HomeMy WebLinkAbout6235-zFORM NO. 4
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
Town Clerk's Office
Southold, N. Y.
Certificate Of Occupancy
THIS CERTIFIES that the building located at . ~/~,/~4~... LC'A~"r~'-q--. Street
conforms substantially to the Application for Building Permit heretofore filed in this office
. ~ .... , 19~, was issued, and conforms to all of the require-
ments of the applicable provisions of the law. The occupancy for which this certificate is
(owner, lessee or tenant)
of the aforesaid building.
Building Inspector
FOEi~I NO. ~
TOWN OF SOUTHOLD
BUILDING DEPARTMENT
TOWN CLERK'S OFFICE
SOUTtlOI. D, N.. Y.
BUILDING PERMIT
(THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL
COMPLETION OF THE WORK AUTHORIZED)
N°. 6235 Z
Permission is hereby granted to:
.... ~.~.r.,c! ,.~ .e.~ .e.~.e. ~ ...................................
........ .l~x..:~;~. ...... ltt~ ........................................
.[ .......... ~at~t~lt, ......................... : ..................
to. Bu.J.l.d.. a, eta.. mxe...:['am:Liar...d~'.e lJZ'~ul~.g ............................. : ...... :.?-'"' ...................................
at premises located at ...L~t-.~ ...... .~L~ge...~. ...... ~ ..........................................................
....................................... .~,l,,1.1 ~ ~ e,., I,a,n~ ........... l~a~.tJ..tuek ................... : ......................................
pursuant to application dated ........................... ~[.~,~/' .......... ~,...+....., 1~..~.'..., and approved by the
Building Inspector.
Fee $.1 ~8.*.30. .........
FORM NO. 6
TOWN OF $OUTHOLD
Building Department
Town Clerks Office
Southold, 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 u~e:
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 Ur~derwriters.
4. Commercial buildings, Industrial buildings, Multiple R~sidences 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.
Date .......c~.~ j,~.,:.~. ] .........................
New Building ....... .~i ........ Old or Pre-existing Building ................ ? ........... Vacant Land ............................
Location Of Property .... ~/.~...~.:k~.~,~,~...~.f~.~.,.~..~..C). Y. ~.o..~.~.~ .o.~ ~:.~. ! .~.~ ,...~.D..~...~.~..~?.~..?.~ ~ ~o ~....
· ~ ·
Owner Or Owners Of Property ~.O,.c;,~..~ ~.:....~ !~..~.]..e.n ~, eznschzck
Subdivision ....~.i~e..~or. ......................... Lot No.....~..kh. Block No ...... r ..... House No....2..?.~...
Permit No..~Q.r.~,~.~... Date Of Permit .................... Applicant ...~?~z~....e. ................
Health Dept. Approval ....... .~::.J~.~..7..~. ...................... Labor Dept. Approval ................................................
Underwriters Approval ....... ~.~.~..0..-.~.~. ...................... Planning Boo~d Approval ........................................
Request For Temporary Certificate ........................................ Final'Certificate .... k~i .......................
Fee Submitted $ 5.,.0D. ..........................
Construction on above described building and permit meets all applicable codes and regulations.
Applicant ......
Sworn to before me this
......
Notary Public .......~i.~...~:~, County
APPLiCATiON FOR' CERTiFiCATE OF OCCUPANCY
A. This application must be filled in typewriter OR ink, and sbbmitted 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 buildifigs, property lines, streets, and
unusua~ naturo~ 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 ali 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 bnildings.
3. Date of any housing code or safety inspection of buildings or premises, or other pertinent
formation required to prepare a certificate.
Date ....9..-.;Z~..-. ?.g ............................
New Building .... XX ........... Old or Pre-existing Building .............. i ............. Vacant Land ............................
Location Of Property ...F~/.~....~.±~L~tg.~...~.~.*...2.5~.~.L~...n..~...r.~.h.....~..~...R..5:.~.'...~5~.5}.~.~.~)..~.~,
Owner Or Owners Of Property ~.~;~b~e`~..6.~:~.~.~..e..5.~.e.B~.~g....~..e..m.~9..~..~9..~ ........................................
Subdivision ...V. SL],a~e..3qazzc~r. .............................. Lot No...~.].~ ..... Block No ....... ..-..,. House No.,,2.~,.,Q ....
Permit No...S.Q=J.22.~. Date Of Permit ....................Applicant ...... ~.c%r[k~ ..................................................
Health Dept. Approval '.......$..~m17.~3. ....................... Labor Dept. Approval ................................................
Underwriters Approval ...... ~...~.~.Q..n~..~. ....................... Planning Board Approval ........................................
Request For Temporary Certificate ................................ (~ ...... Final Certificote'.....L/. ...................................
Fee Submitted $ .5.,..0.0. .........................
o ow
Applicant .......... .~.'.~..:; ..............................................................................
Sworn to before me this
Notary Public ..... ::~Countv ~x ~
SUFFOLK COUNTY DEPARTMENT OF HEALTH
Reference No.
APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE ~EWAGE D.~SPOSA,L ,SYS,TEM
t. Applicant ~ha:~ ~..~o~hiok Phone2~}'~
15. Subdiv. Villag
Address Y~/1, Box 5~, 24atLitu~
2. Pr, operty location V~II~ La~.~
D~t. to Intersection---234' to Rt. 25
Village 1 ~ttit%~k __Township
6. Section ~a
~7. Lot No.
8. Private well y~S
~9. Public water r~o
3. Public Water Company name ~/& Distance to main
4. Lot size. Wid~ feet Length ~t5 feet (Enter on center plot below)
10. Sewage Disposer S~stem:
A. ~00~/gallon septic tank: Precast ~ Equivalent Block
B, ~ching pools: Number 2 Precas'~ /~LBlock _S--~cial '"
If private well fill
in blanks below:
Cla~s lined
Tank capacity l2OGals.
Pump G,P.M.
Total well depth_~
Depth to G.W. 20~
Amount of water in
well ~0~
Test Hole
Data Feet
8
10
12
14
16
18
The undersigned CERTIFIES: "Construction of authorized installations will
be in accordance with the Suffolk County Department of Health's current stand-
ards theretoo"
Date ]1/~:/~/2 Signed - Owner '~r B~ilder
FOR HEALTH DEPARTMENT USE ONLY.'Based on the information presented herewith, it
is the opinion of the Health Department~ that
Disposal System can be installed on this plot.
~.~! .... S~gned
Date
S-15
Revised 4/1/72
an adequate and satisfactory Sewage
APPLI~TION ?OB. A~PR_OVAL _TO CONSTRUC~ .FRIVAT't S~AGE DISPOSAL SYSTFLMS
INSTRUCTIONS: Applications must be submitted in triplicate
1-Means Owner or Builder. Address to which mail should be directed.
2-Means detailed description of property location, together with street name and distance
~earest intersection of ~m~n thoroughfare, also Hamlet/Village & Township.
3~Enter name of Public Water Supply District, together with the distance to thei~ main.
h-Enter Length and Width of Lot under appropriate heading, also enter these dime ~sions
center plot plan shown on the face of this application.
~~Name of subdivision.
6~Section number.
7-Lot number.
8-Private well: ~ter "No" if Public water supply is available. Enter "Yes" otherwise.
9-Public water: ~ter "~es" if Public water supply is available. Enter '~o" otaerwise.
PROPOSED SYSTEM~: Answer to Item number 10, consult the Suffolk County Health ~partment
--~andar~s for Sewage And Waste Disposal Systems Design of Residential Subsurfaceo~ Sewa
Disposal Facilities.
Part I-Residential Subsurface Disposal Systems covering cessRools.
PLOT PIAN: The following information is required concerning the Applicant's lo~:
~--~ size-Length and Width in feet to be indicated at the lot lines of the heavy 1
~ ~'~ square in the center of Plot Plan sh~n on face of this application.
2. Surface waters-Streams, Lakes, & Bays, etc., located within a distance of!lO0 feet
Applicant's lot lines, must be shown on the plot plan also.
3. Wells and cesspools now on adjacent lots m~/st be shown on the plot plan,~ogether
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 pla~.
5. Streets adjoining applicant's lot to the right, left or rear, enter stree~ name.
W~LL LOCATION: To locate the well & sewage disposal systems on Applicant's lot the fo]
Standards must be observed:
Well-lOO feet minimum distance from the nearest cesspools.
Well- 2~ feet distance from rear and rear sides of property lines when pcssible.
Well- l0 feet distance from front, and front sides of property lines whe~ possibl~
Well- ~0 feet minimum below grade for well point.
Well- hO feet minimum into ground water for well point.
Well- h feet 6 inches minimum below grade to well head and lateral wate~ pipe.
CESSPOOL LOCATION: Upon determination of the Sewage & Waste Disposal "t~pe o~ sys%ems
~ui~" th~~,~ ~oi['low~ng Standards must be observed for the location of same:
1-Cesspool- ~ feet ~inimum distance from lot lines to exterior of cesspool.
~-Cesspools exterior must be 1OO feet minimum distance from nearest well.
3-Septic tank exterior must be ?~ feet from nearest well. ,
h-Cesspool exterior must be 7 feet minimum distance from nearest water line.
~-Cesspool exterior must be lO feet from house foundatien.
6-Cesspool exterior must be 1OO feet minimum distance from surface waters~ s ;reams,
& 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 I foot to maximum ~ feet
lO-Bottom of cesspool to ground water m~st be held to minimum of 2 feet.
to
ed
of
~ith
lowing
re-
akes,
MAP OF PROPERTY SITUATE AT MA~TITu~K, T'OWN OF SOUTHOLD,
SUFFOLK COUNTY, NEW YORK° LOT WUMBERS R~FER TO ' MAP
VILLAOR MANOR" PILPTD AS MAP NO, ~6~9 ON OCT. 2h, 1962
SUI~J'ECT PROPERTY BEING LO'i' NO, 2h
SURVEY MADE FOR ; RICHARD R.NEMSCHI~K
GUARANTEED TO SOUTHOLD SAVINGS BANK
GO'
SURVEY MADE OCT.11 , 1972 BY
: MEDFORD N 0 Y
FLIgAL S~RVEY I~tADE MAY 2.5,
2206']
APo. a/,
SUFFOLK COUN~Y HEALT[~ D~PARTMENT
The sev/age disposal and ~vate~ supply
facilities for tb~s loea~on~kave been
inspected by this departmant and found
~t° be satisfactory.T-'~~ ~.
,~ Chief of General E~gineerin~
x Services
/,dP /
BUILDING DEPARTMENT ~/,
TOWN CLERK'S OFFICE
amin~ ....... ~.~..L; ......... ~ ............ , 19 ........ Application No ..............................
. . ................................... , ........ .................................... -
~pproved a/c ................................................................ ~.
.... ~ ..................
................................................................................................................... ~e ~ ~
................................ ~'~'~i~ i~'~ ....... ~/~'~'""~'3'~
..... ......................
INSTRU~IONS
This ip~li~io~ mus~ ~ ~mple*ely filled in by W~wri~er or in i~k 8nd submi~ed
~ of ~ans, ~ur~e ~lo~ plan To ~cale. Fee ~ording ~o schedule.
b. Plot plan showihg location of lot and of buildings on premises, relationship
giving a detailed description of layout of property must be drawn on
c. The work covered by this application may not be commenced before issuance of
d. Upon aPProval of this application, the Building inspector will issue a Buildir
the premises available for inspection throughout the work.
~ No building shall be occupied or used in whole or in pert for any
grant~l~oy the Building Inspector.
premises or public streets or areas, an(
this application.
Permit.
the applicant. Such permit shall be kept
until a Certificate of Occupency shell have bee
APPLICATION IS HEREBY MADE to the Building
Ordinance of the Town of Southold, Suffolk County, New York
buildings, additions or alterations, or for removal or demolition,
ordinances, building ¢ lng code, and reg,
issuance of a Building Permit pursuant to the Building Zon
dicable Laws, Ordinances or Regulations, for the construction of
described. The applicant agrees to comply with'all applicable laws.
d inspectors on premises and in buildings for necessary inspections.
(Signature of applicant, or name, if a corporation)
.._~/.~. ~...~..~.~.,...~.~...k.~ .. ~..,.~.., ..................
(Address of applicant)'
State whether applicant is owner, lessee, agent, architect, engineer, general contractor, electrician, plumber or builder[
owner, General Oontractor
Name of owner of premises R~g~.d R, ~...q~....ch~ck '
If applicant is a corporate, signature of duly authorized officer.
(Name and title of corporate officer)
1. Location of land on which proposed work will be done. Map No.:3..6..6..9. ............ Lot No ............. ...2~ ...... : .....................
Street and Number ........ ~:~ 1 ~1 age..Laae ....................................................................................... ~a,tL~;i,.~Lt.q~. ..............
Municipality
2. State existing use and occupancy of premises and intended use and occupancy of proposed construction:
a. Existing use and occupancy ....... ~.a, ............ ; .................. q:..;~.....? ........................................................................
· ..o.b.e...t~?~ ~..~...~...:: ~ .
b. Intended use and occupancy ..................................................................................................
3. Nature of work (check which applicable): New Building ....... ,~ ............. Addition ..................... A~teration ...............
Repair ...................... Removal Demolition Other Work .............
(Description)
4. Estimated Cost ..~.~.~.A.O...O~...'...0~.. ......................... Fee / ~ ~ ~
(to be paid on filing this application)
5. If dwelling, number of dwelling units ...... ~- ......... Number of dwelling units on each floor .............. ~ ..........................
2
If garage, number of cars ............................................................................................................................................
6. If business, commercial or mixed occupancy, specify nature and extent of each type of use ....... ~.~. .......................
7. Dimensions of existing structures, if any: Front ..... .n./..a..;::;..... Rear ......................... Depth ...................................
Height ........................................................... Numbe~f Stories .............................................................................
Dimensions of same structure with alterations or additions: Front .......................... Rear .........................................
Depth ............................................. Height ......................................... Number of Stories ........................................
8. Dimensions of entire new construct!on: Front ....~.'.~![ ........... Rear ..... .$.~.[ ................. Depth .....,~.'., .....................
· 20' · 2
Height ................................................. Number of Storms .........................................................................................
9. Size of lot: Front ........1.~...0..'. ........................ Rear ........ ..1~...0..'. .......................... Depth ........ .2..1.~.:. ..................................
· n/a
Hmght .................................................... Number of Stories ...... J~/~. .........................................................................
10. Date of Purchase ......1~.../..3../..7...2. ................... Name of Former Owner MicheLle Becket
11. Zone or use district in which premises are situated .....A...Z..R..e.s..i..d..e..n.~.i.a..1.-.-..-A~.,mi,'&~-..t...u~...,,a~L,. .....................................
12. Does proposed construction violate any zoning law, ordinance or regulation: ...... .rig. ..................................................
13. Will lot be regraded .... ~,e,.s, ....................... Will excess fill be removed from premises: [ ] Yes [~ No
14. Name of Owner of premises ....~[,c,,.ha.,,,z~,..~.s..~. ~-~-~c~t~c~a~.R~A~]~N~-~[~t~c~2~[~ .........
(Address) (Phone No.)
Name ~ ~h~+~ Dalton Labbe 1 Briar Court, Rocky Point 7.~4-~1~
................................................................................... i;4'&ir' Wi ................................... ..............
Name of Contractor o~m~er
(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 and indicate wheth-
er interior or corner lot.
See attached map
STATE OF NEW YORK, ) ~
COUNTY OF ................. ~.LL~ ~D~ .....................)
Richard R. Nemschick
.......................................................................................................... being duly sworn, deposes and says that he is the applicant above named.
(Name of individual signing contract}
He is the ....ol~li'ler.~..G. ea~lel~,~..~.~'~.~..~.q~ ...................................................................................................................................................
{Contractor, agent, corporate of~tcer, etc,)
af said owner or owners, and is duly authorized to perform or have oerforrned the said work and to make and file this application; that all
statements contained in this application are true to the_be. RLo~ ~s knowledge and belief; and that the work will be performed in the manner
set forth in the application filed therew;th. NOIAR¥ pUbLIC, la~ ~ .''
.............................................................. ~'"[6fl"~lm' ....
Notary Public, ~.._.~-......-~ ...... County .......... .~../..~.....~.,~.....-.~., ..--: ........ ~ ................
(Signature of applicant)
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