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HomeMy WebLinkAbout6088-z FORM NO. 1 TOWN OF SOUTHOLD EUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined Approved ................. ~J ~.} ........:.~. .......... , 19.?...~. Pemit No. ~...~....~..~....~,,,w.. ........ Disapproved a/c ................................................. '" ................... APPLICATIOH FOR BUILDING ~ERMIT ~ INSTRUCTIONS ~ ~ ' "P ~ o~' g location of lut ana of buiidings on premises, relationshi toad'olnm r ' '~ c. The work covered by this application may not be comme~ed before issuance of Building Permit. d. Upon approval of this application, ~e Building Inspector w issue a Building ~rmit to the ~plic~t. Such pe~it shall be kept on the premises available for inspection throughout the profess of the work. ~ e. No building shall be ~cupied or used in whole or in part for any purpose whatever until a Ce~ificate of ~cup~c~ shall have been granted by the Building Inspector. ~ APPLICATION IS HEREBY ~DE to the Building Depa~ment for the issuance of a Building Permit pu~uant to th~ Building Z~ne Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, O~inonces or Regulations/for ~e construction of buildings, additions or alterations, or for removal or demolition, as heroin describe. The appli~ ogres to comply with all applicable laws, ordinances, buildi c~e, housing c~e, and r~ul~ions. (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ........................ Nome of owner of premises -~) ~ L~ ~ L~..~.. ~ ~/~ ~ If applicant is a corporate, signature of duly authorized officer. ~ (Name and title of corporate officer) 1. Location of land on which proposed work will be done. Map No.: ......~..~~ ............... Lot No ~t/ ........ Street and Number .............................. ,~.~./..,~... ....../~....~..~...9..,.....~....~..~-...~'~./.y....~.....~.~"..,w. iiiiiiiiiill .......... Municipality 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 ........................ ...~..~.....~. (./.~.....~...~.......(~..~ FO~ 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) No. 6088 Z Permission is hereby granted to: ........ Jal, ttAtae~t..l,Z. ................................... at premises located at ........J,/~J..~J&J~j..~lj~.;&.~JU~..g$...; .............................................. ................................................ Jlat, ttAmllil ......... !i.~. ...................................................................... pursuant to application dated ........................... ~....~;~ ............ 19..~1~., and approved by the Building Inspector. Fee $l~j~JJjj ............ 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration .................. Repair .................. Removal .................. Demolition ................ ~,her Work (Describe) ........................................ 4. E,timated Cut ...... ......................... 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 o3rs ,...;~;; ......................................................... :'.,.; ..................................................................... 5. If business, commercial or mixed occupancy, specify noture and extent of eoch type of use ............................ 7. Dimensions of existing sttruCtu;es,.if any: Front ........ ~..L~ ........... Rear ........... ~.../,../. ............ Depth ..~..~.. ....... Neigh ~t~ .~../~?.~..~.. Nu~:)er of Stories ........... Dime;~sions,of ~d~e structure with alterations or additions: Front ....... ..~....~'.,~...~... ........ Rear ............................ Depth ....... ~ ........................ Height ............................ Number'of'Stories ....... ~ ................. 8. Dimensiens of entire new construction: Front ...... ~ ......... Rear .... [.... Depth ...... Height' .;~umber of Stories ...... .q~ ......................................................................................................... 9. size ~)f lot: Fr;nt'.';.:../..,'~,,..O..../. ....... Rear ....L.~...~..../. .................. Depth ......~......~......[.. ........ ~, ~ , 10. Date of Purchase ...... ..~.....~..../~...~.....!..t...]..~..~......~T-. ........ Nome of,j~,ormer Owner ....~..-..~.....~..'..:....~.'..~..~...~.....~...~.. ..... 11. Zone or use district in which premises are situated ................. .'.~....~....~.../....Z~..~../~......~.,./....,~.....J'~... .................................. 12. Does proposed construction violate any zoning law, ordinance or regulatipn? ...... ~..~. ............................................ 13. Name of Owner of premises ..~..~..~.......~...~..~...d.(..../~..Address ~.~../.~.....~....~./.,¢~,,~...~..~-/~e No~:~.~..~..~...~....'~.... Name of Architect ...................................................... Address ............................................ Phone No ..................... Name of Contractor .................................................... Address ............................................ Phone No ..................... PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate oil 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 N~OJ?.~_, ,~ t c c COUNTY OF ...~.U..~.~.?...~.. ...... ............................ .,~....~.....1~...~.~-~....~ .......................... being duly sworn, deposes and says that he is the applicant (Name of in~iduat signing application) 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 tha~ the work will be performed in the manner set forth in the application fiJ~l therewith. Swam to before me ~is ~ · ~ ~ / ~0. §2.§758570 Qualified in Suffolk County ~ommiaaion Expires March 30. APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM ' ' -' ~ t ~/'!~' Phon Subdiv. 1. Applicant f ' i 5 ' Address , .] ~ i' ~, (~, ~ q'~ - />~, Section 2. Property loc,ation "~: , : ~, 7. Lot No. '- ~ ~ , '' ~ ,"~/ '~-' 8. Private well Village //~i' 7 ~ ~/i/ /~ownship , ,ii/ , ~ 9. Public water 3. Public Water Company name ~' Distance to main 4. Lot size: Width /::,~feet Length ;~7(9 feet (Enter on center plot below) 10. Sewage Disposal System: A. 900 gallon septic tank: Precast~z~/_E~uivalent Block B. Leaching pools: Number ,/Preca~-~/'Block Special__ If private well fill iu 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 :ERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Department of Health's current stand- ards thereto." on the ± ormat~bn presented herewith, it Sewage FOR HEALTH DEPARTMENT USE ONLY. Based is the opinion of the Health Department, that an adequate and satisfactory Disposal System can be installed on this plot. Date ':~- Signed/ S-15 Revised 4/1/72 APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE S~.WAGE 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. Enter "Yes" otherwise. 9-Public water: Enter "Yes" if Public water supply is available. Enter '~o" otherwise. PROPOSED SYSTEF~: Answer to Item number 10, consult the Suffolk County Health Department's Standards for Sewage And Waste Disposal Systemm Design of Residential Subsurface Sewage Disposal Facilities. Part I-Residential Subsurface Disposal Systems covering cesspools. PLOT PLAN: The following information is required concerning the Applicant's lot: 1.~ size-Length and Width in feet to be indicated at the lot lines of the heavy lined square in the center of Plot Plan shm*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- 10 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 ~ inches minimum below grade to well head and lateral water pipe. CESSPOOL LOCATION: Upon determination of the Sewage & Waste Disposal "t~pe 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 1OO 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 foundation.. 6-Cesspool exterior must be 1OO feet minimum distance from surface waters, streams, lakes, & Bays, etc. 7-Cesspoo!s 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. lO-Bottom of cesspool to ground water ~st be held to minimum of 2 feet. FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. Examined ...... ~.~....~.~.. J~ ........, 19 ........ Approved .................. '~'..~ .......... '..~. ....... , 19.Z..~... Pemit No..~.'...C.?..~....~,...~,~ ........ Disapproved a/c ............................................................................................. (Built) APPLICATION FOR BUILDING PERMIT Application No......~....~...?..~. .......... Date ................... ?....~. ............ , 19 ............ INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in duplicate 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 detailed description of layout ofproperty must be drawn on the diagram which is part of this application. 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 applicant. Such permit shall be kept on the premises available for inspection throughout the progress of the work. e. No building shall be occupied or used in whole 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 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, as herein described. The applicant agrees to comply with all applicable laws, ordinances, build(~.c de, housing code, and regul?ions. (Sign ~1~1' t, or marne, if a corporation) (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. ................. ........ ....... ............................................................ Name of owner of premises ...... .~..L~. ....... ...~.....[~.....~....~...~.j.../~....~.. .................................................................................... If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) 1. Location of land on which proposed work will be done. Map No.: ........................................ L_t N .................. A/ 0 J) 7-'h ........ Street and Number ..................................... ~I~..~/ ........ ..~......!./°4T..!....~,..,~.. ........................ ~ ............................. Municipality 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 '-'--.~..~;...~.. ~ J) .~../%J(~-- ............ 3. Nature of work (check which applicable): New Building .................. Addition .................. Alteration .................. Repair .................. Removal .................. Demolition ................~ Other Work (Describe) ........................................ 4. timated Cost ............... ............. 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 mrs ............................................................................................................................................. 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 ....... .r~..~..~ ..... 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 ....... ' "'~/(....b....C~......~ ............. Depth ....... ...c~...~....c~....../. ...... 10. Date of Purchase .~f~'x.~/x'.'~-~.~.../-~---.~../.~..~...'.~ame~,~ __~,,--/,/~ of Farmer Owner ..... ..'~.....~....~..../~....../~..?. ........................... 11. Zone or use district in which premises' are situated ....................... i~..~.....~...~!....4~....~......~'.....~../...~.....~..-- .~..~,~ ........................... 12. Does proposed construction violate any zoning law, ordinance or regulation,~ ................. (..v...~1... .................................. 13. Name of Owner of premis~'s~......~...~-~..~.../~...(...~..~ddress ~.'~T'..~...-~.../...~....~.....~...~:~. ..... Phone N .o~..c~..~..~...~...~...~.~- Name of Architect .......... : ........................................... Address ............................................ Phone No ..................... 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,-,VORK . t,, COUNTY OF ...~.9.~..'9~...~..~.....$~'~ ......................... ~..~.....~..1~.~]...../~. ........................... being duly sworn, deposes and says that he is the applicant (Name of i~JJividual signing application) 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 rr~ke and file this application; that all statements contained in this application are t~ue to the best of his knowledge and belief; and thor the work will b~ performed Jn the manner set forth in the application filed therewith. Swo~ to before m~tJt~is ~ '. ........ 19../~'.~.. .... , ................... ........................................................... Notary Public, .L.~.~...~..~E~Oi:E~i,i~ ............. County /// (Si/li'~oture of applicant) 'l~t~ry Public, State of New York ~ No, 52-5758570 Qualified in Suffolk County Commissien Expires March 30, 1974 t ! I$0. lO C,, VAN TUYZ.