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Home My WebLink About6067-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No..z~0~ ..... Date ............. ~ab .... 1 ~ ....., 19.73 THIS CERTIFIES that the building located atDonn&. D~'ive ................ Street Map No. Dae~;. ;tote. (~ogl~{t~te s ........ Lot No...33 ........ }~attlt.uck.. ~( .~f,... conforms substantially to the Application for Building Permit heretofore filed in this office dated ........... Aug...1 ?..., 19.72. pursuant to which Building Permit No. 60677... dated ....... /,.%;g...].8 ......., 19. ?.2, 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. riva.te, on.~.., fatally, d~ell~.ng ...................................... The certificate is issued to 4.Ienry.. & .Linda .Ko~n .... (krnera .................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .Feb...9..~9'~].. Dy.R,..V~.i~& ...... UNDERWRITERS CERTIFICATE No... J. al~l.. -~6...197~ · · lqfoD] -~- ..................... HOUSE NUMBER .... ~ ~20 .... Street .......Donna -Drive ............................. .................. :~ ~. ~' ~' ................. ~'h .eF~.aa. ~.r. ............................. Building Inspector FOR~ NO. I~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N~ Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE P~,EMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 6067 Z Permission is hereby granted to: ~/.:..~../! ~,:.~. ......... f.( L ~.:3L '~- : ......... ~ ~ ~..4-~.~.. at premises located at ................................... ~..~.~..L~.' '~'....--~"~"Ltz:J'~'"'"¢ ...................................................................... ~.z.,~...~::..~...::..~..c.~ ................................................. ~ E ),!.~.....t.].~. ~ pursuant to application dated ............................. /.-~.....J~....[r.~.~.;.., 19~...~., and approved by the Building Inspector. Fee $/~.. ~.. ............... FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted in triplicate to the Building Inspector with the following; for new buildings or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewerage dispasal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installations, a certificate of Code compliance from the Architect 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 uses, or buildings and "pre-existing" 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, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent in- formation required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use 3. Copy of certificate of occupancy $1.00 $5.00 Dote New Building ........ ~... Old or Pre-existing Building ............................ Vacant Land ............................ Loco, on Of Prope,y ' ' ' - ...... ....................... Owner Or Owners Of Property...~,'.....~.~?.,~...~...;~. .............. ' ........ .~.'J...:..~ ................................................... Subdivision .... ;...~.. .................. .d. ...... .~.~ .......... ~.: ........ ,Lot No ............ Block No ............. ,House No ............. Permit No.. . ate O rmit ~. 1.~: ~: .~..Applicant ..., .... Z .................... , ... Health Dept. Approval ..~..!i.~...~.,,~,.'''~-.. ................... Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ .................................... Construction on above described building ~,,~i~ l~ ermit m. eets all\applicable codes and regulations, Applicant ..................................................................... Sworn to before me this ......... ~... day of .~; ................................ Nota~ Public ....... ~J.:55~i.~: ............ Coun, NO~:'" ' FOILM NO. 6 TOWN OF SOUTHOLD Building Delm~tment Town Clerks Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted in triplicate to the Building Inspector with the following; for new buildings or new use: 1. Final survey of property with accurate location of all buildings, property lines, streets, and unusual natural or topographic features. 2. Final approval of Health Dept. of water supply and sewerage dispcsal--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, Multiple Residences and similar buildings and installations, a certificate of Code compliance from the Architect 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 uses, or buildings and "pre-existing" land uses: 1. Accurate survey o~ property showing all property lines, streets, buildings and unusual natural or topographic features. 2. Sworn statement of owner or previous owner as to use, occupancy and condition of buildings. 3. Date of any housing code or safety inspection of buildings or premises, or other pertinent in- formation required to prepare a certificate. C. Fees: 1. Certificate of occupancy $5.00 2. Certificate of occupancy on pre-existing dwelling or land use 3. Copy of certificate of occupancy $1.00 $5.00 Date .................... New Building ..... ~ ......... Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property .~.~.~`~..~..~.~..~``~:.~.~...~`~z~..~.'~.~?.~..?~./~.~/~.~ .......................... Owner Or Owners Of Property ...'.~.'..~-~./~o.~....,.~.....~/~..~,,/.?..~...~....~..~'~.,r.~.~... ........................................................ Subdivision .~...~..¢"./~.~'?.I.~...C!~.f:'..~......~.L,~,::~.~.~. ............ Lot No. ~.',~ ..... Block No ............. House No ............. Permit No .....~.~./~.'.~.... Date Of Permit ~..';/.~.?.~?.~Applicant ..~..~..~;,~..~..'...~.;././.~..~.~.....~.;~.~'.~. ............. Health Dept. Approval ~:~.:.J..~..-r~.7.~..J ...................... Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ .................................... Construction on above described building ~r~d permit meets al) applicable codes and regulations. Sworn to before me this f~PP ........ '-'"~/ ........ ................ aay of .....: .~..: ................................. /~ {stamp or seal) o /~ "~'~ · · · ,~ ~'-";.) ./- · .~. ............... County ., Notary Public LOT .3Z '\ 5.87'19' 20"E." 90.0 %, , _ 76.S4. '. N. 83' 20'40" W. MAP OF PROPI:::RTY SURVEY~.D FOE HENI2Y 5. & LINDA KO~EN SITUATE AT MAT'TITUCK TOWN OF $OUT140LD, Iq.',/. · NOTE: LOT NUME~EES $140NN EEFEE. TO "MAP OF DEEP HOLE (::REEK ESTS.' FILED IN TIlE ;~UFFOLV., COUNTY CLEE, K'$ OFFICE SCALE · 4'0'= I" 13 ~ MOtAUMENT GUARANTEED TO THE CHICAGO TITLE INSuEANCG COMPANY · SUiAVEYED · JUNE ~, 197Z. VAN TUYL & SON LICENSED LAND ~UEVGVOE~ GREENPOET, NEW ~0~K LOT · 3Z S. 87'19' 20"E.- 90.0 LOT, 33 t~'ELL N. os.2o.~o.~. oo DRIVE MAP OF PROPERTY SURVEYED FOE ,HENRY S. ~ LIND~ KOZEN SITUATE AT MATTITUCK T0t~/N OF SOUTt. IOLD, N,¥, ®NOTE: LOT NUMBERS SNOt'~N EEFER. TO "MAP OF DEEP UOLE CI~EEK EST$." FILED IN TIlE SUFFOLK COUNTY CLEI[K'$ OFFICE SCALE . 40'= I" [] ~ MONUMENT · - II:2.ON GUAIr.,~I41"EgD 1'0 SLIFFOLK ¢-OUhi'F¥ FEDEg. AL ~A~/IflG$ iil4O LOAN A.~,5OG'H. AND TO THE CHICAGO TITLE INSU~ANCI~ COMPA, NY · SUIZVEYED · DIC~ &, 1q72, I~.ODE~ICK. VAN TUVL, F.C. v LICENSED LAND GREE~POIZ. T, NEN' to ~:e · .... c ...... ,~gz:~eerzng Services SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D. Reference No.,,S~)-//~<3 APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM Address I~O~ ~-~(~-~%-~ ~ ~(~W~'~;~ 6. Section k4~.~- ~7-~ 2. Property location ~~~ · 7. Lot No. ~ ~ ~~ ~. 8. Private well ~ ~ Village ~;~V~ Township ~T~O~ 9. Public water ~O~ 3. Public Water . Company name ~ Distance to main 4. Lot size. Width~feet Length ~ feet (E~r on center plot below) 10. Sewage Dispo~System: ~,,~ A. ~gallon septic tank: Precast Equivalent Block B. ~eaching pools. Number ~reca~Block Special N If private well fill in blanks below: Tank capacity~Gals. Pump G.P.M. Total well depth Depth to G.W. Amount of water in well Test Hole Data Feet 0 2 4 6 8 10 12 14 16 18 The undersigned CERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Department of Health's current stand- ards thereto." Date ~-~~ · Owner or Builder FOR HEALTH DEPARTMENT USE ONLY. Based on the information presented herewith, it is the opinion of the Health Department, that Disposal System can be installed on this plot. Date ~'~~ Signed an adequate and satisfactory Sewage S-15 Revised 4/1/72 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 thoroughfare, also Hamlet/Village & Township. 3-Enter name of Public Water Supply District, together with the distance to their main. ~ 4-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-Name of subdivision. 6-Section number. 7-Lot number. ~ 8-Private well: Enter "No" if Public water supply is available. Eater "Yes" otherwise. 9-Public water: Enter "Yes" if Public water supply is available. Enter '~o" otherwise. ~OPOSED SYSTEMS: Answer to Item number lO, consult the Suffolk County Health Department's Standards for Sewage And Waste Disposal Systems Design of. Residential Subsurface Sewage DiSposal Facilities. Part I-Residential Subsurface Disposal Systems covering cesspools. PLOT P~AN: The following information is required concerning the Applicant's lot: 1. Lot size-Length and Width in feet to be indicated at the lotlines of the heavy lined square in the center of Plot Plan sh~n on face of this application. 2. Surface waters-Streams, Lakes, & Bays, etc., located within a distance of 1OO feet of Applicant's lot lines, must be sho~n on the plot plan also. 3. Wells and cesspools now on adjacent lots must be shown on the plot plan, together with the distance to the Applicant's proposed Sewage Disposal Systems and well. 4. Where no buildings exist on adjacent lots, state "Vacant" on the plot plan. 5. 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-lOO feet minimum distance from the nearest cesspools. Well- 25 feet distance from rear and rear sides of property lines when possible. Well- l0 feet distance from front, and front sides of property lines when possible. Well- 50 feet minimum below grade for well point. Well- 40 feet minimum into ground water for well point. Well- 4 feet 6 inches minimum below grade to well head and lateral water pipe. CESSPOOL LOCATION: Upon determination of the Sewage & Waste Disposal "type of systems', re- quired, the following Standards must be observed for the location of same: 1-Cesspool- 5 feet minimum distance from lot lines to exterior of cesspool. 2-Cesspools exterior must be 100 feet minimum distance from nearest well. 3-Septic tank exterior must be 75 feet from nearest well. 4-Cesspool exterior must be 7 feet minimum distance from nearest water line. 5-Cesspool exterior must be 10 feet from house foundati~n~ 6-Cesspool exterior must be 100 feet minimum distance from surface waters, streams, lakes, & Bays, etc. 7-Cesspools must be 20 feet minimum distance from large trees. 8-Cesspool exterior to cesspool exterior, must be at least 8 feet. 9-Cesspool cover top to grade must be held to minimum of 1 foot to maximum of 2 feet. 10-Bottom of cesspool to ground water ~st be held to minimum of 2 feet. LOT · 3Z $.87'19' 20'E. - 90.0 76.54. N. 83'20'40-t¥. DRIVE MAP OF PROPERTY SURVEYED FOE HENRY S. & LINDA KOZEN SITUATE AT MATTITUCK TONN OF 5OUTHOLD, N.Y, · NOTE; LOT NUMBERS SHONN REFER, TO ~ MAP OF DEEI~ I4OLE CREEK ESTS." FILED IN TIlE SUFFOLK COUNT'/ CLEIZK'S OFFICE SCALE ' 40'= I" E3 "- MOI~UMEklT GUAIZANTEED TO THE CHICAGO TITLE INSURANCE COMPANY · SURVEYED · JUNEG, 197Z. , VAN TUYL 8, SON LICENSED LAND SURVEYORS GREENPOET, NE~¥ Y01~.K TOWN OF ~O~JTHOLD ~qfft'z.~ 1.,~. , '~ ,~" ~ BUILDING DapARTMENT~ .~. TOWN C~RK'S OFFICe, ~UTHOLD, H. Y. Ex~mi~ed ........................................ , ~9 ......... . . . ~. ~ ~pphc~tlo~ ~o ................................. ~pproved ........................................ , Pemit No .................................. ~ ~ ~ - .............................................................................. ,~.~.~ (Buildin, Inspector) 3 ~ts of plans, $~urate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and ~ buildings on premises, relationshi~ to adjo~i~ premiss or ~ublic streets or areas, g~ving a detailed description of layout of pro~rty must be drawn on diagram which is ~art of this application; c._The w~k covered by this a~lication may not ~ commeo~d before issuance of B~ilding Permit. d. u~n approval of {his application, the ~uilding Inspirer wil~ issue a Building Permit to'the appli~nt. Such ~rmit shall be kept~on the ~embes ~a~table for i.ns~¢tiog througho~ the work. . ' e. No building shall ~ oc~pied 0r u~d in whole or in part for any purpo~ whatever until a ~rtificate of Occupen~ shall have ~e~ granted~y the Building Ins~ctor. APPLICATION IS HEREBY MADE to the Building Department for the issubm:e of a Building Permit pursuant to the Building Zone Ordinance of the Town of Southold, Suffo{k County, NeW york, and other applicable Paws, Ordinances or Regulations, for the construction of buildings, additions or alterations, or for removal or demolit~'i~3, as kerein described. The'~plicant agrees to comply with all applicable laws, ordinances, building ~ode, housing code, and regulations, ahd to adn~it authorized inspectors on p~emises and in buildings for necessary inspections. -[Address of applicant) State whether applicant is owner, I'essee, agent, architect, engineer, general contract(~r, electrician, plumber or builder. Name of owner of premises J~, (~ J~...~,, ~[~.~ ., ..~'{. ..............._../. ..........:~ .................... I' applicant is a corporate, signa~ture of duly authorized officer./ ............................... . .......... . , -,. . 1. Location of land oll'which 'proposed'work will b~done. Map No .................. ~......~. ................... Lot Street and ~ ~) ~ ~ Number ...................... ........ ............................................. .............. .V, ........... Municipality 2.State existing use and occupancy of premises and intended use and o~c~pancy of proposed construction: a. Existing use and occupancy ....~7~. ........................................................................................................................ b. Intended use and occupancy ............................................................................................................. , ................... Nature of work (check which applicable): New Budding ........... Addition .............. : ...... Alterat'on*.~. ....... ~ .... Repair ......................... Removal ......................... Demoli~on ........................ Other Work .........~ .......................... · ~-~ ~ ~' ,~_ ~'- {Description) 4. Estimated Cost ...[..[~.~..0...0..., ........................ Fee .,,....~...., ............ ; ...................................................................... (to be paid on filing this application) 5. If dwelling, number of dwelling units ...! ............. Number of dwelling unitS on each floor ......................................... if garage, number of cars .....~.. ........ i ............................................................................................................................ 6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ...~,..~.~..I..~...E'...~...T..I....~_j 7. Dimensions of existing structures, if any: Front ...~.O......t~... Rear ........................... Depth ................................... Height ..[ .~.../.. .................................... '. ............ Number of Stories ...[ ........................................................................ Dimensions of same structure with alterations or additions: Front .[~.!~... .......... Rear ......................................... Depth ...~-./.. ................................. Height ....,I..~...K .................. i ........ Number of Stories ....t .................................. 8. Dimensions of entire new construction: Front .~;;~.C~../..~.~..~, ...... Rear .....~....~../..~.~.). ....... Depth ..~....~.. ................. Height ..I.~.'../.. .................................... Number of Stories ..~ ........................... ; ......................................................... 9. Size of lot: Front ........ ~.....~....0.. ................. Rear ..]...~. ~.../.. ........................... Depth ............................ ... .................... 10.: Date of Purchase .~'.O.~[~r~'....~..~..I.[.~.~.'..~.... Name of Former Owner ....-~....~.....g~......~..:...~_,~Z~,_~.~J .................... 11. Zone or use district in which premises are situated ...~.~.~...~.~.~..~.T...~..~ .............................................................. 12. Does pr.oposed construction violate any zoning law, ordinance or regulation: .].~.[0. ................................................. 13. Willlotberegraded__~_~_~_ .......................... Will excess fill be removed from premises: [ ] Yes [~No 14. Name of Owner of premises .~...J~.*.~....~.J~.~.:...~ Name of Architect Name of Contractor .~.~...~..~......(~30~-' i.ocate clearly and distinctly all buildin prOperty lines. Give street and er interior or corner lot. existin (Address) (Phone No.) and indicate all set-back dimensions from and show street names and indicate whath- STATE OF COUNTY iEW YORK, they are d. eposes and says that 1~3{i~the applicantSabove named. HENRY ~KOZE~ ~.I...L. 23~i~A KOZF~ ................... ....................au,v ·hey .are _~ o~ers X~s'the ......................................................................................... ~ ....................................................................................................................... co~ac~o~ (Con~cter, a~nt, co~mm o~r. etc.] ~~' an~s duly au~orized to ~rform or have ~rfor~d the said work and to make and file this application; ~at all ~te~n~ ~ntained in this appli~tion are true to t~ ~st of his knowled~ and ~[~ ~rk Will ~ ~ormed in the ~nner ~t fo~h in the application filed therewith. NOTARY PUBLIC, State 0f New Y0~ 17th da' of Auoust -- 72 No 52.0992700, Suffolk CounW .......................... ~5 ...... * ...........~'~ ................................ ]u ............ %~ T~m Expires March 30,~9~ Public~..~.:..~~~ HOWARD E PETERS~ CONSULTANT CHARLES J, IRWIN, ~ BAYPOR'f AVE,, ,i flgfPORT, N, HOWARD g. P[TER~'EN' ,~ONSUL~ANT CHARLES J. IRWIN' AROHIT~GT: ~.BO B^¥PORT AVE.,