Loading...
HomeMy WebLinkAbout6190-zFORM NO. 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold, N. Y. Certificnte Of Occupnncy THIS CERTIFIES that the building located at Ctmt~/' 'Av~ ................ Street Map No~l.th/'J.~lA. ]]Mock No ........... Lot No ....... B.mxthold.. N.,Y, .......... conforms substantially to the Application for Building Permit heretofore filed in this office dated ............. 0~;.. ~0, 19 '7~' pursuant to which Building Permit No. dated ........... 00~,.. ~0-., 197~., 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~.~vat,~ · o11~ .£a~lj,]r. d[tmllln~ ....................................... The certificate is issued to .1~,. ~Ktmb~$~ ....... 0tme~': .......................... of the aforesaid building. Suffolk County Department of Health Approval (owner, lessee or tenant) ..... UNDERWRITERS CERTIFICATE No.. J.~ll~. · .~.8 ·. ~3" b~' .,T,. ]~'llbae .k~ ............. HOUSE NUMBER...$~00 ...... Street... O~l~g~..&~ .................................. FOF, M NO. ~ TOWN OF SOUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTHOLD, Nr. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE P~EMIS£S UNTIL FULL CQMPLETION OF THE WORK AUTHORIZED) N? 6190 Z Permission is hereby granted to: ...... ~.~..~ ....... .'fi'.~...~.~..,~ .......................... ....... ..~/~ ......... ~.....!~.~.~..~.~..V...!....~ et premises Iocoted or ................. ~ ................. *~-~ .............. ~* ....... ~ ................. ~ ............................... ...................................................................................... ~.~.u...~l.~.~..~.~ .................................. .... ........................................................................................................................................ ~o 0~ 7~ pursuont to opplic~tion doted ........................................................ , 19 ........ , ~nd ~pproved by the Building Inspector. Building Inspector SUFFOLK COUNTY DEPARTMENT OF HEALTH HoD. Reference APPLICATION ~OR APPROVAL TO CONSTRUCT A PRIVATE SBWACE DISPOSAL SYSTEM 1. Applicant Z~O ~f~ ~ c ~. Phone~/~ 5. Subdiv. Address ~ ~O ~ ~e~ ~ 6. Section 2 Property locati~ ~ O~ ~'~g- ~ ~ 7 Lot No. 8. Private well Village ~o~ ~7~L~ Township ~o ~ ~t~ 9. Public water . / 3. Public Water Company name Distance to main 4. Lot size: Width~feet Length /~ feet (Enter on center plot'~below) 10. Sewage Dispos~ystem. A. B. ~aching pools. Number ~recas~Block Special If private well fill in blanks below: Tank capacity/~-~als. Pump G.P.M. Total well depth~ Depth to G.W. Amount of wa~er in Test Hole Data ~eet 0 2 6 8 10 12 14 16 18 The undersigned :ERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Department o~ Health~ current_ stand- ards thereto." Date Signed ~ Owner ~ Builder FOR HEALTH DEPARTMENT USE ONLY. Based o~n 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 g,','~?'la~, ~ ~ Signed ~ ~--~ ' ~ S-15 Revised 4/1/72 APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SWWAGE DISPOSAL SYSTEMS INSTRUCTIONS: Applications must be submitted in triplicate 1-~;eans Owner or Builder. Address to which mail should be directed. 2-¥mans 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. ~OPOSED SYSTEMS: Answer to Item number 10, 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: '-~ 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. 2. Surface waters-Streams, Lakes, & Bays, etc., located within a distance of 100 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. WELL 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 fromrearand rear sides of property lines when possible. Well- 10 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. CESSPOOL LOCATION: Upon determination of the Sewage & Waste Disposal "type 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 100 feet minimum distance from nearest well. 3-Septic tank exterior must be 75feet 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 foundatie~. 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 ~st be held to minimum of 2 feet. ' TOWN OF ~UILDING DEPARTMENT , TOWN CLERK'S OFFICE ,. ~ / -~ , //_/ ~mm*d ........................................ , 19 ........ ~pr~ed ............ ; ...................... "..., 19 ........ Pemit No .......~ ................... ~;....~ Di~pproved a/c ............................................... ! ............................................ ............................................................................ ............... ................. ........ ~Su~ldmo In*~tor) ~M~TI~ ~OR INSTRUCTIONS · ~,~ a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, wig 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 adjoining premises or public streets or areas, an~ giving a detaili~d 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. e~ 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 been granted by the Building Inspector. ~ APPLICATION IS HEREBY MADE to the Building Department for the issuance of a Building Permit pursuant to the Building Zo~ Ordinance of the Town of Southold, Suffolk County, New York, and other applicable Laws, Ordinances or Regulations, for the constructionJof buildings, additions o~ 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 ad mit authorized inspectors on premises and in buildings for necessary inspectior~s. ............................................................... ;";;;;Z'; .... (S~gnature of apphcant, or name, p ........ ........ ............ (Address of applicant) / Name of owner of premises ...... ..~....~..../..~.~ .................................................................................. .~. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Street and Number ..~..,...~ ...... ./~..te......~.... ............ ~ .................. ~ ............................. Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existinguse and occupancy ............ ~,,e~ ................................................................. 7 ........................................ b. Intended use and occupancy .................................................................................................................................. ~ Repair ......................... Removal ......................... DemolitiOn ........................ Other Work .......................... ~1 ........ (to be paid on filing this application) 5. If dwelling, number of dwelling units ........ .~. ...... Number of dwelling units on earth floor ...... ~ ................................ If garage, number of cars ............................................................................................................................................ 6. If business, commemial 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 ...... ...~....~.....;. ........ Depth Height ................ ~....~....~. ....................... Number of Stories ...........Z .......................................................................... 9. Size of lot: Front ....... ./...~......~.. .................. 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 from premisasi [ ] Yes ~]-No 14. Name of Owner of premises ~..ZL~....~...~i ....... ..~...~...:./..Z........~.~...v~?~......,~ ............................. (Address) (Phone No.) Name of Architect ............... .,~.. ......... ,z~ ............................................................................................................ ~'~ / / /) ~Address) / / . __ (Phone No.) ~ Name of Contractor ....~....../..~.~....~.. ........... ~...~ ........ 7~....'.~...'7.....'~.....~...?..:Co ..... { (Address~ (Phone No.) 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 ~nd indicate wheth- er interior or corner lot.. j ~-~t~ ~7~ ' - / ( COUNTY O~,~&~-~-. ................... / .......................................................................................................... being duly sworn, deposes and says that he is the applicant above named. (Name of individual signing contraS) ,s he ............................................................... :::..L ............ ......................................................................................... (Contractor, agent, corporate officer, etc.} of said owner or owners ~a~s~xluly authorized to ~erform or have berformsd the said work and to make and file this application; that all atataments contained in this ~llg!~stion are true to ~h~ I:~ll~ [81~ ami belief~ and that the work will be bedorrned in tbe manner set forth in the a I~icafion fil~he~ew;th. No~a~ ........ ~"~ ..................... .~ ~ ,,.~ ..,..-~z::2~ /~ ,~"~°~'.'"*'~'~ ....... ,~ ~. ~ /~ __ DEPARTMENT OF HEALTH · ,RIVERHE AD~ N.,Y. A/ SUFFOLK COUNTY HEALTH DEPARTMEN~ ~A~UN :2 5 The sewage disposal and ~vat~r supply facilities for this location have been inspected by This department and found .%0 be satisfac%ory.~7-~. ~ ~ ~ Chter of General EngineeI~ng Services x, ?Z.