HomeMy WebLinkAbout6230-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificnte O[ Occup8ncy
No. Z5236 ...... Date ............... $1Wl~.. 29..., 19.7.3.
THIS CERTIFIES that the building located at ... 1/8. · N~,~. 8.t~e®~ ..... Street
Map No..xxx ........ Block No... = ..... Lot No...X][[..0lgt.sD%.. N.~Y. ? ............
conforms substantially to the Application for Building Permit heretofore filed in this office
dated ......... 1~o~, .... 6..., 19. :~;2 pursuant to which Building Permit No. 62.30Z - ·
dated ........... l~ov .... 6..., 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 .. Private..one. fam~.l~..d~ll~E ......................................
The certificate is issued to . .0ax'y .Tabo~. ........ 0w~ol' ............................
(owner, lessee or tenant)
of the aforesaid building.
Suffolk County Department of Health Approval 14a7. · .29. · .~.9'/]. · by. R,..Villa ....
UNDERWRITERS CERTIFICATE No.. ])X'~.~X.~.~.~;~,llg ..................................
HOUSE NUMBER. 680 ........ Street ....l{&~".?~. ,B.~.~®~, ................................
Building Inspector /
· 0~ 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? 6230 Z
Permission is hereby granted to:
...e...,.~..~.,....~.o.r ..............................................
............ ~.~...~.~ ......................................................
et premises located at ...... .~../..~.....~..~...~'.~...~.~ ...........................................................................................
pursuant to application dated ................................. .~.g~.~.....~......, 19e~...., and approved by the
Building Inspector.
Fee $~.~..?..6.~. ............
~o]lJ[ NO. I
TOWN OF SOUTHOLD
Building Dq, aNment
Town Clerics Office
Southold, N. Y. 11971
APPLICATION FOR CERTIFICATE OF OCCUPANCY
Instfuctiom~
A. This application must be filled in typewriter OR ink, and submitted in triplicate to the Building
Inspector with the roi Jawing; 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 dispasal--(S-9 form or equal).
3. Approval of electrical installation fram 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 Matures.
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
.... ................
blew Building .................... Old or Pre-exi~ting Building ............................ Yaoant [and ............................
Locat o~ Of Property ,~.~.J~.....~...,Z'..../~....'~...~.. ~ ~.~..l S
Owner Or Owners Of Property ,.~..4~_.........~~ .............................................................
Subdivision ................................................................ lot Ho ............. Block No ............. House No .............
Permit No. ~.~.~.~.... Date Of Permit/./~/.~..Z~..~..Applicant ..................................................................
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 permit meets all applicable codes and regulations.
Applicant ..~ ........................................................................
Swam to before me this
· ..~....~...~... d of. ~ ........ ~.~..~...~..~
.... · . .................. ( tamp or
Notary Publi~k~,,~~ County
T~RI LEE F. UIK
WARY PUBLIC, State Of New York
fla. 52-6168295
. ../~elified in ~uffotk County
TOWN OF SOUTHOLD
Building Delm~ment
Town Cledm Office
Southold, N. Y. 11971
APPLIC:ATION 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 fram 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:
1. Certificate of occupancy $5.00
2. Certificate of occupancy on pre-existing dweUing or land use $5.00
3. Copy of certificate of occupancy $1.00
Dete .... ....................
New Building /~/
.................... Old or Pre-existing Building ............................ Vacant Land ............................
Location Of Property ...~.~..~..~(...~./......~...~.-'..~...~...~... ....... ~...T.~.../..~...
Owner Or Owners Of Property ~.~..~.~....~: ................................................... .
Subdivision ................................................................ Lot No ............. Block No ............. House No .............
Permit No. ~..~..~...~..... Date Of Permit ~../'.~..~..~..~pplicont ..................................................................
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/_~it meets~all applicable codes and regulations.
Ann cant ~.~f~----~'~-~
Sworn to before me this
.~. .......... day. L.~f ........ .~ .~,..~ ............ I...~..-I.. 3
(stamp or seOI) ~ .5'"'-,'~ .~ ~
SUFFOLK COUNTY DEPARTMENT OF HEALTH
H.D. Reference No.~
APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM
1. Applicant (~R~ ~'-~ Phone~23~5. Subdiv, ,--
Address ~D ~ 0~/~/~/,/~,//~_5'2 6. Section ~
2. Property location~/~/3~ ~z3/D ~d~F9 3r7. Lot No. ~
' ' / 8. Private well ~S
Villa8e ~/~ Township S~w~ 9. Public water ~
3. Public Water Company name -- Distance to main ~
4. Lot size: Width/~/ feet Le~th/~D feet (Enter on center plot below)
10. Sewage Disposal System:
A. 900 ~allon septic tank: Precast~Equivalent Block
B. Leaching pools: Number~ Precast ~Block Special --
be
ards
The undersigned CERTIFIES:
in accordance with
thereto."
Date
"Construction of authorized
If private well fill
in blanks below:
Tank capacity~2 Gals.
Pump G.P.M. _~--
Total well depth__
Depth to G.W.
Amount of water in
well /~
Test Hole
Data Feet
~R~ ~ 8
12
16
16
18
installations will
the Suffolk County Department of Health's current stand-
/Owner or Builder
FOR HEALTH DEPARTMENT USE ONLY. Based oD 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 [1/~%-- Signed/' ~,,~'''~ ~
S-15
Revised 4/]/7~
APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE S~AGE DISPOSAL SYSTEMS
INSTRUCTIONS: Applications must be submitted in triplicate
1-Means Owner or B~ilder. Address to which mail should be directed.
2-¥2ans 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.
PROPOSED SYSTEF~S: 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 1OO 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 from rear and 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 "t~pe 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 1OO feet minimum distance from nearest well.
3-Septic tank exterior must be 75 feet 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 1OO 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.
FO~ NO. 1
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOwN CLERK'S OFFICE
SOUTHOLD, N. Y.
........
........................................ lY ........ ~em~ ~o.~ .................................
................................................................. · .......
.................. ...............................
(Su~dino
INSTRUCTIONS
a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspactor, wi~,.(
3 sets of plans, a~urate plot plan to scale. Fee according to schedule.
b. Plot plan showing location of lot and of bu.ildings on premises, relationship to adjoining pramises or public streats 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 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
the premises available for inspection throughout the work. bee~
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, housing code, and regulations, and to admit authorized inspectors on 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, pluml~er or builder.
Name of owner of premises ......... ~'~....~~ ................................................................................
If applicant is a corporate, signature of duly a~thorized officer.
1. Location of land on which proposed work will be done. Map No.: ........ .~.....'~.... .................................. Lot I~o.X~. ...........
Street and Number ........... ~,. .........................~ ........... ...................................................................
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 ............... ~....~d...~..l.~/~.~...~../~ ............................................................. ~....~._~ ~ .... ~
' ' -- ' Iteratl n
3. Nature of work (check which applicable): New uuilding ............... , ....... Addition ..................... ~ 'o ...............
Repair ......................... Removal .................... ,... Demolition ........................ Other Work ....................................
j~/ j~'~ ~ r~ / / ~ t Description)
(to be paid on filing this application) /
5. If dwelling, number of dwe ng un ts . .. ~. Number of dwelling units on each 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 ................................................ i Number of Stories .................................. /. .....................................................
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: [ ] Yes [~'~o
~' (Address) ~' (Phone No.)
Name of Architect .....................................................................................................................................................
(Address) (Phone No.)
Name of Contractor ............................... : ...................................................................................................................
(Address) (Phone No.)
PLOT DIAGRAM
Locateclearly 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 wheth-
er interior or cor. ner lot.
I
STATE OF NEW ¥ORJ~,a '/
cou.w oF .................. ))
.......................................................................................................... being duly sworn, deposes and says that he is the applicant above named.
(Name of individual signing contract)
He is the ................. ~ ......................................................... ~..¢~r2..~'.~.~__,~.~.~.~.. .....................................................................................................
{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 O{:l[hilHk3'K~tll~lJb and belief; and that the work will be performed in the manner
set forth in the application filed therewith. N. dm)' Public, Stqte of New York
/ t,~. 52.034a963 Suffolk
...................................... / -- -----------------' ........ ............................................
Notary Pubhc .. County ~ .~ .................. : ............................................
~' ' ~' (Signature of applicant)
Ad. 89'~7 oo ~-
.5.