HomeMy WebLinkAbout6138-zFOR~ NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
No.. ~.~9 ..... Date ............ ~.eb ..... 8 ...... , 19..~.3
THIS CERTIFIES that the building located at . .8/fl, .B&}w.~.~w. ~ ....... Street
Map No. T. erry..W&te~lock No ........... Lot No...26 .... Sottthold...N,~f.,. ........
conforms substantially to the Application for Building Pemit heretofore filed in this office
dated .......... 5ep% .... '2t, 19.. 72Pursuant to which Building permit No..6538Z.
dated .......... 8ellt... 2~..., 19..7.2, 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 . P. rivate. ~me .fmaily. d,wellin~ ......................................
The certificate is issued to .. Foumiex, s · Homes. She ............ Qwaer. ..............
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval
UNDERWRITERS CERTIFICATE No ..... Il. 6t8723.
Feb .8,..1973...by. R, .¥illa ......
.Ian.. ..1973 ...................
HOUSE NUMBER .... 1 ~1 .~0~. · .Street ...... 2ayview. ao&l ..... ........................
FORM NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTHOLD, N.. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE P~REMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N? 6138 Z
Permission is hereby granted to:
......... ~.¢rma~exm .Ik~.s ..:l.ac ............................
................ ao~,t, helct ............................................
to .,q~a,1.1~..ne~...az~e..~,m~...dwa~Ling ....................................................................................
at premises located at ......~'~"~Oe~ ............ ~,~'""9~ .........-~e-l'~-~'"We.~l-lJ .....................
................................................. Oou~h'o't~ ....... ~';¥';' ...........................................................................
pursuant to application dated .......................... JJ~pt~ ....... 9.1 ......... , 19~ ..... and opproved by the
Building Inspector.
Fee $...¥J..e.OO ..........
~'- ' '~'~ -- TOWNOFSOUTHOLD
· /~'/~ ~ "UI~ING DEPARTMENT
~/'~ TOWN CLERK'S OFFICE
~UTHOLD, N. Y.
....... .......
~ro~ed ............ '..~ ............... '..~ ....... , l~...~..~Pemit No..~..U.~...~... ...............
APPLICATION FOR BUILDING PERMIT
INSTRUCTIONS
e. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, wi
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, and
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 mav 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 or
the premises available for inspection throughdut the work.
e. No building shall be occupied or used in whole or in I~art for any purpose whatever until a Certificate of Occupancy shall have beel
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, housing code, and regulations, and to admit authorized inspectors or~ premises and in buildings for necessary inspections.
(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 .....~'.~..~,..k~.12.,~.,l~.& ...... '~':~:.!~.~.,,~ ........ ~.J~..~..~ .....................................................................
If a~pli,r,a~nt is a corporate, signature of duly authorized officer.
(Name and~tle-"----of corpoFate officer)
1. Location of land on which proposed work will be done. Map No.: .............. ..~.~.~..~..Y......~.....~.?.~,~Lot No.....e~. ....
Street and Number ...~.~....~.~.V..i~.b~...J~.~. ...... ].J.~.!......~...~..e.l~..~..~./.,~...~......~...,~...; .............................................
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.....~..~..~. ...............................................................
3. NatUre of work (check which applicable): New Building ................... Addition ..................... Alteration ......
Repair ......................... Removal ......................... Demolition ........................ Other Work ..... ...., ..........................
~. ~.~ ~ I Description)
4. Estimated Cost ......... .0....O...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 .......k~....c..J~...~.. ...................................................................................................................
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 ....~'.~..../. .......... Rear. '-~z'l ..... Depth ..~. ...........................
Height ..... ~.~.. ...................................... Number of Stories ...... /.. ............................................... ~ .........................
/ !
lbo ...
9. Size of lot: Front ...... /./.~... ......... Rear ....... ~../~. .......................... Depth ..........................................
10~ Date of Purchase ..~..~..-['.....-....J.~..~..~. ...... Name of Former Owner ............................................................................
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 ..................................... Will excess fill be removed from premises: [~g~] Yes [ ] No .
~ ~ ~ ~ (Address) ~ ~ (Phone No.)
N~e of Archimct .....................................................................................................................................................
~ ~ ~ ~ (Address) ~ t (Phone No.)
Name of Contractor ...................................................................................................................................................
(Addre~) (Phone No.)
PLOT DIAGRAM
L~te clearly and distinctly all building, whether exi~ing or propo~d, and indicate all ~t-b~k dimensions from
prope~ lines. Give ~reet and block number or d~ription according to deed, and show ~reet names and indicate whe~-
er interior or corner lot. ~~ ~~S -
STATE O~ NE~¥OBK.
CO U N Ty O F .....~...~....~.:..~ ..,.~y:~
...................................................................................................... ,.. being duly sworn, deposes and says that he is the applicant above named.
(Name of individual signing contract)
~a 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 that the work will be performed in the manner
set forth in the application filed therewith.
.,-~ 'TE..I LEE
' ~¥~.' .OTARY PUBLIC, State ol
......... ~. ....... :: ............ day
,. s.,,o,,
· ~mmission Expires ~lrch
Notary Public .................................................................... ~,ounw ........ ...~.I~.~.0.(...~ ..... I:A&*..*. ..~; ....................
[~tgnature of applicant}
lrOlt.M NO. 6
TOWN OF SOUTHOLD
Building Dsparl'matt
Town CJeJ4[I Office
Somhold, N. Y. 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 dispcsol--(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 "pm-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.
Co
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 ..... ...v~.... ........ Old or Pre-existing Building ............................ Vacant Land ............................
Location Of Property ..~..~.~..'~..~..!.~...~...l~..I].T.././~.[.~.~...~.C~.~..~/..~./.,~......;Z ...... ..S...O..?..?....~.~.?.. ...........
Owner Or Chvners Of Property ...~..o....~..ED.~..~-..~..~.......~..o...~.....~.~. ....... 1.~,,.~...: ...............................................
Subdivision ....~.~.&.~...~.........M~.....~j..'~..~..~...~. ................ Lot No...~.~..... Block No ............. House No. ............
Permit No. ~.~..~.~.....~,.. Date Of Permit~.~.~l.?~p~pplicant . .F..o...¥....~...D...-~...~...~.......~.~....e~....~...~.....I..~.~...c..;...
Health Dept. Approval ............................................ Labor Dept. Approval ................................................
I
Underwriters Approval ..~.R..~...~.~.;).~..~.~...~Planning Board Approval ........................................
Request For Temporary Certificate ........................................ Final Certificate ..........................................
Fee Submitted $ ....................................
Construction on above described building a~r~ ~2t. m~eets~ all applicable codes and regulations.
Applicant ....~~....~... ....... ~, .........................
Sworn to before me this
................ day of ............................................
Notary Public .................................... County
(stamp or seal)
SUFFOLK COUNTY DEPARTHENT OF HEALTH
.D.Reference
APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS
Approval to construct said systems is requestod,pertinent data herewlth: Date.~,~
/
1-Applicant Tt
Address . _. 7-Sectmon
2-Detail~ ~r6~e~ty locatio~ · 8-Lot No.~_~~
Hamlet ~.~.'I'~A,=~.,'~ Town _~'I",A,,.L~ 9-Private we-ll?
Distance to nearest main ' -
3-Public ~ter supply name
4-Lot Size: Width~ft. Length~_ft. (also enter on center plot plan below:)
5-Dwelling: Single Family ~Two ~Family? ~.JCellar? ~.Slab? ~_~Crawl Space?
10-Proposed system: Septic tank ~w~Precast ~Cesspools ~(~YShallow pools
ii-Septic tank inside dimensions: V~olume~$Gals.Length ft. Width ft. Liquid depth ft.
12-Precast sections: .~_/.Number~Squar~ Ft. Cesspools: Block size~--- incs. D_~ins. H ins.
Total blocks below inl&t: ~1 ~2 ,~3
PLOT PLAN
Street
Capacity ~Gal s.
o.P.~. Y
Grade
Indi
No
"Construction of authorized installatiom
Data Feet
0
2
6
8
10
12
~6
will be in
can be installed on this Plot.
Dat~~..
(10/65 Revis.)
S-15
Signed ~ -"*"""=~--~.
The Undersigned CERTIFIES:
accordance with the Suffolk County Health Departments' current Standards, Bulletins,
and amendments thereto, covering Private Sewage Disposal Systems".
Date~_~ Signed~.
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
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 ~ame 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
7-Section Number
8-Lot Number
9-Private well: Enter "No" if Public water supply is available. Enter '~es" otherwise.
PROPOSED SYSTEMS: Answers to Items number 10, 11, & i2 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 " u . , ' " Septic Tanks
Part 1~ " " " " " " 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, & Hays, 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 s~own on the Plot Plan
together with the distance to the Applicants ~
propos?d 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-lO 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
TO THIS SUKVEY IS A VIOLATION OF
EDUCATION LAW,
Chiuf of Csueral Engineering
SorviceS