HomeMy WebLinkAbout6114-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No. Z~.].8~ ...... Date ............. ~'..'e~o. .... ~ ..... , 19.7.3.
THIS CERTIFIES that the building located at .Re,on. D~..&. ~. D.~... Street
Map No.~ .Sh,. Block No... ~ ...... Lot No.~2~.,.~3,~ ...... SO~0!d..
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ........... ~ept...~., 19 ~2. pursuant to which Building Permit No.
dated ........... 8opt...]~.., 19.72., 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 .~Vg~0. ~. ~9~Y. ~g .......................................
The certificate is issued to . ~tghe~. &..~oseph~. ~e~ ...... ~0~ ........
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval . ~. 3~,. ~9~3.. b~ .~. Y~ .....
UNDERWRITERS CERTIFICATE No...~. ~.... ~.. ] 6...~973 ...................
HOUSE NUMBER.. ]~OO ...... Street. ~O~ .D~ .....................................
~ Or~e D~ive
....
Bt]ilding Inspector
FORM NO. ~
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)
~? 611~ Z
Permission is hereby granted to: ·
.......... ~ ~. ~ .e.~...~...~.e.,~ ,e.~.~. ~.e...,~.te.~..a
.......... $3~)....G~eve--]~ ......................................
~o ..... ~.~l~t ..~... ~..e....f..a. mll2....d..w..e, ll~ ................................................................................
at premises located at ..... ~.$.~..~..~.~e...~e...~-.....{J.~.{~..]L-.~DJ~..~l~"~ll' ........................
.................................. G~e..&..Re~ct ea..D~. ..................... ~at~ml& ............................................
pursuant to application dated .............................. ~.a]~t,..-..~J-~ ...... , ]9.~r~.., and approved by the
Building Inspector.
Fee $..~.'J....O,,~ ..........
Building Inspector
TOWN OP SOUTHOI.D
~uildin~ DepeWment
Town C;ledm Office
Southold, Iq. ¥. 11~/1
APPMGATION FOR CERTIFICATE OF OCCUPANCY
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 disposal--(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. Dote 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
D te ..... .......................
New Building ~ Old or Pre-existing Building Vacant Land
Location Of Property .../..~...°...°....../~.~...o/.g .~......~....r'.;....~.~.~..~.4..l.~. ...... ~-~.../.....~./..~.,?.../. ...................................
Owner Or Owners Of Pr6perty . ..~...~..~.~...~...~....~..~...~.~..~.C/...~..f~..~....,~...°.~..?.~.,~.~.¢~.. ...........................
Subdivision . .~...C.~.~.e.~.....~..~',.~..~J' ......................... Lot No~.,[.-/',~../. Block No......--.. ..... House No......"T.. .....
Permit No..~./../..¥..*~.. Date Of Permit~-~/L?x~-/.~7,~.Applicant ..,~..~....~.~.~/.~/...~..~..~dq.~/.,.U.~..~..~/...~a.~.~J~
Health Dept. Approval .~...~..5'..........~....7..//...~...~.. .......... Labor Dept. Approval
Underwriters Approval .~..~.~'....../..~...q..~..e...,~..~.../. ........ Planning Board Approval .....-T ..................................
Request For Temporary Certificate ........................................ Final Certificate
Fee Submitted $ ...~.:...o...~..~. ....................
Construction on above described building and permit m,eets all applicqble codes and regulations.
Applicant .~~ ........................................
Sworn to before me_this 6~-~
...... ...... o,o,
Notary Pub[~t~t~b~,~ County
MYRTLE A. SELG
NOTARY PUBLIC, Stale of New York
No. 52-8913915-Suffolk County
Commisskm Expires March 30,
/
SUFFOLK COUNTY DEPARTMENT OF HEALTH
H.D. Reference
APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM
4.
10.
Applicant Uatthew ~TeKiernan
Address 130 Grove Dr. Southold~
765-
Phone 9258 5. Sm%~W. l~ap531
'*.¥. 11971 6. Section H
7. Lot No. 1/2 of 22/23/24
8. Private well yes
9. Public water
Distance to main ---
(Enter on center plot below)
Property location
Village. Southold Township Southold
Public Water Compan~ name
Lot size: Width 80 feet Length. 1~ feet
Sewage
Dispos~ystem: A. ~0~gallon septic tank: Precast x Equivalent Block
B. ~-~'aching pools: Number2 Precast/~c~lock Special__
If private well fill
in blanks below:
Tank capacity 82 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-
Date ~-/~ ~_~ Signed
Owner or 'Bu'i~],~er
FOR HEALTH DEPARTMENT USE ONLY. Based oD the information presented herewith, it
is the oplnion of the Mealth Department, that an adequate and satisfactory Sewage
Disposal System can be installed on this plot. (_~
Date Signed ~
S-15
Revised 4/]/7Z
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-Meaus 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 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 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 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 shown 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.
%~LL 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.
C~SSPOOL LOCATION: Upon determination of the Sewage & Waste Disposal "tj~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 foundatien..
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.
lO-Bottom of cesspool to ground water mast be held to minimum of 2 feet.
M'~.~'~ ,V TOWN OF SOUTHOLD ~'~/ -
' '~ ~ t/~ TOWN CLERK'S OFFICE _,'j./
.
Approved ., '9 .... .............. ~.....~.~.~, - ~, ~
........................................... ~ ~ , - ,
................................... ....... ...... "7 ...... ....
/ ~ ~ r~ ~ ~uiming Inspector) I
~ . ~' APPLICATION FOR BUILDING PERMIT ~ ~ ~ --
~ t~ Dote ~.~...,
· . Thi~ ~p~limtion mu~t be compl~tel~ filled in b~ W~writ~r or in ink and ~ubmitt~d in tri~licat* to the Buildin~ In[pe~or, h
3 mt* of ~l~n~, ~eeurat~ ~lot ~lan to ~c~l~. Fee aceordin~ to *cbedul~.
o. Tbe ~ork e~d b~ thi~ a~lication ma~ not be eomm*nmd ~for~ issuance o~ Buildin~ ~rmit.
d ~n ~ro~al of thi~ ~p~lication, !he Buildin~ ~n*~ctor will issu* ~ Bui~din~ ~ermit to tbe a~plicant.
the ~r~mi~ ~ilabl~ for in~ction throughout th~ work.
· . ~o buildin~ ~all be oecupi*d or u~d in whole or in Cart for an~ purpo~* wbet*~or until
gr~n~ bY the Buildin~ In~ctor.
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, building code, housing code, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections.
~~.L...; .......
(Signature of applicant, or n~l'e, if a corporation)
(Address of applicant)
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder.
Owner
Name of owner of premises ....... ~.~,l;~3~.~/..T. gn~.]~E1.n~...M~;ie~.n~n .........................................................................
If applicant is a corporate, signature of duly authorized officer. '~
(Name and title of corporate officer)
· · · . 6;51- Seo H t No [,~.~ ,e,,f
1. Location of land on which proposed work wdl be done. Map No ....................................................... L,,o. - . ~....
8outhold ~ew York
Street and Number ............ l~&e,...~w~......~-~b... ............................. ,t ....................................................... :..:....:: .............
'- -'~ , MummpanW
2. State exi~ing u~ and omupancy of premiss and intended use and ~cupancy of propo~ con~mction:
a. Exi~ing u~ and ~cupancy . X~.~.~...~R.g~ ...................................................... :..-
b. Intended u~and ~upancy 1 f~mtl~ ~e~td. .
3. Naif, re of ~ork (check which applicable): New Building ...... ~...... ......... Addition ..................... Alteration.:. ...........
Repair ......................... Removal ......................... Demolition ...................... Ot.~_her Work ....................................
......... ~ ..... ~r~'. 0 t I Description)
4. Estimated Cost ..... ~.~a.U.~.U. ........................ ; Fee ..... ,~ .......... (~.....~. .............................. .......................
(to be paid on filing this application)
5. If dwelling, number of dwelling units ......8. .......... 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 .....:-."..' .................................... Height ....~... .................................. Number of Stories ........ :~ ..............................
8. Dimensions of entire new construction: Front ......5.§.t..0..~ .......... Rear ..... .~..§~. ............. Depth ....~.2.,?..0.~ ..................
Height ....~..~.~.0..! .................................. Number of Stories ..........~. ............................................................................
9. Size of lot: Front ..... ~..~..5...*..0...~. ................... Rear ....... .~.[~.~.(~ ....................... Depth ..................................................
10. Date of Purchase .../...]:./...~..9.?...].. .................. Name of Former Owner ....~*~..G~J:~.~ ..................................................
11. 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 ~'ee ·
.................................. Will excess fill be removed from premises: [ ] Yes [~] No
Name of Architect ...~.~.h..~....?.........~..o..u..a...g..b..1..?..o.~.......[..o..w...~... (...[..2.~.~.:::!. ................................... (.~.h..o._.n..e...N..o.:). ...............
Name of Contractor ?~s...t;.*b~.e,w ~eK[e/'R&~ 150 Gl~o~e (j~d. reS~)out;hold 765-9~5~Ph°neN°')
(Address) (Phone No.)
PLOT DIAGRAM
I*ocate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-beck 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.
. )
COUN ¥O ............. ................ I
........ ~....~..~.~'.<.~..*..~.... ....... (...~..~..6?.dt...~.. ............................... being duly sworn, deposes and says that he is the applicant above named.
(Name of individual signing contract/ .
He is the .............C..?.....-~.....~..~...dt.~...~..o.~.. ......................................................
{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 andj~i~R~t~S~l~[~tion; that all
statements Contained in this application are true to the best of his knowledge and belief; and that the ~lr~ll[~B[q~, ~l'~do~ ~er
set forth in the application filed there)/vith. , No. 52-8913915-Suffolk County
/ "~ ~ ,~ -'~"~- / - Y.~ Commission Expires March 30, 19~
.............. /..~'..*. .............. day o~ ............ 19/...~.~. .... ' ' ) ~
· ~ (./ (,Signature of' al~licant)
F~NCE~
TITLE CJ3MPANY BO,
FErtCE AT' LINE,
9LIO
N. 69"'~ 8' 40%,M
2. 5TOP..Y FH. HO,
UNDEP.,
GA~,A~E
\ 23
LANE)
2"7,6
TITLE COhlPANY NO,
12-/266 t
(20',
4o,o
MAP, OF PF. LOPEP..TY
8UP~VEYED FOE
4 ~'' 'T'7,' F' . - -. ~.1C
P ,/<,, !4LW~JOSE PI. q1 NE XIE~NEN
TOWN
AT
BAYVi
OF SOUTH ,~'L.D~ N,Y
SUFFOLK COUN~y HEALTH DEPAR~.~EN~
o.~E MaY 3 0 1973 ~. o. ~. ~T_~
k
~'- t/lO N U ~ E HT
WELL
ftO,TT.'LO"hO'5,~t-OV'lhl kNF'EP. TO"'MAPOFP. EYD(3~I 5~oPr-'r Nr
,~.~ 1~4AP N0,631.
FENCE
AT LINE
,44,0
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