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Home My WebLink About6283-zFORM NO, 4 TOWN OF SOUTHOLD BUILDING DEPARTMENT Town Clerk's Office Southold~ N. Y. Cerlificnte Of Occupnncy THIS CERTIFIES that the building located 'at .. I,Ong~ .l,m~ .:? ........ Street Map No. TOrrY .l~.&~;.~'~lock No ........... Lot No..1~8 ...... [~p~th. O~. !~.o~, ....... conforms substantially to the Application for Building Permit heretofore' filed in this office dated ........... Ney .... 30., 19..~t'~ pursuant to Which Building Permit No..628~Z · dated ........... D. ee...~ .... , 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 ~,v~t,e. one. fa~,ly. 4ve,llZn~ ...................................... The certificate is issued to .. Ilage..~Ons.truet~,an. C~ .Ino ..... Ovae~. ~ ............. (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval ~ Julae · · ~..197.~..b~'. ao.¥~,lllt .-. UNDERWRITERS CERTIFICATE No .... .]1..~.3~.~'~, ..... ~1~., 3.0... 19~1 ................ HOUSE NIdMBER...14.O~ ...... Street ..... l'OIl~v~.O~'-.~a~iO ........................... Building lnspector~ FORM NO. ~ TOWN OF $OUTHOLD BUILDING DEPARTMENT TOWN CLERK'S OFFICE SOUTIfOLD, N.. Y. BUILDING PERMIT (THIS PERMIT MUST BE KEPT ON THE PREMISES UNTIL FULL COMPLETION OF THE WORK AUTHORIZED) N? 6283 Z Permission is hereby granted to: Ba gLO,nat r.,.?.o.. ]ina ....................................... ......... ~e~the~ ....... 15,¥., ................................... to ....J~_~__~.,!..~...a~u~..£~.~3~...dwe~l.]4L~ ................................................................................. at premises located at ...,IT,~l;..}¢~- .............. ~'®z, rll~..Ideqe~'~ .............................................................. ................................................. /,on~'&e~..~,~ne ............... 8e~ebo.~.....N~.~.,. ............................... pursuant to application dated ....................... lOql' ......... '30 .......... , 19~...., and approved by the Building Inspector. Fee ~.t, ~. ............ FORM NO. S TOWN OF SOUTHOLD 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 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 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. Fees: 1. Certificate of occupancy $§.00 2. Certificate of occupancy on pre-existing dwelling or land use 3. Copy of certificate of occupancy $1.00 $5.00 New Building ~[ Old or Pre-existing Building Vacant Land ............................ Location Of Property ......~...~..A/..~...I~/...~....z~.....~....~....~...~.... ......... ....~...~..~.~..~...J~.. ............................................... Owner Or Owne~rrs Of Property ...~...~...~...~........~...~...~/....5~...~...~...~.~.[..~....~.........~......T..~..~..., .............................. Su ,v,s,on ........................ Lot B,oc, No ............. No ............. · '~ D f P ' /~ '~ Ii nt ~ ~,~.~" Perm,t No. ~.~..~......~.. ate O er, m,t ....~/.~./..~.~:...App ca ...... ~.~.. ............... /.: .......... .~...~.~ ............ /~ / / 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 me~ts al_l~applicable coc~s and .regulations. · -~op ... =-.,~..~...~. ...... ~ ......................... 1>,? ...... ~.._...~.....: ~,., , Sworn to before me ~ls ~ ('/ '~'~- ........... [.~.. day of ...~.....L~...~....~. ........ · (stam~or seaT) v ' Noto~ Public .................................... Coun~ SUFFOLK COUNTY DEPARTMENT OF HEALTH H.D. Reference No. APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM i '6. Section 2 7. Lot No.----~ 8. Private well Village ~F~4~ Townshi~p~9.~__ Public water 3. Public Wate~ Company name Distance to main 4. Lot size: Width ~ feet Length /~-- feet ~Enter on center plot below) 10. Sewage Dispos~ ~ystem. A. ~00/gallon septic tank: Precast~ E~uivalent Block B. ~C~ing pOOlS: Number~ Precast~Block Sp-~cial If private well fill in blanks below: Tank capacity~ Gals. Pump G.P.M. ~ Total well depth ~/ Depth to G.W. be in accordance with the ards thereto." Amountwell of w~ in Test Hole Data Feet 0 2 4 8 10 12 14 16 18 The undersigned CERTIFIES: "Construction of authorized installations will Suffolk County Department of Health's current stand- 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 can be installed on this plot. Date fff~/% -- Signed ~ -. S-15 Revised 4/]/72 APPLICATION FOR APPROVAL TO CONSTRUCT, PRIVATE ShWAGE DISPOSAL SYSTEMS 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 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: hhter "No" if Pubt~c water supply is available. Enter "Yes" otherwise. 9-Public water: Enter "Yes" if Public water supply is available. Enter 'No" otherwise. PROPOSED SYSTEMS: Answer to Item number 10, consult the Suffolk County Health Department's Standards for Sewage And Waste Disposal Systems Design of Residential Subst~rface Sewage DispoSal Facilities. Part I-Residential Subsurface Disposal Systems covering cesspools. pLOT PLAN: 2. 3. 4. 5. The following inforwmtion 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 shm~ on face of this application. Surface waters-Streams, Lakes, & Bays, etc., located within a distance of 1OO feet of Applicant's lot lines, must be shown on the plo~plan also. Wells and cesspools now on adjacent lots must be shown on the plot plan, together with ~e distance to the Applicant~s Proposed Sewage Disposal Systems and well. Where no buildings exist on adjacent lots, state "Vac~t" on the plot plan. Streets adjoining applicant's lot to the right~ left or re~, enter street name. WELL LOCATION: To locate the well & sewage disposal systems on AP~icaut 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" re7~ 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 75 feet from nearest well. 4-Cesspool exterior must be 7 feet minimum distance from nearest water line. 5-Cesspool exteri0r~must belO feet from house foundatie~. 6-Cesspool exte~i~must be i00~ feet minimum distance from surface ~a~ers, streams, lakes, & Bays, etc. 7-Cesspools ~st 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. 10-Bottom of cesspool to ground water ~st be held to minimum of 2 feet. TOWN OF SOUTHOLD BUILDING DEPARTMENT,,~ ~, TOWN CLERK'S OFFICE S~THOLD, N. Y. x i.ed .................. .................. ~proved " ~ 19..~.~ PemJt No. ~ ~ ~ ~ ~ ......................... Di~pproved a/c ..~~ , ~ APPLICATION FOR BUILDING PERMIT 4 Date I~la V. ;~O 19..?.~....,~ INSTRUCTIONS . ~ a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, w' 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, an~ giving a detailed description of layout of property must be drawn on diagram which is part of this application, k 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 o1~ the premises available for inspection throughout the work. e. No-building shall be occupied or used in whole or in pas't 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, Suffoll~ Count~, 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 inspection~ ,¢, ....... Bege .. ~,a na~z~c.tJ, art ..F,a .... ia ~. ................ (Signature of applicant, or name, if a corporation) (Address of applicant) State whether applicant is owner, lessee, a~nt, architect, engineer, general contractor, electrician, plumber or builder; , Name of owner of premises ...... ~ge., Pnna~u~t~aD..nn,..[nc, .................................................................................. If. applicant is a corporate, signature of duly,a~fi[;~orized offi~r.~ (Name and title of corporate officer) 1. Location of l~nd on which propo~d work will ~ done. Map No.: .................... Lot No .............................................. Strut and Numar ...... ~e~.~..~.~..~ ...................... ~g~e..~ .................................... ~ Munieipali~ 2. State exi~ing u~ ~nd occupancy of premiss and intended use and occupancy of propo~d eon~metion: ~. Exi~ing u~ and ~eupaney .................................................................................................................................... b. Intended u~ and occupancy Nature of work (check which applical~le): New Building ....... .x.. ............. Addition ..................... Alteration .............. Renair Re oval ................. Demolition ........................ Other Work ...................... ................ (Description) 25 0 4. Estimated Cost ..J~.....s...l~J .............................. Fee ................................................................................................. (to be paid on filing this application) 5. If dwelling, number of dwelling units ....,1, .......... Number of dwelling units on each floor ......................................... z If garage, number of cars ............................................................................................................................................ 6. If business, commercial or mixed occupancy, specify nature and extent of each ty'pe 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 ......... ,5,5. ........... Rear ....... .~5.~. ................ Depth ....~0 ........................ Height ................................................. Number of Storms ....................................................................... 9. Size of lot: Front .'. .......... lDO. ................... Rear ........ lOti ............................ Depth ...... 1.35 ...................................... Height .................................................... Number of Stories ...................................................................................... 10. Date of Purchase ...... ..0~...t.......]:.9...7..2. ............ Name of Former Owner ......~...~.{~R.h...ff..h..~R{4~ .......................................... 11. Zone or use district in which premises are situated RaaJLden'~J.a]. .... 12. Does proposed construction violate any zoning law, ordinance or regulation: ......... J~3 .............................................. 13. Will lot be regraded .... _y_.e..a. ......................... Will excess fill be removed from premises: ~: ] Yes [ ] No 14. Name of Owner of premises ...................... (Address) (Phone No.) Name of~J~llet ~.,E ....... .F..duaz'd..,]o..Ba~ ............ ~,ugh~,~ld~ss~t,e> ............................. i~;~-~'r;?e~o~3'C~], ...... · .~r,^,,+.o,.+,~r Bage r. ona~o Co° Ince .. . Name ,~. ~.v,,..~...... ................................................................................................................. (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 st 'eet names and ind cate wheth- er interior or corner lot. t ' STATE OF NE~YQ,R~, ) ~;OUNTY OF ..,'~..~.' ..~...~.~ ............................. ) SS ..~...~......g~.~.. '"'~"- ..~,~....~ being duly sworn, deposes and says that he is the applicant above named. He is the ....................... .~.~.~b~°-,~.... ............................................................................................................................. ~ .......... ! .......................... (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. "rh'' k-"~Jz, ~t~t~~ 1~dq ~TERRI LEE ELAK 19 ....'~7...~. /'-- ~ ........... .............. .......... / Notary Public, ..~.._~ '~"gl~ss..i...~~ ....... County ........ ~,2...~....7/../...~¥....~.;;...,~r~..a--~ .................... (Signat~e o.r appaca~ ~F'~ % ~ ~uFFoLK COUN~Y HEALTH ~he sewage disposal a~d facilities for this lo~ation k~e been lnspscted b~ this depar%men%/gnd found --~ C~i~f-of~n~r~l ~ngineerins ~ ~ervices T