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Home My WebLink About6116-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. Z~.089 ...... Date ........... Aprl'l .. 19. ..... , 19.73. THIS CERTIFIES that the building located at .NidS, elton .Road .Ext~ ..... Street Map No...~X ........ Block No.. ~t~ ...... Lot No.mmt .... Greenpert;. · · N...Y-. ....... conforms substantially to the Application for Building Permit heretofore filed in this office dated .......... Sel~t ....1.1., 19..7.2 pursuant to which Building Permit No. 6116Z.. dated .......... ~.~.~t.. ~13..., 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 . .prSwgl;e..o~.. f.a~i~.y, d~c~.ling ...................................... The certificate is issued to . 14~..&. la~j,, golan, l~.ed~r.~n ....... 0wn~j ............ (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval AprJ. l....1.8.. :197.3....by. tr...Villa. UNDERWRITERS CERTIFICATE No.. ~ .?~;~9.1....F.~b.. ~J$...1.9.~.3 .................... ttOUSE NUMBER..127.~. ...... Street ......Ml~l,~lO~;Oia .l~t'l .15X1;~ ..................... Building Inspector ~0~ NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, N. Y. BUILDING P. ERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) 6116 Z Permission is hereby granted to: to ~d. ld ne~ one...ff..a.~.~7..~.~...e..]....3,~..n.§ ............................................... at premises located at .....~..~.........~.~.~..~;L.e..~.~TI....~.~...~-...~..~.~. ................................................................ ............................................. Oz~.em_uor. t ......... ~,,~, ........................................................................... pursuant to application dated .......................... J~.]3~ ......... ~J......, 19...~.///~., end approved by the Building Inspector. Fee $...~.,..~. ........... pEP~MIT INCt_UD~S APPROVAL TO ?,EMoVE EXCESS FiLL FLOM ABOVE pREMISES BY ~,'.-:"~ LCT ~ U~d'v'Ev/AY cON~-TRUCT;O~'t ~- ~ ~ ~ cONS~KUC~[GFI CELLA~ CONS] RUC] ',ON ~ Building Inspector · FORM NO. 6 TOWN OF SOUTHOLD Building Depo~tment Town Clerb Office Southold, N. Y. 11971 APPLICATION FOR CERTIFICATE OF OCCUPANCY Instructions A. This application must be filled in typewriter OR ink, and submitted in duplicate 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 Resirtences 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. ,~ccurate 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 3. Copy of certificate of occupancy $1.00 $5.00 / ' / / .... .................... New Building ..... . .~... ......... Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Pro.erty Owner Or Owners Of Property ..,~...~....~..~..~..~..:.....J.0..~- ....~.........?...~....~...~..~....~.....~,.../~... .......................... Subdivision .............. ~ ............................................. Lot No.... ,~....... Block No....,~,,..... House No...,J..,~,].;~ Permit No....~.!../...~.....'~.... Date Of Permit~..?~../.!J.l~.,~pplicant ~u~-G~:~[~`~/~ Health Dept. Approval ............................................ Labor Dept. Approval ................ ..~....'.....~... ................. Underwriters Approval .............................................. Planning Board Approval ...... ..~.....~../~ ................ Request For Temporary Certificate ........................................ Final Certificate ....~....~.... ........................ Fee Submitted $ ...'~....~ ............................ ................ day of ............................................ Notary Public .................................... County Construction on above described building(~er, mit mee~.~al~a~ph~le codes and regulations. ~ Applicant ...~-~...~....~.~.~ ........................................... Sworn to before me this /~'~'~ ~' ~ '7~ (stamp or seal) /'~' '5"0°c ~ SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D.Reference No~Q Date~l'/7~ EASTERN DISTRICT, RIVERHEAD,N.y. APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Approval to construct said systems is requested,pertinent data herewith: i-Applicant ~t~ ~ ,~ ~ Gu ~ ~- f' ! [- ~ ) Phone 6-Sub div Address f~ ~_-_,~ ~ ~ ,~- .~, ~. 7-Section 2-Detazled b~roperty locatzon_=,-A'- .~, ~ ~,~ ~4. ~ ~, ,~ ~· ~ 8-Lot No. Hamlet/'~:~,~ ~,~,,,~ Town ~',~~ 9-Private well? J-P~blic 5~a~er' s~ply name ' Distance to nearest main 4-Lot S.tze: Width.~ft. LengthjA_~ft. (also enter on center plot plan below:) 5-Dwelling: Singl~ Family ~ Two Family? /,/Cellar? ~/Slab? ~ ~ Crawl Space? lO-Proposed system: Septic ta~k ~/Prec~z~.__/Cesspoo s~'/K/Shallow pools / /Other / / 11-Septic tank inside dimensionsf Volum ~;,,~Gals.Length ft. Width ft. Liquid depth ft. 12-Precast sections: /2~Number~Squa~. Cesspools: Block sizeL incs.D ins. H__~ns. Total blocks below inlet: ~1 ~2 PLOT PLAN Capa cit~als. Indi ~te No "Construction of authorized installations will be in ~A~__ Data Feet 0 2 4 6 8 10 12 ~6 i8 ~h The Undersigned CERTIFIES: accordance with the Suffolk County Health Departments' current Standards, Bulletins, and amendments thereto, covering Private Sewage Disposal Systems". Date ,~ u~ Signed ,. . . ~ ~ Builder FOR HEALTH DEPARTMENT USE ONLY. Based on the information presented herewith, it is the opinion of the Health Department, that an adequate and satisfactory Sewage Disposal System can be installed on this Plot. Date ~////~, Signed (10/65 Revis.) S-15 APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS INSTRUCTIONS: Applications must be submitted in triplicate i-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 thorofare, also Hamlet/Village .% Township 3-Enter name of Public Water Supply District, together with the distance to their main. ~-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-Dwellings: Check-mark "V" items applicable to the proposed new dwelling. 6-Name of sub-division ?-Section Number 8-Lot Number 9-Private well: Enter "No" if Public water supply is available. Enter '"les" otherwise. PROPOSED SYSTEMS: Answers to Items number 10, 11, .% 12 please consult the Suffolk County Health Department's Standards, Bulletins and Amendments for Sewage & Waste Disposal Facilities. i.e., Part II-Residential Sub-surface Disposal Systems covering Cesspools Part III " " " " " " Septic Tanks Part IV " " " " " " Unusual soil conditions Part V " " " " " " Shallow Leaching Pools PlOT PLAN: The following information is required concerning the Applicant's Lot: 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 shown on face of this application. Surface waters-Streams, Lakes, .% Bays, etc., located within a distance of 50 feet of Applicant's Lot lines, must be shown on the plot plan also. Wells and Cesspools now on adjacent lots must be shown on the Plot Plan together with the distance to the Applicants proposed Sewage Disposal Systems and Well. Where no Buildings exist on adjacent lots, state "Vacant" on the plot plan. 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-100 feet minimum distance from the nearest cesspools Well-25 feet minimum distance from rear, and rear sides of property lines Well-10 feet minimum distance from front, and front sides of property lines Well-50 feet minimum below grade for well point Well-40 feet minimum into ground water for well point Well-4 feet 6 ins. minimum below grade to well head and lateral water pipe CESSPOOLS LOCATION: Upon determination of the Sewage .% Waste disposal "type of systems" required, the following Standards must be observed for the location of same: Cesspool-10 feet minimum distance from lot lines to center of cesspool Cesspools exterior must be 100 feet minimum distance from nearest well Septic tank exterior must be 75 feet from nearest well Cesspool "Center" must be 12 feet minimum distance from nearest water line Cesspool "Center" must be 15 feet from house foundation Cesspool exterior must be 50 feet minimum distance from surface Waters, Streams, Lakes .% Bays, etc. Cesspools must be 20 feet minimum distance from large trees Cesspool center to Cesspool center must be at least 16 feet Cesspool cover top to grade must be held to minimum of 1 food to maximum of 2 feet Bottom of Cesspool to ground water must be held to minimum of 1 foot as 5UR. Va'YED .. VA~ T.UYL~,5ON / SUFFOLK COUNTY HEALTH DEPARTMENT 9A;E APR 1 8 1973 .. 9. ~EF. The sewage disposal and water fne!!i~es for this location hav~'been ~ns~ccti3d bV this depar_~nt ~d ~ound-- Chief of General Engineering Services Examined .........~......I...~......, Approved .................... ..~,. ................ , TOWN OF SOUTHOLD ~/,~-~ ,UILDING DEPARTMENT TOWN. CLERK'S OFFICE '~ ~ / ~ ~'~: '~-''~ SOUTHOLD, N. Y. Disapproved a/c .................................... i ......... ' ' (Bui(~J'ing Inspector) { APPLICATION FOR BUILDING PERMIT Date .~.e.~..~.....]:.[. ............................... , 1c~....2. ........ o} Thi~ opplicotion must be complotelv {ill,d in by ~pewriter or in ink ond submittofi in doplic~t~ to th~ Buildino~ Inspector. ~ b. Plot plan showing location of at and of buildings on premises, relationship to adjoining premises or public streets or~ areas, and giving a detai[~ description of layout ofproper~ must be drawn on the diagram which is ~ of this application.~ ~ c. The work covered by this application may not be comme~ed 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 pr~ress of the work. e. No building shall be ~cupied or used in w~ole or in part for any pu~ose whatever until a Ce~ificate of ~cupancy~ shall have been. granted by the Building Inspector. APPLICATION IS HEREBY /V~DE 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 a~terations, or for removal or demolition, as herein described. The applicant agrees to comply with all applicable laws, ordinances, building code, housing code, and regulations. (Signature of applicant, or name, if a corporation) Ney S'u~£o].k Ave. (Address of applicant) State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder. .............. iii: ........... .......................................................................................................................... Name of owner of premises ..... ...)~...~....~......~....8..e....~.o....h~.......l~....~..e.~..a.. ..................................................................................... If applicant is a corpQrate, signature of duly authorized officer. .................. i~ame and title of corporate officer) 1. Location of land on which proposed work will be done. Map No.: ........................................ Lot No. Street and Number .....~..~..~..~...o..~......~1~....~..~.. ................................... .G~--~m.131~t~e...~,~..,~ ........................................ Municipality State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Exisiting use and occupancy .....~.~.~,~.~.~...~¢~.1~. .................................................................................................... mew aaa £amil~r ~ell~ b. Intended use and occupancy .............................................................................................................. 3. Nature of work (check which applicable): New Building ........ .~[ ....... Addition .................. ^Iteration ....... ?. ......... Repair .................. Removal .................. DemolitJor. .................. Other Work (Describe) ........................................ 4. Estimated Cost ...... .$~.~OlJlJe/~O ................................ 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 ....... ..[. .............................................................................. ~ ............. ~ ....... .~. ............................. 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 alteratio~s or additions: Front~ ....................................Rear ............................ Depth ................................ Height ............................ Number of Stories ................................ 8. Dimensions of entire new construction: Front ............ t~..(.J. ................... R~, ..~..0.. ~ n~,~ 2 Height ..... .[~....~. ....... Number of Stories ....... ..[. ............................................................................................................ 10. Date of Purchase ........................................................ Name of Former Owner ........................................................ 11. Zone or use district in which premises ore situated 12. Does proposed construction violate any zoning law, ordinance or regulation? ...... ~ ................................................. 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 ~,,~' COUNTY Of .... ~/j~./.-~..:...~.$ ' ..~ ............................. .~l~.:.~.~.J;~. ................... ~ ...... being duly swam, deposes and soys that he is the applicant (Name of individual signing application) ..... .................. ...................................... above named. He is the ~:"c~'~, c~'offic~'~: 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 application filed therewith. Swam to before m,e this .................. l- da of ........ .... ',,j II 0 ,~ - ,~ ~ >'~' ~ .._~....,~.. ox~ ...... ( / _ ~ .-.,-~ ..'"T-'-7'..'(.,~ ~.. · · · ..-',~.'~N'F.'~. .......... ~...~...va-d.,,,.,,..,..~. ....................... Notary Public~~..,.~,.~'-;~-*~.....~County ~ (Signature of applicant) ~ ' JUDITH T. BO~J~bJ . CtJr, tl,,~ i,~rl Ex~!lre~ Mc~tch exrepl by ,a Licensed Profes- sional Engineer, is Ille§a" $~lior~ 7209, ,Subdivision 2, N, ¥. Stere, Edu~cqtl6n Law. '!Alteration of thls Document ~,--'-.,-'-.-~- except b}' a Licensed Pro[es-~ Sechon ~0~, Subdivision ~ e×cepf by ~ Licensed Profes- sion,~l E,~gineer' is £~chon ?209, Subdivision N. Y. Sl~le Educ~lfon Law. n I I ---I -I I AI~aroton of Ibis Document exc?~ by n L~censed Profes~ $~onol Enguleer, is ilJegoi". N. Y. Stele Education