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HomeMy WebLinkAbout6287-zFORM NO. 4 TOWN OF $OUTHOLD BU~,BING DEPARTMRNT Town Clerk's Office $outhold, BI. Y. Certificate Of Occupency THIS CERTIFIES that the building located at .E./.$.....S~....~....If~... ........ Street ~,a~, ~o ............. -,o~ ~o ........... Lot ~o. ~ ..... S.~..t?.~....~.:.~.: ........ /conforms substantially to the Application for Building Permit heretofore filed in this office dated ......... ..D?? .... 7. .... , 1~..~.. pursuant to which Building Permit No. dated D~C 7 1972 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 ...~..~.::.~....o.~...f...,~...~.. d..~.x..x..~. ...................................... The certificate is issued to Gel. aid & Franeel T~th~ll (owner, lessee or tenant) of the aforesaid building. Suffolk County Department of Health Approval A~ ¶6 1973 by Bo ]i 096~19 June 1~ 1973 UNDERWRITERS CERTIFICATE No ............................................. HOUSE NUZvZ~E~ .............. Street. ~.r....~?. ............................ Building Inspector FORM NO. 2 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) 6287 Z Permission is hereby granted to: .f~.~d...~.. ~e~ s...~tth~l~ ..................... ....... ~a. il~-....Lv.e ................................................ ............... {)~.~ eu~.~r.t ......... IL.Z,, ........................ to ~t.lJ.~l ..~o.v.e.. 2a3,~ ..~ew...o~e...£a~$~v.. 4.,~1.1.:~ ............................................................. ~3t premises located at ..~o:~..~]l....l~a~l:~;~;],~...~.~.F&o~ .................................................................. ...................................... F~. ~,..f~u~er...I~n~ ........ ;~mathe .l~l.....1~.,~, ........................................... pursuant to application dated ..................... ~1~.~. ......... ~. .............. , 1~......, and approved by the Building Inspector. Fee ~(~.,* ~ .............. Bui ding nspectC~r FORM NO. 6 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: !. 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 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 aT 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 $5.00 2. Certificate of occupancy on pre-existing dwelling or land use 3. Copy of certificate of occupancy $1.00 $5.00 Date .....~'/~...../..-~..~.....~.....~.. L..~..7.~ New Building ....~..'~.~. Old or Pre-existing Building ............................ Vacant Land ............................ Locaton Of Pr · ~.~.~/..~...~. 1~.~ ./--/~/.,~.. ~..0//.~..~Z.~,~.~' ' ~ ............... .... ................................................... .................. ~ner Or ~ners Of Prope~y .~ ~.~.~..~.~. ......... ~.~.~.~.~.....~..~.t.~.~..~.~.~ ~ r ~ $~ ~ /~Z~. Lot No...~.~.. Hou~ No...~ Su~ivisJon .. .~. ............................... Bilk No. ~ Heath ~-t An~rn~a ~ /~ --' ~. -- ' ~ ~ pprav rovo, .......................... g ~P .... ~ ........ . .......................... Request For Tempom~ Ce~ificate ........................................ Final Ce,ificate ..~.~.=..~.~..~:~... Fee Submi~ed $ .................................... Construction on above described building and permit meets all applicable codes and regulations. App cant ~ 0 '~ . . Sworn to ~efore me this ~J'-~'"~ .......... :~ ........ ~"'~"~'-~ 'z .. ~ day of . ~/..,~ ' ' ~ -/ SUFFOLK COUNTY DEPARTMEN'T OF HEALTH APPLICATION FOR APPROVAL TO CONSTRUCT A PRIVATE SEWAGE DISPOSAL SYSTEM 37/6 -.~77 1. Applicant ($~R~-D O~ r~r~/'/~" Phone ~/z,~3 5. Address ' ~O~ ~M~ 6. 2. Property location-- ,[ ~0T'g~ ~ ~ 7. Village _~6 L~ Township ~0 ~"~ 3. Public Water Company name 4. Lot size: Width f~ feet Length yD5~3'Y feet 10. Sewage Disposal System: A. 900 gallon septic tank: Pretest~ Equivalent__ B. Leaching pools: Number / Pretest ~ Block ' Section ~A~9,~m 7ER~C~ Lot No. ~%d 8. Private well ~ 9. Public water Distance to main (Enter on center plot below) Block __Special__ If private well fill in blanks below: Tank capacity~ Gals. Pump G.P.M. Total well depth~I Depth to G.w. Amount of water in well Test Hole Data Feet o 6 8 10 12 16 18 The undersigned :ERTIFIES: "Construction of authorized installations will be in accordance with the Suffolk County Department of Health's current stand- ards thereto." Date ~&C-~ 7 / ~-- Signed ~Owner Oor 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 Date ~ /~/~ ~ Signed~ S-15 Revised 4/]/72 APPLICATION FOR APPROVAL TO CONSTRUCT PRIVATE SEWAGE DISPOSAL SYSTEMS INSTRUCTIONS: Applications must be submitted in triplicate 1-Means O~ner or Builder. Address to which mail should he directed. 2-Means detailed description of property location, together with street mmm~ 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 SYSTEm. 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 100 feet of Applicant's lot lines, must be shown on the plot plan also. 3. 'Jells 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-100 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. .C~SSPOOL 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 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 foundation. 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. 10-Bottom of cesspool to ground water ~st be held to minimum of 2 feet. N.~4'5~*$0'W. - 101.?1 LOT · ?1 Cc--,'.-..,) IAI:IP O[ LI:IN il 5UII~VEYE N FB~, I~IT URTE nT 50UTHOLD TOWN OF' $§UIIJBLD, N.Y. TITLE o I~nyslO! TtKRaCli"lrlLEQ tNTUIi SUFFOLK COUN1¥ CLEkK'$ OFFICE RS Il, aP N,e '~054. .) O~ TiTL[ i,1o. LOT'. LOT · ?1 IA~P 01:LI~NI1 ~IT UItTE NT SOLJlUOLD BliYSII)F. TT,~,Ki~CE" IrlLE~ IN TI~I~ SUFFDLK TOWN OF $OUTHOLD/ BUILDING DEPARTMEI~IT / TOWN~: CLERK'S OFFIC~ SOUTHOLD, N. Y. c.__ App)ication No .............~.. ................. Approved ........................................ , 19 ........ Pemit No ..................................... Disapproved a/c ..................................... APPLICATION FOR BUILDING PERMIT ])eoe-be:e ? 19...~..~. .... INSTRUCTIONS a. This application must be completely filled in by typewriter or in ink and submitted in triplicate to the Building Inspector, with~ 3 ~ts of plans, accurate plot plan to scale. Fee according to schedule. °' b. Plot plan showing location of lot and of bui!dings on premises, relationship to adjoining premises or public streets or areas, and~ giving a detailed description of layout of property must be drawn on diagram which is Part 0f 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 promises available for inspection throughout the work. e. No building shall be occupied or used in whole or in pert for any purpose whatever until a Certificate of Occupancy shall have been granted by the Building Inspector. T' 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, Suffotk 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, plumber or builder. O~mer Name of owner of premises ...~..:R.I~L(~.....~:~.]-..~....~.....~..~-..~..e. .............................................................................................. If applicant is a corporate, signature of duly authorized officer. (Name and title of corporate officer) Builder's License No .......................................................... Plumber's License No ......................................................... Electrician's License No ..................................................... Other Trade's License No ................................................... .. BaTs:[de Terrace __., 20 1. Location of land on which proposed work will be done. Map r~o .......................... ;. ........... ~.:~...LO~ ~o ......................... Street and Number .................... Rh~m~:..~l~:te ......... RO~l.t;bX:t]/1 ....~.,~, ............................................................... q ~ o Municipality 2. State existing use and occupancy of premises and intended use and occupancy of proposed construction: a. Existing use and occupancy ~.~..C..~...~..~....~ .......................................................................... b. Intended use and occupancy .......... (~;~.e...~'~t~;[~.~..~.~W~L~...,, ....... ; ....................................... , .................... 3. Nature of work (check which applicable): New Building ....~ ....... Addition ..................... Alteration ............... Repair ......................... Removal ......................... Demolition ........................ Other Work .................................... (Description) 4. Estimated Cost .........1...~.~.Q[~..,~+ ................... Fee ......%~)...e..2..0.. ................................................................................ (to be paid on filing this application) 5. If dwelling, number of dwelling units ..... ~ ..... Number of dwelling units on each floor ......................................... If garage, number of cars ....................................................................................... 6. If business, commercial or mixed occuoancy, 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 ........ 2,.If .................... Height ................................................. Number of Stories nnA ...... 9. Size of lot: Front .....:~QQ...,., .................... Rear ..... ~.~ .............................. Depth ......1.O~ ..................................... 10. Date of Purchase ............ ~.7.~. ............... Name of Former Owner ........... ~J~13~ ..................................................... 11. Zone or use district in which premises are situated ........ .~&~..~;~t ........................................................................... 12. Does proposed construction violate any zoning law, ordinance or regulation: ........ ~Q ............................................... 13. Will lot be regraded -...~,T~l ....................... Will excess fill be removed from premises: [ ] Yes [~:No 14. Namei~f Owner of premises ..... ~e~&]~:l,.~c.~.a3:to~8..,~%l,t,h;[3,~_ .......................... G.~..ee~[0~:~ ......................... · (Address) (Phone No.) Name of Architect .................................... ~ (Address) (Phone No.) Name of Contractor ..... (Address) (Phone No.) PLOT DIAGRAM Locate clearly and distinctly all buildings, whether existing or proposed, and indicate all set-back dimensions from property lin~ ,s.' Give street and block number or description according to deed, and show street names and indicate wheth- er interior o~ corner lot. STATE OF NEE COUNTY OF YORK~ . ) ............ ................... ) ................................ ,~t~,.~X~.lll a...~"XI,'~ ::L3,3. ................................ being duly (Name of individual signing con. tra. ct} s~vorn, deposes and says that he is the applicant above named. He is the .......................................... 1(~1~_ ~. ...................................... (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 s.tatements contained in this application are true to the best of his knowledge and belief; and that the work will he performed in the manner set forth in the application filed therewith. TERRI LEE ELAK NOTARY PUBLIC, State of New York 7 ~ .... f Dee ,o. ~-~ .......................... ~ .......... ~ ....................................... ~afified- ,in~ ~uf~k.-~o=my ~/~ %.~ - ~ ~ _ . Commission Expires March 30. 1~' ~ ~ ~,~ ,,~/] Notary Public, .~.~.~ ......... County ............ .~~.../~ .............................................. (Signature of applicant)