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Home My WebLink About5323-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No...Z. ~+..(~... Date ........ ~.eptegl~.~r. ~.~ .... , 1~.3.. THIS CERTIFIES that the building located at . ~llg. ¢l~.~tet~. l~.~,Ve ........ Street Map No. ~eP41e~t.t .l~l~k No. Y~X ....... Lot No. L~ ............................... conforms substantially to the Application for Building Permit heretofore filed in this office dated ........ ~ .25! ...... , 19.7.1. pursuant to which Building Permit No.. dated ........ l~ty..215~ ......., 19.?1., was issued, and conforms to all of the require- · merits of the applicable provisions of the law. The occupancy for which this certificate is issued is . .t~.v.a.$.e..o~.e.. ~.a4~y..d~f~.~l,~g ....................................... The certificate is issued to . .R.o..1~..~.~...L.~...Bq.g.e~. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval D~.t.q~.-f[e_~.$~..1~,~. ~.7.~. R.,..¥$..]~.... UNDERWRITERS CERTIFICATE No. HOUSE NUMBER.3~~ ......... Street. 1,0.~ Cve ...................................... . .S0.ut. ........................ Braiding Inspector FO~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT OH THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 5323 Z Permission is hereby granted to: .......... le....,ameaee..;~aee~ ............................ to ..... ...~g~.. ~...eRS...~'~Z..~MJ.~4 ............................................................................... at premises located at ........... .~,~lr,..~& ......... .~&I~4144dl, g..~ ...................................................... ............................................... &eeC.. 4;a~l~ ..~ ..~.~..aee4 .............. leMIm~ .................. pursuant to application dated ................................... ~ ....... ~....., 19~.S..., and approved by the I~uilding Inspector. SUFFOIX COUNTY DEPARTMF~T OF HEALTH H.D.Ref. No. APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE iDIsPOSAL AND WATER SUPPLY SYSTEMS Inspection for approval is requested, pertinent [installation data herewith. 1-Name of Owner ./~e~£~ / ~_, Address ~ /_~/~-- ~:,~,.~¢~ ?~C/~ Phone Address ?-Sewage Sys~ installed by~.~,, CA~-.~/~ ;~cC, Address ~: ~z~;~-, ~ /. 8-(a)Deed location of property (b)H~let or Village. ~ 9-Septic tank-Gal L ft.W it.Liquid Depth ft. lO-Cesspools-(a)No.pools ~(b)Blocks below inlet-l) 2) . 3)__ (c)Block size-L in.W in.H in. Id)PreteSt pool ~ (e)l__2 3__ (f)H ft. _ in; Di~ ~.__in.(g)F nisbed g~rade to cover SA ft. (h)Backfill Material . ll-Water Supply: Public Syst~C~;C~ If Private, the following questions are to be answered: 12-Private Water Supply System installed by ~ Phone Address l~('a~-Total Depth of Well 14-Diameter of well pipe ~5-Name of LaboratorM 17-Date ready for inspection (b)Depth to static water Level in, 16-Method o~ Disinfection 5-Lot Number ~z~. 6-Bldg.Permit No. ~ Phone The undersigned CERTIFIES: Above system~ have been constructed and are in compliance with the Suffolk County Health Department's c:rrent Standards, Bulletins and Amendments 18-Date ~j~f $ ' Signed ~ ..... ' !~ner - Build~ M-Inse~t~ sketch of location of Water & Sewerage FaCilities with accurate dimensions. STREET ~ .~OR~LTH DEPONENT USE O~LY ~I../_. Based upon the iulomation stated above, s~tisfacto'rf fun~tioning of the above systems can be expected ~ich proper maintenance ~nd care. Chief of ~eneral ~n~meer~.n~ Servlce5 Instructions for Submission of Installed Private Sewage D%sposal and Water System App~icatton. 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 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: East 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 ~o well point. (b) Depth in feet from top of well pipe or casin§ to water level in well. 14. Inside diameter of well casing. 15. Name of laboratory performing the examinations. 16. Describe method of disinfections for example: quart of laundry bleach in ten gallons of water poured into well and allowed to stand six hours. 17. State date on which installation will be ready for inspection. 18. Application must be signed by builder or owner. Signatures of subcontractor, superintendent, etc., will ~ot be accepted. 19. Indicate location of Water & Sewerage Facilities with accurate dimensi~s on sketch. SCHD SUFFOLK COUNTY DEPARTMENT OF HEALTH Date Bldg. Permit No. TO WHOM IT MAY CONCERN: The sewage disposal facilities for a structure located (GiYe deed location) / have been inspected by this department and found to be satisfactory. SEPt ~ 1973 Chief of Gen~ erml Engineering Services BUILDING DEFARTMEHT O/ · ~ P, ~ ~' ~..~ ~,~ ......... ....~. ..... ,1..2Z ~ ,~,~,~ No. .......... Di~ ./c ............. ~ ....... ~ ............................................... r' . ........................ ....................... (Buildi~ In~r) / ~t ~ ~ ~_ J APPLI~ON FOR BUILDING Pl~17 ~ ~. ................. ~ ....................................... , ~.~ INSTRUCTIONS a. ~ls applicati~ must be completely flll~ in by ~ewriter or in ink und submitted in ~pllc~ In~r. b. PI~ plan s~i~ I~ation of I~ a~ of buildings ~ premiss, relationship to ~joinl~ pmm~ a~s, a~ glvl~ a ~aped ~ri~l~ of I~t of p~ must ~ drawn on the dl~mm ~l=h II ~ d ~ ~.~ c. ~e ~ c~er~ by this ~llcatl~ ~y not be ~mmenc~ bifom i~uQ~e of Bulldl~ ~lt. d. Up~ ~r~al of this appllcatl~, the Building Ins~ctor will I~ a Bulldl~ Pe~lt ~ ~e ~ll~nt. ~h ~lt ~all ~ k~t ~ the premiss a~llable for ins~ction throughout the p~ms of the wo~. /- e. No building s~ll ~ ~cupi~ or u~d In whole or In pa~ for any pu~ ~ate~r until a Ce~lflc~ of shall h~ ~en gmn~ by the Building Ink,tar. APPLI_CATION IS HEREBY MADE to the Building Department for the ilsuance of a Building Permit purduant to the Building Zone Ordinance of the Town of Southold, Suffolk County, New York, Grid other applicable Lawl, Ordlnancel or Regulations, for the construction of buildings, additions or al.temtions, or for removal or demolition, al herein dlecrlbed. The applicant agrees to comply with all applicable laws, ordinances, bui code, code, and regulations. =u,~g code, housing (Signature of applicant, o/name, If a.eor~oomtlon) (Address of applicant) State whether a~ant is owner, I~ge?,'~hit~t, engln~ general ¢ont~t~r, el~trlelon, plum~r er bull~. If applicant Is a co~omte, signature of duly authorized officer. (Name a~ title 'of comorate officer) /~ 1. L~ation of land on ~lch p~,~ wo~ will ~ done. Map No.:~~..~ ....... ~t No.: ~ .......... Munlcl~li~ 2. State existing u~ and ~cu~n~ of pmmiNs and intended use and ~cupancy of b. Intended use and ~cu~on .................... ~ ............................................................................................ 3. Nature of work (check which applicable): New Building ~ ................. Addition .................. Alteration ............... Repair .................. Removal .................. Demolition .................. Other Work (Describe) ...................................... 4. Estimated Cost ................................................ Fee .......................................................................................... (to be paid on filing this applicati~) 5. If dwelllng, number of dwellin! .~Lts............................Number of dwelling units on each t~oor ............................ 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 olte~r~ons or additions: Front .................................... Rear ............................ Depth ................................ Heigr~'-' / ............................ Number of Stories ................................ 8. Dimensions of entire new construction: Front ...~....~..../. ....................... Rear ~¢ / ............................ Depth ........................ Height i..o../.~....~.. ..... Number of Stories ........ ~ .......................................................................................................... 10. Date of Purchase ........ · .............................................. ~ome of Former Owner '~'~,e/,~,,a 12. Does proposed construction violc~e any zoning law, ordinance or regulation? ..... ...~'...O. .............................................. '. Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor .................................................... Address ............................................ Phone No .................... PLOT DIAGRAM Locate clearly and distinctly oil 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_.~.O~4 u I. ee COUNTY OF ................... · ~.~.~-~,~ ........ / '~-'o&~,..~ ................... ~ing duly sworn, d~o~s and says t~ he is the applicant (Name of individual signing application) above named. He is the ........................................... ~.~.~.~0.~. ................. ':: ................................. ~ ..................... (~ntractor, ag~t, co~orate officer, ~c.) of said owner or owners, and is duly authorized to perform or have perfo~ed the said work and to ~ke ~d file this application; that o1~ statements contained in this opplicoti~ am tree to the ~st of his knowl~ge a~ ~lief; and that the work will be peHormed in the manner ~t fo~h in the applicoti~ fil~ therein. ..... ....... : ........ . _ .;i /- /¢' o" I ,J