~ing this application) 5. 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~ speci~ 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 ....~....Z.:.~...~..~.... Depth ~-..~..~....~. ..... Height ..../~....~. ...... Number of Stories ........... ~'.. ........................................................................................................ 9. Size of lot: Front ...... /..~...~.. .......... Rear ............ /...~....~. ............. Depth ........ /..u~.....O. ............ 10. Date of Purchase ......... ~.l...,~.~.....~.../. ..................... Name of Former Owner ..~.~......4~,~..-~.~,~.~..~..?~1~ ......... ! 1. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation2 ....... .,_ ._': _ 13. Name of Owner of premises ...~..~...~'~..~.....~..~..~.~:414Addmss .~..~...~..~J~ ~..~'....~.£ ....... Phone NO'. .................. .7 Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor .,~......@..~fL4~..~..~........./J.,~./,~.~,$.Addmss .~,~..~.....~....~.~./.~.~Phone No.~....~.?..:../.~..~. PLOT DIAGRAM Locate clearly and distinctly oll 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 comer lot. I STATE OF NEW YORK, tee COUNTY OF ................................ ....... · .~.~../~;.~.....~...~.~.....~.~.~.-~.....~...~.....~.. .................... being duly sworn, deposes and says that he is the applicant (Name of individual signing application) above named. He is the ....~....~....~..~..,~.~..~..~..~..4~. ....... ; ........................................... '~; ....................................................... (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 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. Swam to before me this ..... oo, ..... ........... Y ......... Cou ty y (Slgnature of applicant) U ................ Notar7 Public, ......... ~~... 'n'' ~''~''~'' ~'"*'~/'~"/' ' 7-ROIVT EZ EK,~ T/O/V .S c ,~ i- E - , y~ =.-.. -'" CItE ELEi4,4?/O/V EL Eli,4 T/ON ,PLUMB lNG .... f~l~/-/F ,SIDE col / 7~- -L_