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Home My WebLink About5242-zFORM NO. 4 TOWN OF $OUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupency THIS CERTIFIES that the building located at b ................... 2 $ ~ ~ ~ ~ I)W ~ V ~: Street Map No ..... -. ..... Block No ....... Lot No ..................... conforms substantially to the Application for Building Permit heretofore filed in this office dated ..... [. ~ . AP ~, , 19'71. pursuant to which Building Permit No. 5 ~ .... ~ 2 Z~, dated ... ............... I (~ r~-Pi-~ , 19'7f. , 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 .... .~.¥ ~ ....... ~.?. ~,a.~ I.~.,I '/)~ ~ 1.~ ~ ~ ~ The certificate is issued to ~ k C U ~ 5 ~- ff ~' ~ l: L b~. (owner, lessee or tenant) of the afores~d building. Suffolk Cowry Department of Health Approval D~I ~t E Build~g Inspector FORM NO. ~ TOWN OF SOUTHOLD BUILDING DEFARTMENT 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°. 52 t2 Z Dote .................... ~..~ ..... .~. .......... , 19~.~... Permission is hereby granted to: ..:/~ ~...~.~.~,..~.~dt.....~..:L~t~.. ~....~.~ ....... ~.....~e~p~n~..~f, ve ............................... to .... .~;la~.~..~.~ ~,.~.. ear~ ..~..~e.~:~g .............................................................................. at premises located at ......... ~..~ ...... ~Z~V~ .......................................................................... ............................................... ~e~..D~iw ................ q~e~ .................................. : ............... pursucznt to application doted ................................... ~,p-Z'j,:,~L-'.~ ....... , 19..~¶., and approved by the Building Inspector. tee $~4~.-¢X~ ........... SUFFOLK CODNTY DEPARTMENT OF HEALTH EASTERN DISTRICT County Ceuter, Riverhead, New York PA ?-4700 APPLICATION FOR APPROVAL OF INSTALLED PRIVATE SEWAGE DISPOSAL AND WATER SUPPLY SYSTEMS Inspectlon for approval is requested, pertinent installation data herewith. Address ~=,~M/~'. ~"~CFF~&6~ Phone 7~'~/~7 4-Section No. 2-Name of Builder L, ~.~'~;~ PhoneT'~f-~z~ ~-Lot Number Address ~ ~Z~, ~ ~/V~~. _ 6-Bldg. Pemit No. Address ~~ ~ ~M~ ~/~~ .... (b)H~let or Village ~~/O~ (c)Town 9-Septic tank-Gal L ft.~ it.Liquid Depth ft. lO-Cesspools-(a)No.pools~(b)Blocks below inlet-l) /~o 2) /o~ 3) (c)Block size-L /~ in.~__in.H~ in.(d)Pre~pool (e)~2_ 3 (f)~ft..~n; Di~ft.~n.(g)Finished grade to cov~ /f~ ft. (h)Backfill Material~/~W --~/~ ll-Water Supply: Public Syst~ ; Private Well ~ t.. -] . If Private, the following questions are to ~e a~sw~r~d: . .~ ~ Address, ~/~~ ' -- ,--" - 13(a)-Total Depth of Well ~7 .... (b)Depth to Static Water Level 14-Diameter of well pipe ~ tn. '~ 15-Name of Laboratory 16-Method of Disinfection ~~2X/~ 17-Date ready for inspection The undersigned CERTIFIES: Above syst~s have been constructed and ar in compliance with the Suffolk County Health Department's ~rrent Standards, Bulle~ and ~endments thereto. . ] ./ ~ ~ , ~_ =~_ 18-Date. ~/~7' Sigued~ ~ ~ ~ ~er - Builder 19-Insert sk~t~hf~_location of Water & Sewerage Facilities with accurate dimensio" STREET FOR HEALTH DEPARTMEN~USE ONLY Based upon the information state~ above, satisfactory £unctionin~ above systems can be expected with proper mainte~)tF~ an~ care. 71,~ S-5e S-9 SCHD SUFFOLK COUNTY DEPARTMENT OF HEALTH TO WHOM IT MAY CONCERN: at Date OCT 1 8 197t Bldg. Permit No. The sewage disposal facilitie.s fo,~ a str~cture located have been inspected by this department and found to be satisfactory. Examined ,. Approved ........................................ , 19 ........ Permit No ............................. Disapproved a/c ....Z ..................................................................... APPLI~.ATION FOR BUILDING PER. Mr/ ;~- Date .............. ...~...........~....~..:..1~...~...4C'.. ............ , 197!I ~ INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink ond submitted in c~plicate to the Building 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 de,ailed description of layout of property must be drawn on the diagram v/nlch Is I:~rt of ~nll a',:kOllcation. c. The Work covered by this application may not be commenced before issuance of Building Permit. d. Upon approval of this application, the Building Inspector will Issue a Building Permit to the pppll~Qnt. Such permit,~,, shall be kept~on the premises available for. Inspectic)n ~roughout the progress of the work. e. No buiTding shall be occupied or used in wh0~e or in part for any purpose whatever until a Certificate of Occupancy --. shall have been granted by the Building Inspector. APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pumuant to the Building Zone OrdJnonce of the Town of Southold, Suffolk County, New York, ond other applicable Laws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolition, el heroin described. The applicant agrees to comply with all applicable laws, ordinan/~ building c~e,~uslng code, and regulations. ........ ................. ....... State whether applicant is owner~ lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. Nome of owner of premise ..~...~.~..:.~..~..(~.~.~......~ ..~..~....~...A. ~. ...................................... If applicant is a corporate, s~gnature of duly authorized officer. ................................................................................................(Name and title'o, corporate officer, ~.~ -~--~'0 ~ 1. Location of land on which proposed work will be done. Map No. ..~...~..~...l~../...~'..p~.. ........ Lot No.: ...................... ~ StreW' and Number ............................................................................ ~. Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed cormtructlon: a. Existing use and occupancy ................................................................................................................................... b. Intended use and occupan:-, ~..~....~.../...Z~.....~.....~...C.~..~... ....................................................... 3. Nature of work (check which applicable): New B ng ,..~1~ .......... Addition ................. Alter tion ................ Repair .................. Removal .................. Demolition ........... ~ ...... Other Work (Describe) ...................................... 4. EStimated Cost ............. ~.~.....~.~..~.~. ..................... ~....Fee .......................................................................................... (to be paid on filing this application) A 5. If dwelling, number of dwelling units ...... .~.. ............. ~Number of dwelling units on each floor ............................ If garage, number of cars .............. ~.........~.~..4~.....~..~.~.~'h~..~. .......................................................................... 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 ...,...~.~...~.....~.. 10. Date of Purchase ........................................................ Name of Former Owner '..........~.~..../~.._~...~.....~...~.~...~..'"'""'""y'-- ~--m~ __ ..... 11. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zonim3 law, ordinance or regulation.;> ......... ~ ................................... ~'~.:... 13. Name of Owner of premises 4.f[~.../~.~ ...~'....~.~..~..~'.~-.(~. Address ..~..~...y/.~fow~. ~/.,4. Phone No. Name of Architect ......... ~t.~.~i~l:}.~ ,.~. .......... Address ...~..~...~'....~..~.1~'.~....~..~.:..~.,.. Phon, No. 7.'~..~..?' .~..~..~'' Name of Contractor ..... ~. ~-/~-'.~.~_.~..~:. ....... Address ............ .~.. ...................... .". ..... Phone No..7.~. '7'"..Z.."~'~' PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from properh/ 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, lac .................................................... ~ ....... ~ ..~..~. ............. ~.. ...... being duly sworn, deposes and says t~t he is the applicant (Name of individual signing application) o~ve named. He is the ~~ ................ ~, (~ntmctor, agar, co~orate officer, ~c.) of said owner or owners, and is duly authorized to perform or have perfo~ the said work a~ to ~ke ~d file this application; that all statements contained in this applicati~ are tree to ~e ~t of his k~wl~ge a~ ~lief; and that the work will ~ perfo~d in the manner ~t fo~h in the appIIcatl~ fil~ ~r~ith. Noto~ Public,~.~~ Coun~ ~ (Slgna~r, of applicant) ~ ELI~BETH AfiN NEVILLE ~ P~ NOTARY PUBLIC. ~ of New York No. 52-81258~, SUrfak C~ Term Exp~ Ma~h ~, 1 / ) F L~ J