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Home My WebLink About5655-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte Of Occupnncy No. ~.0.0. ...... Date ............... J..1~..~...~ ...., 19. ?~. THIS CERTIFIES that the building located at ...Fx'e~. Av.e ............ Street Map NoGarderA. Rtz. Block No ........... Lot No...~.~.~4~ .... ~a~;~;l~i~ck...]~,Y.°.. conforms substantially to the Application for Building Permit heretofore filed in this office dated .......... Dee ..... 6..., 19.?$. pursuant to which Building Permit No.. dated ........... Dec... 6 .... , 19.7.1., 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 .. P.3rivate. one .family. c~welling ...................................... The certificate is issued to . Thcs .. F~ ....... 0~nez, ............................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .. Pendin~ .(R.~/:l. lla~ .............. UNDERWRIT£RS CERTIFICATE No.. ~ .1~17~... ~apt...l.~ ..... 1.972 ................. HOUSE NUMBER...~$~ ....... Street ....~-~e$laa~..A~'~e .............................. Building Inspector / FORM 'NO. 2 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE $OUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) NV 5655 Z Permission is hereby granted to: to pursuan,t to application dated ,...' .................... ~JJil~jJ ....... ~J ............. '.t",, 19.... ,~.., and approved by the Building Inspector. Fee $..,.~10~ ....... INCLLJDt-'~ t-, __,,,. eXCESS FILL CONS t ¢ jCTION vuilding mspector J FOP/~ NO. $ TOWN OF $OUTHOLD Building Department Town Clerks Office Southold, N. Y. 11971 AFFLIGATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted in duplicate to the Building inspector with the following; for new buildings or new us~: 1. Final survey of property with accurate location of all ~uildings, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewerage disposal--(S-9 form or equal). 3. Approval of electrical installaton from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple ReSidences and similar buildings and installations, a certificate of Code compliance from the rArchitect Or Engineer responsible for the building. 5.Submit Planning Board approval of completed site plan requirements where applicable. B. For existing buildings (prior to April 1957), Non-conforming u~es, or buildings and ' pre-ex'sting" land uses: 1. Accurate survey of property showing all property lines, streets, buildings and unusual, natural or topographic features. 2. Sworn statement of owner or previous owner as to use, o~cupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildin~js or premises, or other pertinent in- formation required to prepare a certificate. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use' $5.00 3. Copy of certificate of occupancy $1.00 ~' /~ //~../7_ Date ................................... New Building ...~ ............ Old or Pre-existing Building ................. ~ .......... Vacant Land ............................ o, ..................... Owner Or ~ners Of Property ...~..~...~, ....... Z~ ...... ~ ............................................................. Subdivision ~C~z~r~....(~.,~ ............. Lot No~¢~Block No....~.....r~ouse Permit No.~.~.~ Date Of Perm,t/~Z]Z~..Appl,cant Health Dept. Approval .... f~. ........ ' ......... .~ .............. k~bor Dept. Approval ........... ~...~ ......................... Underwriters Approval ........ ~i/..:~.Z~. ................ Planning Boar~ Approval .... ~..~.~- ......................... Request For Tempora~ ~ificate ........................................ Final Certificate .......~ ................. Fee Submitted $ ~..;::~] .......... Construction on above described building and permit meets all a~plicable c~es and regulations ....... ............................... Sworn to before me this ................ day of ............................................ (stamp or seal) Nota~ Public .................................... County SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D.Reference No APPLICATION FOR APPROVAL.TO CONSTRUCT PRIVATE S .EWAGE DIS~AL SYSTEMS Address ' ~-Se0tion 2-Detailed property location 8-Lot No. 'i Hamlet A,//-~~ ~'7~xd~' ' Town P-Private well? 3-Public water supply name , ' DistaNce to nearest main 4-Lot Size: Width /l/6) ft. Length ,/~,~ ft. (also enter bn center plot plan below:) 5-Dwelling: Singl~ 'Family ~ Two Family? ~JCellar? ~.Slab? / ICrawl S~ce? lO-Pressed system: Septic tank ~ ~Preca~t ~Cesspo~l~ ~ /Shallo~pools ~Other ii-Septic ta~ inside d~mensions: Volvo ~Gals.Lengt~ft. Width ~.ft. Li~ui~ depth ~ ft. 12-Precast sections. ~Number~Square Ft. Cesspoola~ Block sizeL/~.incs.~ins. H ~ns. Total blocks below inlet. ~1~2~ ~3 ~ ~ '' PLOT PLAN Ta~ Ca~c~ty ~)~als. ~e m,~ Street ~ ,~t'l~ ~, . ~ ~ ~ Indi e The Undersigned CERTIF~S: "Construction of authorized inst~llation~ will be in accordance with the Suffolk County Health De~rtments' cur ~ent Stan8a~s, Bulletins, amendments thereto, covering Private~~ S~wage ~posal S 'stems". Date 7 ~/ Signed ' <%~r or Builder FOR ~ALTH DEPART~NT USE ONLY. Based on the info~a~ion ~r~sented~here~h, it is the opinion of the Health De~rtment, that an adequate and sat~sfacto~ Se~ge Disposal System can be installed on this Plot. Date (10/65 Revis.) S-15 TOWH oF . BUILDING DEFA~TMENT~ ~ ~ ( ~ ~ TOWN CLERK'S OFFICE ~y~,~ ~ ~,'1~ ~ ~ ~UTHOLD, ~. ~. ~ ~t~ .......... ................... ................................................................ ............. ~~~;-i;~g~ .............. ~"[3 ........... ...... INSTRUCTIONS This application must be completely filled in by ~pewriter or in ink and submitted in duplicate 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 ofproper~ must be drawn on the diagram which is ~ of this applicatiom c. The work covered by this application may not be comme~ed before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such permi shall be kept on the premises available for inspection throughout the profess of the work. e. No building shall be ~cupied or u~d in whole or in pa~ for gny pu~ose whoever until a Ce~ificate of ~cupancy shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Deportment for the issuance of o 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, os herein described. The applicant agrees to comply with all applicable lows, ordinances, building code, housing code, and regulations. (Signature of applicant, or nome, if o corporation) (Address of applicant) If applicant is a corporate, signature of duly authorized officer. T~ ~/~ .................. i~a;"i'r;~i"ii~'~';"gF~;'~;;';a'i;';;¥ii;;';i ......... /--- ~7 7 1. Location of lond on which,,_l~,,r~op_9~sed worl~ will be, done. MapNo.:. .. LotNo ....... Street ond Number .................................................................................................................................. ~ ~ Municipal 2. ~State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy ..................................................................................... b. Intended use and occupancy ..................................... :~.......~ ................ ~ ........... , ...................................... , 3. Nature of work (check which applicable): New Building ...~... .......... A~klition .................. Alteration .................. Repair .................. I~moval .................. Demolition .................. Other Work (Describe) ....................................... 4. Estimated Cost ....... ..~..J..~/~..~....~. ................................... Fee .[..0....~. .......................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units .......... J. ................ 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 ................ Depth ..~...~... ............. Height .................... Number of Stories ............/ ...................................................................... 9. Size of lot: Front ......../..~...O. ............. Rear .................................... Depth ......... ./..~... ................ 10. Date of Purchase ........................................................ Name of Former Owner ........................................................ 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation? .....~.l~. ........................ 13. Name of Owner of premises ..~....~ ......... Address .............. ~ ............................. Phone No.....'~ ............... · Name of Architect ....~..~.~,~.~ ...........................Address ...~,~.1~.....~.~.~ .......... Phone No. ~.~.:~1/../ ..... Name of Contractor .................................................... 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 comer lot. STATE OF NEW' YORK, COUNTY Of ...... .~.~.~.~../~ IK ....... ~o.~ ........................ ....~J~L~C~...~.~,~ ....................................... being duly sworn, deposes and' says that he is the applicant (Name of individual signing application) above named. He is the ....................................................................... [)~J.~t~.~J~ .............................................. (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 end 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 therewitl],,.--,, Sworn to before me this .......... ~, ........... ~o~..'g~..~ ................ , ~.....~. -~ . ~'_ ( ~ ..), Notary Pubhc, . k/~.. 0.,~JA~l:~'~,,gunty (Signature of applicant) DORI~J. GLA~EMANN Notary PubJic, Stole of N~w Yor~ No. 52-6534085 Qualified in Suffolk County ,i iJ, FL_-, 1 I_;;;N t LW~IBER ~ET