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Home My WebLink About6137-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificate Of Occupancy No. ~..~99~ ...... Date .......... .FgD.*.... ~. ........ , 1973.. THIS CERTIFIES that the building located at . .t~a~,ew..Rd..g,. ~.ong.v;l.e~¢. l~treet Map No?e.r.~M. ~:~.~q?;'~lock No ........... Lot No..1 ..... .8.o.t~;hP.!d.' ~.~5~ ~ .......... conforms substantially to the Application for Building Permit heretofore filed in this office dated ............ '.3~.p.1; .... 2] 1972.. pursuant to which Building Permit No. 6.1.37S.. dated .......... 5.'e.p~;....2.2 .... , 197.2.., 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 . Pa~SLva~;e. one..£am~L&y, d~/e k ~ ~Ln g ....................................... The certificate is issued to .. F9 .u~.q~9~'.a..Hpm. e.s...I.n.e. ...... .oy~..e..~ ..................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval ..Feb .8...1.97~...t~y. ~...¥~l].a ..... UNDERWRITERS CERTIFICATE No .... .l~I. 68?22 .... ~.~...2bt .... 1.973 ................. ttOUSE NUMBER..'1.'~.2.00 ...... Street ....~.a..5:'kV.~ ..Rd ................................. ~o~ 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) N? 6137 Z Permission is hereby granted to: ~'.o..-m~ .e.~. ~...~ ~.~... ,'I.x~.. A~. ............................. · lem'~ .~...~..~.....~.:~,: ....................... to .. ~.~i~...~...a...X~z~LX3r...4w~L~:U~ ................................................................................... at premises located at ......... Z~t..,~J ............... ~a~,.1~J~,~e~'l ........................................................... ............................ iS~:,r'~...II, mi.. & ..l~m~,~e~.../,~. ........... ~14 ...................................... 8 t, 21 19~...., and approved by the pursuant to application dated ........................ ..~ ........................... , Building Inspector. FORM NO. 6 TOWN OF SOUTHOLD Building Department Town Clerks Office Southold, N. ¥. 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 oW 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 pete ............ New Building ..... ..~.... ........ Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property .... ~...~...~.~.~.~..~.~.~..~../~..~c~.~..~.~...~.~`~..-~.~.~..~..~.~.~(~. ....................... Owner Or Owners Of Property ....~...o..~....~...I..~...~..~...5.......~.?...~......~...s.......l.j.~..~... ................................................... Subdivision .....~.~.~..~..~.........~....~...~, .~...~..~%. .............. Lot No....../. ...... Block No ............. House No ............. Permit No. ~../..~..~..~.. Date Of Permit~..~..?~Applicant , .~..~..~...~..i.?.,.~...~....~......~,.,o'. ~/'~,...~...~...~...~....C~.. .... Health Dept. Approval ............................................ Labor Dept. Approval ................................................ Underwriters Approval ~J.~.~...~..~,.~.~...A/r.4~f.)~l, planning Board Approvol Request For Temporary Certificate ........................................ Final Certificate ........ .'..../~. ......................... Fee Submitted $ .....-~...~ ............. Construction on above described building and [~ermit meets all applicable codes and regulations. Sworn to before me this Notary Public .................................... County (stamp or seal) O F /~oP~-/~T y AT- ~[CIION 7209 OF THE NEW YO~ STA~ [DUCATION LAW, SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D.Reference No,-,~ -//~ EASTERN DISTRICT, RIVERHEAD,N.Y. APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS Date ~.~ Approval to construct said systems is requested,pertinent data herewith: 1-Applicant ~ ~ NS ~ Phone~6-Sub div~ Address 7-Section locatio · - ~ V ~ W~m,. 8-Lot No. -~-- I 2- Deta il ed ~o ro~.~r ty Town ~ ~ 9-Private well? ~.~ Hamlet ~m~ ~%- %~, ~ ~ 3-Public water suppl~ name Distance to nearest main 4-Lot Size~ Width~_ft. Le~ngth~-~ ft. (al~o enter on,center plot plan below:) 5-Dwelling. Single Family ~ Two family? ~ Cellar? ~F'/~S~ab? ~ ~ Crawl Space? lO-Proposed system: Septic tank ~Precast ~/Cesspools ~Shallow pools / /Other / / 11-Septic tank inside dimensions: Volum~ Gals.Length ft. Width ft. Liquid depth ft. 12-Precast sections: ~$;eNumber/ /Square Ft. Cesspools: Block sizeL incs.D ins. H ins. Total blocks below inlet: ~1/fd$2 ~3 PLOT PLAN -i Indi e No ~th The Undersigned CERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Health Departments' current Standards, Bulletins, and amendments thereto, covering Private Sewage Disposal Systems". Date~7 ~- Signed ~ ~.~ ~ Owner or--Builder Street Capacity~ls. Data ?eet 0 2 4 6 8 10 12 ~6 i8 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: Appl~tcations must be submitted in triplicate i-Means Owner or Builder. Address to ~ich mail should be directed. 2-Means detailed description of property location, together ~*lth street name and distance to nearest intersection of main thorofare, also Hamlet/Village & Township 3-Enter name of Publid Water Supply District, together with the distance to their m~in. ~-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 "Yes" 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 l~ " " " " " " Unusual soil conditions Part ¥ " " " " " " 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 line~ of the heavy lined square in the center of Plot Plan sho~m on face of this application. Surface waters-Streams, Lakes, & Bays, etc., located ~dthin 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 s'howm 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 i food to maximum of 2 feet Bottom of Cesspool to ground water must be held to minimum of i foot FORM NO. 1 TOWN OF SOUTHOLD BUILDING DEPARTMENT .......... , .............................................................................. (Bu,ld,n~ I~ctor) APPLIGATION FOR BUILDING PERMIT r~A~ Date 5..1~..~ ...... S~,! ..................... , 19..~.~.... INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector ~th 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Plot plan showing location of lot and of buildings on premises, relationship to adjoining premises or public streets or areas,.~,id giving a detailed description of layout of property must be drawn on 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 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 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, building code~ ~lou ~ns.L~de, and regulations, and to admit authorized inspectors on premises and in buildings for necessary inspections. / J .......... / ' ~. --- '. ,--~ / ~L ~./ (Signature of applicant, or name, ,, a corporation, State wheth~ ap~',[~o,,[ ~s ~v,~-,~i-, l;~;oo,-agent, architect, engineer, general contractor, electrician, plumber or builder, ..................................................... ...... .............................................................................. owner of premises ...~'..O..~.~ .~?~..~ ........ ~.....t~..~.~........I..~...C~...: ......... ~...... ................ Name of If agplic,~pt is a corporate, signature of duly authorized officer. (Name and title of corpora~ officer) 1. Location of land on which proposed work will be done. Map No.: ....... ..-['~.~/~..'~.......~.....~..'~.~..~...~..~..... Lot No..J ........ Street and Number ...... ~j~/~V~P~-.~`~/~/~(~j~-~/~e~/~N~ ............................. 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 ...... /......~...e..~..~..L....~. ........ ~....~.....~..~,.I,t...~..~t. ............................................................. 3. 'Nature of work (check which applicable): New Building ...... . .~...... ........ Addition ..................... AIteration....~ ......... Repair ......... ........... ...... Removal ......................... Demolition ........................ Other Work .. ................ ............. · .... (Description) ,,,O,5~'o o O Fee ................................................................................................. 4. Estimated Cost ........... v ................................ (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 ......L...~,.~...~.. ..................................................................................................................... 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......... ............ · .......... · ....... ', I ~ ,~ 8. Dimensions of entire new constructioh: Front ....~,~. ............. Rear ...o'~'.~. ................. Depth .~. ............................ Height ..... /1~. ....................................... Number of Stories ...... /.. ................................................................................ .,.,,,~ " Si,a of ot: Front...lld. ........................... Raar ........................... Dapth ..... ................................... 10. Date of Purchase ..'~...~..~.,.T.......L~..~ ....... Name of Former Owner..~.....P.~//~A ................... ~ ................................... 1 1. Zone or use district in Which premises are situated ..................................................................................................... 12, Does proposed construction violate any zoning law, ordinance or regulation: ...... .,/.~. ................................................. 13. Willlctbere~aded .............................. Will excess fill be removed from premises: [ ] Yes ~ No 14. Name of Owner of premises ..~..~..~..~..eAg. A..../3~.~.C-~....,~Y...q ................................ ~.~:...2...3..~.Q ............... (Address) (Phone No.) Name of ' · · Architect ................................................................................................................................................... (Address) ·· (Phone No.) Name of Contractor ................................................................................................................................................... (Address) (Phone No.) PLOT DIAGRAM I,ocate 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~;cording to deed, and s_~how street names and indicate wheth- er interior or corner lot. ~ _^a,, .. ,, ,..,.ne ------- ' ~o,,'1 et-LO STATE OF NEW YO_RI~, . ) COUNTY OF ...~..~..~'n.~,~ ............................ ) ~ ~ ~ . L I ~O U~. . ~ing duly s~rn, depots and says that he is the appli~nt above named. (Na~ of indivi~ si~ing con~cO He is the .......................................................................... .~.g~6C~.~.~......a.E~.~.g.~ ...................................................................... { ~nt~tor, ag~t, coyote officer, etc. of~d owner or owners, and is duly authorized to ~orm or have ~rfor~d the said work and to make and file this application; that all state~nts contained in this application are true to t~ ~st of his knowled~ and ~lief; and that the work will ~ ~Hor~ in the ~n~r ~t fo~h in the application filed ~rewith. TE~I ~E E~.. ~ ,. ~ ~ NOTARY PUBLIC. S~te Or ~ew ~or~ .......... · ~ .............. d.vo~ ............ ~ ~ .~.o...~*~ : 5~C~IOH: £ ~,~ INANCEs, T~:,.$HALL BE CONS DE~'ED AS PART, 'O~, ~[CIFICATIONS FOR THI~ lNG AND*SHALL TAKE O~ ANYTHING SHOWN, OR IM~ED WH~RE S~ A~E AT ~ARIANC~ 1 FO UN DA, TIOH RLA. N PL~xN.! 12 L~" ,/ "" i .... . /4- O.C FULL S'F_c~' 1o N 5~z7 55Z7