Loading...
HomeMy WebLinkAbout6156-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Cerli[icale O[ Occupancy No. ~ ...... Date ............. Doo.. 2t ....... , 19.72. THIS CERTIFIES that the building located at .... l~p~t .l~la~l~,sg. lloa(l. · Street Map No..1~1[ ........ Block No... ;~t ..... Lot No. llalat .... 80~t~015...1~][., ......... conforms substantially~ to the Application for Building Permit heretofore filed in this office dated ........... 0Or. - ~..., 19..~$ pursuant to which Building Permit No. dated ............. 00~...~...., 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 ...P~..~?~?,0...o~....f..~.~..l,y..d..~..1.1...~tg .................. . .................... The certificate is issued to .. J. ohlt l~l'~l~tg~ ....... 01~tox' ....................... (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval .. UNDERWRITERS CERTIFICATE No. ]}~e-~8.1~.-b~'. ~--][l]ll~k]. ................... HOUSE NUMBER... ~,.~[ ...... Street .... ~l[[~l~ .I~11S~1].11[~. ,i~O~l]. ....................... Building Inspector FOF~ 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? 6156 Z Permission is hereby gronted to: pursuant to opphcobon doted ........................................................ , 19 ........ , and approved by the Building Inspector. Fee $....~...?...J~... ......... Chief of ,, . .. Services FORM NO. 6 TOWN OF SOUTHOLD Building Department To~n Clerks Office Southold, N. Y. 11971 APPLICATION FOR GERTIFICATE OF O~¢UPANC:Y 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 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. Date of any housing code or safety inspection of buildings or premises, or other pertinent in- formation required to prepare a certificate. C. Fees: I. 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 Date .. ~,~.,.....~,..~.. ....... ..?,,,..~... New Building ....... ~. ........ Old or Pre-existing Building ............................ Vacant Land ............................ Location Of Property..~.~/~' ....... .~..~.~..~...~.~'~..../~....~.. ....... ..~'..~.....~.'...~..../."~".~_. ........... ...~.;....~....:.;....~,,,~...~..~...~. '~ Owner Or Owners Of Property ~..O....~....~.......c~......./~.....)~......~.....~. .......... ~....~..'..~....~..~....~...~...~.../....~.. ................ Subdivision ................................................................ Lot No ............. Block No ............. House No ............. Permit No.~.../..~.~.....~.... Date Of Permit ../..~./.~...?.....~.Applicont ...... ~...?~.....~. ...... ...~...~.....O....(.......~.... ................ 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 pe~rl~ meet,~ll applicable codes and regulations. Applicant ......... .~..............~.~...~..." .................................................. Sworn to before me this /-'~--~ c~ ~ ................ day of ............................................ (stomp or seal) z/~/?/~' Notary Public .................................... County ~~ SUFFOLK COUNTY DEPARTNENT OF HEALTH APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM 7z~ 1. Applicant l~ ,~ ~.~[~.- Phonef~t~g5 Subdiv. ~ Address ~ tO~_~_ -~P~'7-/-~;~ 6[ Section __ 2. Property location ¢~ ~ 4'J ~t~ /~' Lot No. ~ Private well ~ Village ~'~ ~' ~ Township ~ ~ ~ 9. Public water -/ -- 3. Public Water Company name ~/~ Distance to main ~ 4. Lot size: Width /f/ feet Length /~ feet (Enter on center plot below) 10. Sewage Disposa~ystem: A. ~0~gallon septic tank: Precast ~Equivalent Block B. ~eaching pools: Number_5 Precast ~lock Special__ If private well fill Street in blanks below: Tank capacity~oZGals. Pump G.P.M.~ Total well depth Depth to G.W. Amount of water in well ~"~ Test Hole Data I Feet0 L~.'z-~ 7""~'~'~i 10 12 14 16 18 The undersigned CERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Departm~r~ of Hx~a?th's current stand- ards thereto." , / ' Odner or 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 f/~f-- Signed ~ ~~ ~ S-15 Revised 4/]/72 TOWN SOUT.OLD BUILDING DEPAI~TMENT TOWN Exomi.ed ....... ~.~ ....... , l 9..~..~ ~'. ~.~ ,,....Z *e i, Di~pproYed o/c ............... __ ..................................... ~'~'~ ..................... · ........................... ( uilding Inspector) Dte INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building nspector, witl~l~ 3 sets of plans, accurate plot plan to scale. Fee according to schedule. b. Pict plan showing location of lot and of buildings on premises, relationship to adjo n ng premises or public streets or areas, an~, gwmg 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 bee~ granted by the Building Inspector. Orot. A. nPaPnLc~lCoAfTtlhOeNT 'oSwnHoEf~ButYholMdA, ~uEffto°t~uBn~iyl,d~legw~Po:~(t,~toft~re~pil:Sc~l~aC~sa O~iilne2~rr~teg~l~i~t' ftc°r tt~l: BcoUr~lsdt~ungctiZo°nnoe~ 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 pre mis~.~nd in buil~[b~s for necessary inspections. (Address of applicant! State whether ~essee, agent, architect, engineer, general contractor, electrician, plumber or builder~ Name o owner of premises ..~..~;~i .........................................................................., If applicant is a corporate, signature of duly authorized officer. ~ (Name and title of corporate officer) ~ 1. Location of land on which_j~/.~ /~/__ ,,~ ~ _,_. ~proposed work will be done. Map No:: ................. Lot No ................... ~i ......................... ' Street and Number .......F-./....d......~/_.~..~/~.....~....~..~ .......................................................... '~ ~5- ~/ V 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 .... .~...~..~ ......................................................................................... Nature of work (Check which applicable): New Building ....... ~.. ........Addition ..................... Alteration ............... Repair ......................... Removal ......................... Demolition ........................ Other Work .................................... (Description) 4. Estimated Cost ..(~.,~.,.,~,,.,,~,..,~,...:..?.,..~,, ............ Fee ................................................................................................. (to be paid on filing this application) 5. I;~cT~lllm~ number of dwelling units ................. Numar of dwellin~b~its on each flo~ ~ ........ ,J ........................ f _ . ~ ,. '~ ~ ' ~, r~ ~l . .. ~ra~, numar OT cars ......................... ,~..,..,.,..,..~ ....................................................................... 6. If busine~, commercial or mixed occupancy, specify nature and extent of each ~pe of u~ ..................................... 7. Dimensions of existing structures, if any: Front ...... ~ ........ Rear ..... Height .................. ~ ..................................... Numar of Stor~s ....~ ...... .~...~ .......................................................... Dimensions of same structure with altera~r ~dit One: Front ~ ...... ~ ............. Rear ......................................... Depth ............................. ~ ............... Height .................................... Numar of Stories ........ ~ ............................ 8. Dimensions of entire new construction: Front ....... ~.~...~. ...... Rear ....... .~.~..' .......... Depth ................................. of Stories Height .......... ~.~...~.~ ........ ~ ................... Number ...... ........................................................................... 9~' ,Size of lot: ~ront .........~ ...................... Rear .......... ~/. ......................... Depth ....~ .................................... Height .................................................... Number of Stories ............................................................................. · 10. Date of Purchase ..................................... 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 fro, mpremises: [ ] Yes [~(] No 14. Name of Owner of prerp'~......~...../'M...~/.. ....... ~...~.....~..~....~...~..~....~'..'~..~'.. .............. .~....,...o....~../.~..~...4..~. .................... Z ~ ,,~ (Actress) (Phone No.) Name of Architect ~.~ ........................................i~J~'~i ................................... i~'~'~"~l'~;~ .............. Name of Contractorc~.......~...../..~....~f~...~x"L~ /~' ................... .~......~....~... ............ ........................... ..................................... (Address} (Phone No.) PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from I~per~ lines. Give street and block number or description according to deed, and show street names and indicate wheth- STATE OF.EW SS .......... .......................................................................................................... being duly sworn, deposes and says that he is the applicant above named. (Name of individual signing contract) He is the ................................................................................................................................................................................................................. (Contractor, agent, corporate officer, etc.} of said owner or owners, and is duly authorized to perform or haveperformed the said work and to make and file this application; that all statements contained in this application are true to th~,U~l~*~o~ ~I~EN~I~e and belief; and that the work will be performed in the manner set forth in the app~l~cation filed therewith. No. 52,0344763 Suffolk Counl~,~ ................................... (sign'S;;; ';;; ';;;;;ii;;;;;i .....................................