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Home My WebLink About5195-zFORM TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. ~4'36~t Date A~g 26 19. THIS CERTIFIES that the building located at . ~0n~n?t.t.. p..a~... ~ ...... Street Map No.~.*..~.. Block No ........... Lot No. ~ ...... ~k...~Y.* ........ conforms substantially to the Application for Building Permit heretofore filed in this office dated .......... ~e~ ... ~., 19.~. pursuant to which Building Permit No.. dated .......... ~ ...~.., 19.~., 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 . .Pr~6~..~. ~ .dW*.~g ...................................... The certificate is issued to ~e~ .SV~ ..... ~e~ ............................... (owner, lessee or tenant) _ of the aforesaid building. H0~ deek to ~ e~pleted ~der pe~it Suffolk County Department of Health Approval . .~...~,..~...b~. ~. V~... House ~ .... ........... Building Inspect~ T~VN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PER~IT CFHIS PERMIT MUST BE KEPT ON TH~- PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 5195 Z Building InSPe~:tor. Fee SJ.. ........ ;.;.,~ ...... · ' Building I.n_sp~ $-9 SCHD SUFFOLK COUNTY DEPARTMENT OF HEALTH Date TO WHOM IT MAY CONCERN: ~.Q The sewage disposal facilities, f~ r a structure located ~' /~ (Give deed location) have been inspected by this department and found to be satisfactory. Chief of General Eagineoring Services SUFFOLK COUNTY DEPARTMEN~OF HEALTH H.D. Reference No~O-~ ~ EASTERN DISTRICT, RIVERHEAD,N.Y. APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Date Approval to construct said systems is requested,pertinent data herewith: . 1-Applicant ~,L-~< 0~ Phone ~-~6-Sub div ~,w,~,.~$ Address ~,~,~ ~ ~,~Y~..~ 7-Section 2-Detailed property location ~a~w~.~'l'~ ~o~ ~ ~ 8-Lot No. Hamlet ~ ~4 ~--~x To~ ~ ~ ~ u ~ 9-Private well? 3-~blic ~ter supply_name Distance to nearest ~in 4-Lot Size: Width/~ ft. Leith ~j~t. (also enter on,enter plot plan below:) 5-~elling: Single Family ~w~ Two Family? ~ /Cellar? ~Slab? ~Crawl S~ce? lO-Pressed system: Septic tank ~ /Precast y /Cesspools ~Shallow pools Y /Other/./ il-Septic ta~ inside dimensions: Vol~e Gals.Length. ft. Width ft. Liquid depth ft. 12-Precast sections: ~ /Number/ /Sq~re Ft. Cesspools: Block stze~incs.D {ins. H ~ns. Total blocks below inlet: $i/~ $2 ~OT P~N ~%o ~ O.~ pacity k~als. iP. M. ,] 5- 0 ~0 I o ~ fade , -- Ind~ ~:thte Data ~ee~ 0 2 4 6 8 10 ~2 14 No 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". Date ,7/~,~ ~. ~¢~t Signed /~.//~,~5 H~,~.:~ /~¢ ~:~-~--~-~ Owner 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 ~/~/~/ Signed ~ (10/65 Revis.) V111811 QUII AI~LICATIOH FOR IUILI)I#~ IIIMIT INSTRUCTIONS ~ cl. Thil aPPlicQtim must be c~mpletely filled in by typewriter or in Ink end submitted in duplicate to the BulldinG ~~' Impect~. b. PI.M .plan ~ ~_b~?io~. ~ Io4' ~ of IxJ.iklbtgl an pre.mills( relaflem~lp to ~djoiflin~ pmm~ll m' public ~b~ts M ~ ureas, arm g~ng a ammma owcnlman of layout ot pmlxrty must oe arawn on thi diagram wh'ic~ it ~ M ~ al~llcatkm. .h~i~' ue~- c~p..,~ o~ ~. ,~.? .~.q. ~, ~ e.~k, no tap,to,' .w,~ ~ue. eu~unO Permit to ~ ap~icant. Sue, ~.n,,, ~ De ~ on m~ premmel ava,aOle for im~NCtl~n threughout the proOrell M the Work. e. No budding ihall be occupied or used In whole or In port for Qny IOUrPQM whatever until a CefflficMe of ~ ~. ~holl have bien granted by the Building Inspector. · , .A.?.PLI.CATIO_N .?S HEREI~.Y.A,4A_DE to .the. B.u, lld. l.ng..Dflx~.rtm~ent.for, the .lu ,uenc, ,of ,e Bulldln~ Permit Wmm~t to the ~. ,~u,e!n~l./oe~. o~.. InO~ o1' _m.e 17 .ot..aoumo.klL.~uttolK ~ou~?/ rd~w 'rom, Gna .omer Ol~lid, oble L. ew~ Oedinonc~ M ~ .~l~U~mT ..mm, ?or t~ .c~mtmcti? m'...~u~..~llngS) m~..Itl.One or alterotmnl, or ?or r~movol or demolition, M h~Mn dlm:rlbed. "' opO,¢ant ogr~ to comply wire Q, oppllCeDle lava, ordlnoncN, building co~0 houllrl0 co~, ~ i~0uIotio~L lVlunlcll~llfy 2. Sfote exllflng uM Ulmncy of pmmlm and Intlmbd u# and occupancy of prc:pa~d coflltKictkm: 3. Nature of work (check which applicable): uilding ........ Addition .................. Alteration .................. Repair .................. Removal .................. Demo t on ..... Other Work (Describe) ........................................ 4. Estimated Cost ....... ..~/..~..~...o...O....O.. ......................... ; ....... Fee .......................................................................................... (to be paid on fi~ing this application) 5. If dwelllng, number of dwelling units ....... ...~... ............... 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 ..... /.....~... .............. Rear ....... ~.,~..,~....~ ............... Depth ~..°..~..~..~.....'T...~...~.~/.~-- 10. Date of Purchase ...~..~-...~........~.~. Nome of Former Owner ....................... ,. ,, ................... 11. Zone or use district in which premises are situated ../~.~.....~ ............................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation? ............................................................ 13. Name of Owner of premises .~.~.~....~....I~'..~...A/...~.....Address .../~...~.~..~..~.~.~.~...~...x:.~.~..~..~Phone No. ~..~.2:.~..~...~../ Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor .~.~...~...~....D...~.~..~.......~....~...c.~.~..~.~..Address ~o..J.~F..#...~/..../..~I~...E....~.~...u..'~.[.....~z'~p. hone No?..~...5.-.-..~..~...~... PLOT DIAGRAM Locate clearly and distinctly a~l 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 ~'~1~,,~ COUNTY OF .,...'-~,d~fd, i~ .......... )'.~'~' .................. ................. be,ng du,..war., dep e, and sa....t h. ,. 'he opp,,con, (~16me of individual signing ap~icatiom above named. He is the ................................ ~ ................................ '~; ....................................................... (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 .... ~...... day of ...... ~ Notary Pu blic~JJ~.. ~.,~.~. ][LIZABETu I~OTARy PUBLIC, N0. 52-8125~50 ~erm Expires ~ le ~f ~ew York uffolk Counh~ ,