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HomeMy WebLinkAbout6108-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. 2~. ~0..8~.... Date ............AI~.I. · .1.6 ..... , 19. THIS CERTIFIES that the building located at Ba~aa~ran. Lane ............ Street Map No... Bay. tiave~Block No ........... Lot No. 3~[ ....... Sou~laold .............. conforms substantially to the Application for Building Permit heretofore filed in this office dated .......l]®l~t .... 1.1 .... , 19.72. }~/trsuant to which Building Permit No. 6.1.08Z.. dated .........F~pt .... ~ll..., 19/2.~'I~, 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~,vate..one. tYa~.ly .dv®.l.],~ng ....................................... The certificate is issued to . .W,~.,W,. Custom .llul. lders. In~ .... O#l~l, ............. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval . .Al~r$,],.. ~6 .~97~ · .by. ~t. · UNDERWRITERS CERTIFICATE No..Il..7.8916 .... gar.. 20...t97.3 ..................... HOUSE NUMBER....,11430 ..... Street...l~y..HaTelrl .La ................................ Building Inspector FOBM NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT 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. 6108 Z Permission is hereby granted to: Building Inspector 1~0~ NO. ~ TOWN OF $OUTHOLD Building D~lm~'mont Town C:le~k~ Office $outhold, N. Yo 1197] APPLICATION FOR GERTIFIC:ATE OF O~CUPANC¥ 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 aT 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 D te ....... ......... New Building ..... ..~. ............ Old or Pre-existing Building ............................ Vacant Land ............................ ~avhaven ~,ane Southold ~¥~a~ 2910 hot No. 35 Location Of Property .............................. ~ .................................................................................................. Owner Or Owners Of Property w.N.W. Custom ~uilders inc. Subdivision ................................................................ Lot No....,,~.5.... Block No ............. House No ............. Sept. 11,1972 Permit No. 6108Z Date Of Permit .................... Applicant W.~.W. !Custom Budders Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ .................................... Construction on above described building and permit meets all ap~liceble codes and/~egulatJons.,__ Applicant ......................................... : ............................................................... Sworn to before me this ..... ./'~.... day of .~...~...~'~/. , · .................... Notary Public ...........,/.~r,~c~.~..~o~nty - , (stamp or seal) OEPARTMENT OF HEALTH E./,.M .AD, N.Y. APR I~. AH Il:q8 WI LLIAIN4 F~ILL5 · UNAUTHORIZED ALTERATION OR ~ TO tHIS SU~¥E¥ IS A VIOLATION OF SECTION 7~09 OF THE NEW ': -~-~ ~ ~ / ~: ~ ~re e,, '0.% ,'ve~ SUFFOLE COUNTY HEALTH DEPARTMENT Chief of General Engineering SUFFOLK COUNTY DEPARTHENT OF HEALTH H.D. Reference No. ,~(.'~- APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM AddressC~,~ ~L)~.J"~"~.~ .~Jt ~.~, ~O., 6 Section 2 Property location,,j/ ~ ,~ 7 Lot No · ~ ~ ~ ~. i~~ ,'~_ . . .., .,~ 8. Private well Village~o~ O~ Township ~..~ j--. ~; ) 9. Public water 3. Public Water Company name Distance to main 4. Lot size: Widtk~ feet Lengthi~q feet (~nter on center plot below) 10. Sewage Disposal System: ./ A. 900 gallon septic tank: P..Decastv Eq~/~valent__Block B. Leaching pools: Number_~)__Precast w'Block Special If private well fill in blanks below: Tank capacity t~g.~als. Pump G.P.M. ~ Total well depth ~''~ Depth to G.W. ~ Amount of wa~ in well Test Hole Feet Da~. £ 0 ~ ~--4~ 2 6 8 10 12 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." , --~wn~r-~gt~de~~-~~ FOR HEALTH DEPARTMENT USE ONLY. Based on the information presented herewith, it is the opinion of the 'Health Department, that an adequate and satisfactory DisposalDate ~/~/~$~'~System can be installed on this SignedPl~ ,,) Sewage S-15 Revised 4/~/72 APPLJCATION FOR APPROVAL TO CONSTRUCT PRIVAT!~ S~WAGE DISPOSAL SYSTV~MS INSTRUCTIONS: Applications must be submitted in triplicate 1-Means O~ner or Builder. Address to which mail should be directed. 2-Meaus detailed description oi' property location, together with street name and distance to nearest intersection of ma~n thoroughfare, also Hamlet/Village & Township. 3-Ehter 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. ~ter '~o" otherwise. PROPOSED S~STEM£: Answer to Item number 10, 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 ~¥stems covering cesspools. PLOT PLAN: The following information is required concerning the Applicant's lot: ~ size-Length and Width in feet to be indicated at the lot lines of the heavy lined square in the center of Plot Plan sheen 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 shown on the plot plan also. 3. ~ells 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. ~LL LOCATION: To locate the well & sewage disposal systems on Applicant,s lot, the following Standards must be observed: Well-lOC 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 LO~ATION: Upon determination of the Sewage & Waste Disposal "t~e 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 t00 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 1OO feet minimum distance from surface waters, streams, lakes, & Bays, etc. 7-Cesspools ~st 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, 6 ?OWN OF SOUTHOLD Building Delm~tment Town C:ledcs Office Southold, hi. ¥. 11971 APPLICATION FOR CERTIFICATE OF OC:¢UPANCY InstructJonl 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 dispcsol--(S-9 form or equal). 3. Approval of electrical installation from Board of Fire Underwriters. 4. Commercial buildings, Industrial buildings, AAultiple 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 aT 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 $5.00 3. Copy of certificate of occupancy $1.00 Date ...... .A ~. ~..1....1.~ .r % .e, .%~ ......... New Building ..... ~ ............ Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property ....... .~.~h~w~:~n~;:;~e~;~`~u~t.?:z~;L~l.~;"~.~9~l~J{~°~?~5 ..................... Owner Or Owners Of Property .:t.t.d.~.:'i.,....~..l~.~..~..O..~.....~.~..~...~.~..~....~..~..*. .................................................... Subdivision ................................................................ Lot No .....~,... Block No ............. House No ............. Permit No...~!..1.~..~.~ ....... Date Of Permit ...~.~.~.l;...*.....1..ZA~c?c~lt ~...~,..........C.~.,.~,O..n...~LZ~.u.~X~. ,, i .~ ~- · .~ ., , ............ ~i!!i~.~ ~. ~%lills P2es. Health Dapt. Approval ............................................ I.~bor Dapt. Approval ................................................ Underwriters Approval .............................................. Planning Board Approval ........................................ Request For Temporary Certificate ........................................ Final Certificate .......................................... Fee Submitted $ .................................... Construction on above described building and permit meets all a~plicable codes end regulations. Applicant ............... ..'?.. Sworn to before me this ...... · /'~... day of .~-~ .:..~. ..................... Notary Pub I ic~..~ ,,~'/. ,:~,~.~.~.~'~........... County (stamp or seal) TOWN OF SOUTHOLD /~'t,{~ z. /~-~ ~-~ C,~E~ ,~,~ .,~?~, ~ BUILDING DEPARTMENT/~, 2~ ~ ~ ~ ~UTHOLD, N.Y. ~ /'~ ~'~ , ~.'. ~ ~ . ~ ]9 ........ ~ ~~tion No ......... : ....................... Ex~ined ............. r.~....~,.;~...., ?~ ~'>~ '~ ~/ ~ ~ ~ 5~.5~.,~.. ~ ~ ~ ~ ~ ...................................................................... .............. ~ APPLICATION FOR BUILDING PERMIT ~' b ~ D~te ....~, 1 ~.~.~. I NSTRU~IONS ~ a. This application must be completely filled in by ty~writer or in ink and submitted in triplicate to the Building Inspector, with 3 sets of plans, accurate plot plan to scale. Fee a~ording to schedule. ~ b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas, a giving a detailed descriptioh of layout of pro~rty must be drawn on diagram which is part of this application. c. The work ~vered by this application may not ~ commenced before issuance of Building Permit. ~ d. Upon approval of this application, the Building Inspector will issue a Building Permit to the applicant. Such ~rmit shall be kept o the premises available for ins~ction throughout the work. e. No ~ilding shall ~ occupied or used in whole or in part for any purpose whatever until a Ce~ificate of Occupancy shall have beeR% grant~ by the Building Ins~ctor. APPLICATION IS HEREBY MADE to the Building Department for the issuan~ of a Building Permit purs~nt to the Building Zon~ Ordinan~ of the Town of ~uthold, Suffot~ County, New York, and other applicable Laws, Ordinance or Regulations, for the ~struction o~ buildings, additions or alterations, or for removal or demolition, as herein descried. The applicant agrees to comply with all applicable laws. ordinance, building code, housing ~de, and regulations, and to admit authorized inspectors on premises and in buildin~ for n~ary ins~ions. (Signature of applicant, or name, 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 ...... ~....~...~......~..~......--~. ..................................... If al;>pl~cant~is a co?orate, ~j~ature~fj:lul¥ aj~,eri'~ed office~'. ..... ...... ....................... (Name and title of corporate officer) 1. Location of land on which proposed work will be done. Map No.: ......~T...?'/..~.... Lot No ............. ,~ ........................... Street and Number .......... ~....~...¥....../'~..~..~..~;'~.....'~.......~'~-~..~'..~.. ......... ..~..-0.....(~....-~.~.~-'~';~'. ....................... MuniciPality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ................................................................... b. Intended use and occupancy ....... ~........~..x~....~...~...~....~........~.~.~.../-.~.~...~.../-..~....~. ..................................... 3. ~' N'atm:e of work (check which applicable): New Building ....................... ~ Addition ..................... Alteration ............... Repair ......................... Removal Demolition ........................ Other Work .................................... ......................... {Description) Fee ............... i;; ;; '3; 6;;"ic,i;6 ................................. 5. If dwelling, 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 ............. He ght , , Number of Stories ........................................ 8. Dimensions of entire new construction: Front ..... .~....,/.....{...... Rear ....~..../...../....% ..... Depth ....~A....-~..........q.. ......... Height ........ /{0..{. ............. ]/Jl'): ............... Number of Stories]/j ........ ~ ................................................ ]]~ ~; ..................... 9. Size of lot: Front ....... /....':2...~.. ................... Rear ........ z...r,f, ......................... Depth ........ /......~=.~-~ ............................ Height .................................................... Number of Stories ...................................................................................... 10. Date of Purchase ......J.£./:.~...~.../..P...~..~.. ...... __, ~, m ..... r~ .... ,4£TtCt~ ,r' o-),',¢*//.'uco, l'g3 1 1. Zone or use district in which premises are situated ..................................................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ....... ~ .......................................... 13. Will lot be regraded .... ~ ................. Will excess fill be removed from premises: [ ] Yes [ ] No 14. - .~,6/fflL/ C'zz~m-k~~ .,~ ,~.~_.~ ,~..~:~...~.. ?..5.~-- ~ [~ J~w ~ ~ ' /~ O-~,._ .~J._~,__'~~'~ s ~ ~ ~-~ ~ (Address) ~'~ MJllZeZ~none Name of Architect ..... ~ . ~uu,: ~,,,~,,~,.~., L~' '~'"'/"~t"~'"'"'~'~'i/Y~"¢"L"~';'"""'"f~"~';~ ......... Nameof Contractor ~../~..~.. ~~,._~,:, · .- .~.f-J' '~"~C)~"~'~l~o/~'-'[q'"~ ............... .............................. ~ ,^~a,~#~ ¥ ( one o.~ 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 wheth- er interior or corner lot. STATE OF NEW YORK, COUNTY OF ............................ /,o7- ~o )~P&SS ) · being duly sworn, deposes and says that he is the applicant above named, (Name of individual signing contract) .............. .¢...E ....... ............. :..--... ......... ................................................... (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 applicat~j~Kfiled therewith. ~, ........................ ................................. ............ _, W Notary C~uQ~:'~!~~.?-~..-~--~,.- ~to;~ 1'/~ ........ ~"'~'" · ....... '"~'"'"' '"~'"'"'~"~ ..................... (Signature of applicant) FOR REVERSAL of the' house design, these plans are reprinted (in reverse) on the back of each page. To facilitate u~e of the reverse Dlan_takethe main dimensions from the front 'ofe~ch ~ beet. DRAWN BY APPROVE~D BY number APPROVED BY DRAWN B,Y design number sheet' no. f design number I sheel' no. n 1 design number sheet no.